S. Pirzada Sattar

Aripiprazole possibly worsens psychosis.

Aripirazole is a novel antipsychotic that functions as a partial agonist at the dopamine D2 receptor and, thus, might theoretically worsen psychosis. We report a series of four clinical cases of exacerbation of psychosis related to initiation of aripiprazole therapy. Cases 1 and 2 demonstrated the worsening of psychosis following initiation of aripiprazole (15-30 mg daily) while tapering off the previous atypical antipsychotic. Cases 3 and 4 demonstrated worsening of psychosis following the addition of aripiprazole (15-30 mg daily) to an atypical antipsychotic. In two out of the four cases, discontinuation of arpiprazole resulted in improvement of psychotic symptoms. Although the cases presented are suggestive of a relationship between initiation of aripiprazole therapy and worsening of psychosis, further research is needed to clarify any potential association.

Inert Medication Ingredients Causing Nonadherence Due to Religious Beliefs

OBJECTIVE To report 4 cases of medication nonadherence due to presence of inert ingredients forbidden by the patients’ religion. CASE SUMMARIES We describe 4 cases in which religious concerns about prescribed medications’ inert components led to discontinuation of these medications. These inert components are gelatin and stearic acid, which might be derived from pork or beef products. In these 4 cases, patients of Muslim, Orthodox Christian, and Seventh Day Adventist faiths, who consider it against their religion to consume pork products, stopped their medications on discovering this possibility. This led to relapse of their illnesses. DISCUSSION These cases demonstrate that, for some patients, inert medication components that are forbidden by their religion may lead to discontinuation of medications. This could lead to relapse of symptoms and might even lead to hospitalization. Therefore, it is important for prescribers to inform patients of this possibility when treating patients whose religious background might conflict with these inert medication components. CONCLUSIONS Patients with religion prohibitions against consumption of pork and/or beef products might stop their medications when prescribed those with pork- and beef-derived gelatin and/or stearic acid. Prescribers should discuss this possibility with their patients, perhaps as part of informed consent.

Somnambulism Due to Probable Interaction of Valproic Acid and Zolpidem

Objective To report a case of somnambulism due to a probable interaction between valproic acid and zolpidem in a patient with no prior personal or family history of somnambulism. Case Summary A 47-year-old white man with a history of bipolar disorder was being maintained on citalopram 40 mg once daily and zolpidem 5 mg at bedtime. During treatment, he developed manic symptoms and was started on adjunctive valproic acid therapy. Soon after this, he developed episodes of somnambulism, which stopped when valproic acid was discontinued. On rechallenge with valproic acid, somnambulism returned. Discussion To our knowledge, this is the first report in the literature describing a probable interaction between valproic acid and zolpidem leading to somnambulism. Even though valproic acid has been associated with sleep changes, there are no published reports of somnambulism with this agent. Zolpidem has been associated with somnambulism, but our patient did not experience this when he was on zolpidem monotherapy. However, within 2 days of starting adjunctive valproic acid, sleepwalking occurred. It stopped after valproic acid was withdrawn. On rechallenge with valproic acid, sleepwalking recurred. However, when zolpidem was discontinued and valproic acid was continued, somnambulism did not occur. An assessment on the Naranjo probability scale suggests probable pharmacokinetic or pharmacodynamic interactions between the 2 medications. Conclusions Valproic acid and zolpidem are generally safe medications that are commonly prescribed and often used together. No interactions have been previously reported with combined use of valproic acid and zolpidem. This case suggests a probable interaction between these 2 agents that can have a serious consequence, somnambulism. This could be frightening to patients and put them in danger. Recognition of such interactions that place patients at risk for potentially serious adverse events is imperative for appropriate care.

Quetiapine Therapy for Posttraumatic Stress Disorder

OBJECTIVE: To report a case of improvement in posttraumatic stress disorder (PTSD) after adjunctive therapy with quetiapine. CASE SUMMARY: A 49-year-old white man witnessed a traumatic event and experienced severe PTSD. He was started on paroxetine, with increases in dosage and no significant improvement. Quetiapine was added to his regimen, with increased doses resulting in improvement of PTSD symptoms, both clinically and as measured on the Hamilton-D rating scale for depression and the clinician-administered PTSD screen. DISCUSSION: This is the first case published in the English language literature describing improvement in PTSD symptoms after treatment with quetiapine. There are several treatment options for PTSD, but some severe cases may require treatment with antipsychotic medications. Because of the lower risks of serious adverse effects, the newer atypical antipsychotics are much safer than the older antipsychotics. Although use of risperidone and olanzapine in the successful treatment of PTSD has been reported in the literature, there are no reports of quetiapine use in this clinical condition. CONCLUSIONS: Quetiapine appeared to improve clinical signs and symptoms of PTSD in this patient. It may be a treatment option in other severe cases of PTSD.

