Alprazolam-induced dose-dependent anorgasmia: case analysis.

BACKGROUND: Sexual dysfunctions are associated with multiple medical and psychiatric disorders, as well as pharmacotherapies used to treat these disorders. Although sexual dysfunctions negatively affect both quality of life and treatment adherence, patients infrequently volunteer these symptoms and clinicians do not pose directed questions to determine their presence or severity. This issue is especially important in psychiatric patients, for whom most common psychotropics may cause sexual dysfunctions (antidepressants, antipsychotics, anxiolytics and mood-stabilising agents). There is limited literature addressing benzodiazepines, and alprazolam in particular. AIMS: To report dose-dependent alprazolam anorgasmia. METHOD: Case analysis with PubMed literature review. RESULTS: A 30-year-old male psychiatric patient presented with new-onset anorgasmia in the context of asymptomatic generalised anxiety disorder, social anxiety, panic disorder with agoraphobia, obsessive-compulsive disorder, major depression in remission, and attention-deficit hyperactivity disorder treated with escitalopram 10 mg q.a.m., gabapentin 1000 mg total daily dose, lisdexamfetamine dimesylate 70 mg q.a.m., nortriptyline 60 mg q.h.s. and alprazolam extended-release 2.5 mg total daily dose. All psychotropic doses had been constant for >6 months excluding alprazolam, which was titrated from 1 mg to 2.5 mg total daily dose. The patient denied any sexual dysfunction with alprazolam at 1 mg q.d. and 1 mg b.i.d. Within 1 week of increasing alprazolam to 2.5 mg total daily dose, the patient reported anorgasmia. Anorgasmia was alprazolam dose-dependent, as anorgasmia resolved with reduced weekend dosing (1 mg b.i.d. Saturday/1.5 mg total daily dose Sunday). CONCLUSIONS: Sexual dysfunction is an important adverse effect negatively influencing therapeutic outcome. This case reports alprazolam-induced dose-dependent anorgasmia. Clinicians/patients should be aware of this adverse effect. Routine sexual histories are indicated. DECLARATION OF INTEREST: None.

Bipolar disorder, comorbid anxiety disorders, gynecomastia and dental pain: case analysis with literature review.

Bipolar disorder with comorbid anxiety disorders frequently requires rational polypharmacy, including use of serotonergic psychotropics. These may result in adverse effects, influencing adherence, complicating treatment and confounding diagnoses. Serotonergic non-adherence is associated with discontinuation syndromes. In this complex case with an on/off/on/off design, both dose-dependent buspirone-induced gynecomastia and buspirone discontinuation syndrome with dental pain are reported. Clinicians and patients should consider these findings to maximise treatment adherence, minimise any unnecessary interventions and address unusual adverse effects. Since patients may not voluntarily disclose specific adverse effects and often do not acknowledge non-adherence, clinician-directed questions are required. This case further emphasises the importance of medication and symptom timelines to guide determination of causation for adverse effects. Although findings from this case cannot be generalised, they suggest the need for continued clinician and patient education, as well as the benefit from detailed case reports. DECLARATION OF INTEREST: None.

Trastornos de bipolares y comorbilidades - consideraciones éticas en deportes / Bipolar disorders and comorbid conditions - Ethical considerations in sports

Introducción: El objetivo de la intervención farmacológica es el resultado terapéutico: máxima eficacia con mínimos efectos adversos. Esto resulta difícil a la hora de tratar el trastorno bipolar, debido a las comorbilidades y/o fármacos complementarios necesarios para abordar los efectos adversos. La polifarmacia racional óptima puede maximizar el resultado terapéutico, aunque podría crear cuestiones éticas en los deportes competitivos. El Código Mundial Antidopaje (WADC) y la Lista de Sustancias Prohibidas de la Agencia Mundial Antidopaje, publicada anualmente, tienen como objetivo disuadir y sancionar a los atletas que utilicen agentes para mejorar el rendimiento, y promover un marco de igualdad para todos los competidores. Este documento presenta tres ejemplos hipotéticos (TDAH/temblor secundario al litio/dolor) en los que la contravención no deliberada de la Lista de Sustancias Prohibidas derivaría en descalificación por violación de la norma antidopaje sin aprobación de las Exenciones por Uso Terapéutico (TUEs). Método: Análisis de caso hipotético con revisión de la literatura. Resultados: TDAH Comórbido: la Lista de Sustancias Prohibidas excluye los psicoestimulantes (metilfenidato/anfetaminas) en la competición (S6) pero permite guanfacina/atomoxetina. En los casos en que los psicoestimulantes constituyeran un tratamiento eficaz para el TDAH en los atletas con trastorno bipolar, a diferencia de guanfacina/atomoxetina, estos pacientes-atletas deberán presentar TUEs, junto con la certificación y documentación de respaldo del clínico. Temblor secundario al Litio: a menudo se prescriben beta-bloqueantes para controlar el temblor secundario al litio, pero que no están autorizados para deportes específicos (P2). En caso de que los fármacos alternativos (primidona) resulten ineficaces, serán necesarias las TUEs. Dolor: el manejo del dolor crónico es difícil en atletas, ya que los analgésicos narcóticos (S7) y cannabinoides (S8) están prohibidos en la competición. Cuando el dolor comórbido no se controla con fármacos autorizados, son necesarias las TUEs. Conclusión: Los pacientes-atletas con trastorno bipolar y comorbilidades precisan enfoques holísticos, con reconocimiento tanto del WADC como de la Lista de Sustancias Prohibidas. Los atletas deberían realizar un listado de todos los fármacos incluyendo diagnósticos/obtener TUEs/verificar el estado de la medicación propuesta (prohibido/restringido/permitido) con las Federaciones Internacionales adecuadas y/u Organizaciones Olímpicas. Los clínicos deberán ser conocedores de estas cuestiones a la hora de tratar a los pacientes-atletas