Aripiprazole reduces alcohol use.

Dear Editor: Few pharmacotherapy options exist for the treatment of alcohol dependence. Recent reports suggest that newer atypical antipsychotic medications may reduce alcohol craving and use when prescribed to patients with alcohol abuse or dependence (1). Aripiprazole, a new atypical antipsychotic, has partial dopamine agonist and antagonist effects (2). Since dopamine stimulation in the nucleus accumbens has been suggested to cause addictive behaviour, aripiprazoles partial dopamine agonist effects in this area of the brain may reduce this behaviour (3). We present a case wherein aripiprazole reduced alcohol craving and use. Case Report Mr S is white, aged 39 years, and diagnosed with schizophrenia, paranoid type, according to DSM-IV criteria. He received outpatient psychiatric treatment with psychotherapy and pharmacotherapy (olanzapinc 20 mg daily). He continued to experience delusions of reference and periodic auditory hallucinations. His Brief Psychiatric Rating Scale (BPRS) score was 31. Mr S also met the DSM-IV diagnostic criteria for alcohol dependence, which started at age 18 years with an occasional beer and progressed to his drinking a 12-pack daily. He denied any medical problems, but admitted to problems with employment and relationships caused by his alcohol use. Despite several attempts to quit, including treatment in 2 substance use treatment programs, he relapsed repeatedly. His current use amounted to 6 cans of beer daily. He refused to attend any addiction program, including Alcoholics Anonymous. He also suffered from glaucoma. During treatment, he discovered through the Internet that olanzapine might exacerbate glaucoma, which led him to stop olanzapine on his own. At his next meeting, his psychiatrist discussed several options, including the newer atypical antipsychotic, aripiprazole. Mr S finally agreed to try this medication, which has limited anticholinergic effects and therefore might not worsen glaucoma. Aripiprazole was started at 10 mg initially and increased to 20 mg daily over 2 months. During follow-up, Mr S reported reduced psychotic symptoms (his BPRS score decreased to 23). He stopped daily drinking and reported decreased alcohol craving (his Pennsylvania Craving Scale score decreased from 27 to 5; his Self-Report Likert Craving Scale score decreased from 7 to 3; and his Addiction Severity Index score for alcohol decreased from 6 to 2). His only reported side effect was increased anxiety, which resolved within a week. Discussion Approximately 50% of patients with schizophrenia abuse alcohol and (or) drugs. …

Diagnosis and treatment of alcohol dependence in older alcoholics

Treatment of alcohol dependence among older alcoholic patients should be multidimensional to address as many potential relapse factors as possible. As the literature suggests, alcohol-related disorders often are under diagnosed and under treated. More efforts are needed to identify and improve diagnosis of these disorders in older alcoholic patients. For better outcomes, age-specific programs should be implemented. Furthermore, when treating elderly patients, basic therapeutic principles like respect for privacy and a respectful attitude should be adopted. Adequate medical, pharmacologic, and psychiatric treatment should be provided when appropriate. Medication to reduce cravings should be considered in patients without contraindications to its use. Participation in individual, group, and family therapy and attendance at self-help group meetings such as AA should be encouraged (Table 8). Despite the lack of empiric testing to validate these recommendations in an elderly population, clinical experience suggests that adherence to these recommendations will benefit elderly patients just as it has the general adult population. Research is necessary to explore the benefits of alcohol treatments in elderly patients. Until then, adherence to these recommendations should be the best available approach.

Impact of problem alcohol use on patient behavior and caregiver Burden in a geriatric assessment clinic

There has been a growing interest in understanding issues surrounding alcohol use in late life. Information about the relationship of alcohol use to behavioral problems in older persons living in the community is particularly limited. This study used information obtained from an outpatient geriatric assessment clinic to study this relationship and the effects of these behaviors on caregivers. Data on alcohol use, problem behaviors, and caregiver burden were collected prospectively in consecutive patients undergoing geriatric assessment primarily for cognitive problems over a 3-year period. All patients were evaluated by a multidisciplinary team, which included a geriatric psychiatrist. The evaluation screened for current and/or past alcohol use through interviews with the patient and a collateral source. The collateral source also completed the Neuropsychiatric Inventory and the Family Burden Scale. Subjects were classified into 2 groups: those with a current or past alcohol problem and those with no alcohol problem. A total of 349 patients were evaluated, with 17.8% being designated as having a current or past alcohol problem. This subgroup represented 35% of the men and 9% of the women from the study population. Approximately half of the subgroup was actively drinking alcohol. Patients with a history of problem alcohol use, regardless of current use and cognitive status, exhibited more behavioral disturbances including agitation, irritability, and disinhibition. Their caregivers reported significantly higher caregiver distress. Current or past alcohol problem use was frequent in this population of frail, older adults undergoing geriatric assessment. Regardless of current alcohol use, these patients displayed more behavioral disturbances than those without a history of problem drinking, and their caregivers experienced significantly more burden. A history of problem drinking appears to be a significant marker for behavioral disturbances in late life and merits further study. (J Geriatr Psychiatry Neurol 2007;20:120—127)

Visual Inspection of Medications in Preventing Unexplained Relapses

TO THE EDITOR: Stable psychiatric patients may relapse for various reasons such as treatment noncompliance, breakthrough illness, concomitant bio-psycho-social stressors, progressive worsening of illness, and development of tolerance to medications.1 This may also occur if patients take the wrong medications through errors of prescription, dispensation, or diversion.2 We present 2 cases of medication errors that led to exacerbation of our patients’ illness. Case 1. A 45-year-old white woman had major depression with psychotic features based on Diagnostic and Statistical Manual of Mental Disorders, 4th ed.3 (DSM-IV) criteria. She was maintained on olanzapine 10 mg at bedtime. During routine follow-up, she received a prescription for the same medication. Within a few days, her condition worsened. She was taken to the hospital with increasing paranoia and auditory hallucinations. In the hospital, ongoing through her medications, it was discovered that the bottle labeled olanzapine contained pills inscribed with “Zyrtec 10 mg.” Apparently, the prescription had been filled with Zyrtec (cetirizine) instead of Zyprexa (olanzapine). She was restarted on olanzapine 10 mg, with significant improvement, and was discharged with a new prescription. Case 2. A 47-year-old white woman had generalized anxiety disorder, based on DSM-IV3 criteria. She was treated with paroxetine 30 mg in the morning and clonazepam 0.5 mg at bedtime. During routine follow-up, she reported increasing anxiety and frequent headaches. After considering other etiologies, benzodiazepine tolerance was suspected. She agreed to a tapered dose reduction after the current symptoms subsided. Her clonazepam was increased to 1 mg at bedtime. On follow-up, she described an erratic response to clonazepam, with occasional improvement after half or 1 pill but often no improvement even with ≥2 pills. She brought her pill bottles, and examination of the clonazepam bottle revealed 2 types of similar-looking pills. Some were slightly darker and smaller than others, with different markings. Further investigations identified the darker pills as “baby aspirin,” not clonazepam. Apparently, the patient’s 16-year-old son, who was struggling with alcohol and drug dependence, substituted his mother’s clonazepam with similar-looking pills to support his drug habit, hoping his mother would not notice. Realizing this substitution, the patient resumed her regular dose of clonazepam, with instructions to keep the medications secure. Her son was referred for drug dependence treatment. Discussion. The extent of medication errors in psychiatric populations is not known, but Bedell et al.4 found that, in a cardiovascular patient population, 75% of the prescriptions did not match the information on the charts. Johnson et al.5 reported similar discrepancies in 12% of the cases in a pediatric sample. However, both of these studies did not specify whether these were prescribing or dispensing errors. Estimates of dispensing errors vary. Bates et al.2 reported dispensing errors in 4% of their sample. Peterson et al.6 suggested that dispensing errors are much higher than those reported to regulatory agencies. They suggest that this may happen because of high workload, pharmacist fatigue, and poorly written prescriptions. Cohen7 suggested that medications with similar sounding names are more prone to substitution. One of every 4 medication errors in the US occurs because of name-confusion error.8 Benzodiazepines are frequently used to treat symptoms such as anxiety, insomnia, muscle spasms, epilepsy, and several other disorders. However, they are commonly abused as well. They may be abused by patients who are legitimately prescribed these medications or may be diverted to support another drug addiction or simply for profit.9 Whatever the cause of the medication errors, patients generally experience ill effects and can have a relapse in their illness. In treating relapses, the American Psychiatric Association treatment guidelines10 suggest ensuring compliance, checking medication concentrations, using adjunctive medications, ruling out new bio-psycho-social stressors or substance abuse, and rethinking the diagnosis. However, these guidelines overlook recommending direct visual inspection of medications, which may be the best way to ensure that patients get what is prescribed, especially with sound-alike and look-alike medications, narcotics, or other controlled medications that may be intentionally substituted or diverted. Medication errors are a multidisciplinary problem and a multidisciplinary approach is required for their control. Pharmacy standards should require zero tolerance for errors, but psychiatrists can help ensure further accuracy by familiarizing themselves with appearances of commonly prescribed medications and frequently inspecting these pills to ensure that patients get what is prescribed. They can become familiar with the pills by frequent direct visualization of their patients’ medications or medication samples, using the Physician’s Desk Reference (PDR) photo identification pages, Internet resources from the PDR (www.PDR.net) or pharmaceutical companies’ Web sites, or consultations with the patients’ pharmacists or pharmaceutical representatives.

Sedative hypnotic abuse

Sedatives, or anxiolytics, are drugs that reduce tension and produce a sense of clam. A hypnotic is a drug used to induce …