Introduction: The goal of pharmacologic intervention is therapeutic outcome: maximal efficacy with minimal adverse effects. In treating bipolar disorder, this may be complicated by comorbidities and/or adjunctive medications required to address adverse effects. Optimal rational polypharmacy may maximize therapeutic outcome yet could create ethical issues in competitive sports. The World Anti-Doping Code (WADC) and yearly published World Anti-Doping Agency Prohibited List are intended to deter and sanction athletes using performance-enhancing agents while promoting an even playing field for all competitors. This paper presents three hypothetical examples (ADHD/lithium-tremor/pain) wherein unintended Prohibited List contravention would result in doping violation disqualifications without approved Therapeutic Use Exemptions (TUEs). Method: Hypothetical case analyses with literature review. Results: Comorbid ADHD: the Prohibited List precludes psychostimulants (methylphenidate/amphetamines) in competition (S6) but permits guanfacine/atomoxetine. When psychostimulants effectively treat ADHD in athletes with bipolar disorder but guanfacine/atomoxetine do not, these patient-athletes, with clinician’s certification and supportive documentation, should file TUEs. Lithium-tremor: beta-blockers are frequently prescribed to control lithium-tremor but are not permitted for specific sports (P2). If alternatives (primidone) are ineffective, TUEs are indicated. Pain: chronic pain management is difficult in athletes as narcotic analgesics (S7) and cannabinoids (S8) are prohibited in competition. When comorbid pain is not controlled with approved medications, TUEs are required. Conclusion: Patient-athletes with bipolar disorder and comorbidities require holistic approaches with appreciation of both the WADC and Prohibited List. Athletes should list all medications with diagnoses/obtain TUEs/verify proposed medication status (banned/restricted/permitted) with appropriate International Federations and/or Olympic organizations. Clinicians should be cognizant of these issues when treating patient-athletes

Attention-deficit/hyperactivity disorder treatment: what are the long-term cardiovascular risks?

INTRODUCTION: This drug safety review provides an update on the long-term cardiovascular risks of therapeutic stimulant class medication for children and adults with attention-deficit/hyperactivity disorder (ADHD). AREAS COVERED: Relevant literature on the long-term (defined as ≥ 12 months) cardiovascular effects of stimulant class medications for ADHD was sought using PubMed searches for clinical literature, epidemiological reports, as well as reviews of post-marketing data and clinical guidelines/consensus statements. Comparison was made to the non-stimulant atomoxetine. EXPERT OPINION: Long-term cardiovascular risks of stimulants for healthy children and adults with ADHD are limited to minor mean elevations in blood pressure (≤ 7 mmHg) and heart rate (≤ 10 bpm). In a sizeable minority of individuals these elevations are greater and/or reach a clinical threshold. Subjective complaints may also be anticipated during long-term treatment, yet without an increase in serious cardiac outcomes above background rates per age. Future research is needed on possible latent or cumulative cardiovascular risks in healthy individuals, as well as the longer-term cardiovascular safety in vulnerable populations.

Validation of a measure of alliance for an adolescent inpatient setting.

UNLABELLED: The link between alliance and treatment outcome is robust. Nevertheless, few, if any, self-report measures exist to assess the alliance between hospitalized adolescents and their treatment team as a whole. The present study looks to extend the use of a brief self-report measure of inpatient treatment alliance designed for adult inpatients to be used with adolescents. The scale is designed incorporating items that tap the three factors of alliance (bond, goals and collaboration) to assess the alliance that the patient has with his or her treatment team. Our results show that the Inpatient-Treatment Alliance Scale is unifactoral, shows good psychometrics and is linked in theoretically meaningful ways to global clinician ratings of engagement in individual psychotherapy. KEY PRACTITIONER MESSAGE: Inpatient treatment of adolescents requires the assessment of alliance to be between the patient and his or her treatment team rather than an individual clinician. Assessment of the alliance can benefit clinicians treating hospitalized adolescents especially because these patients are difficult to engage with in treatment. This study shows that the Inpatient-Treatment Alliance Scale is a promising measure for assessing treatment alliance on an adolescent inpatient setting.

Construct validity of the Schwartz Outcome Scale: validation using a 28-day inpatient chemical rehabilitation patient sample.

The Schwartz Outcome Scale-10 (SOS-10) is a 10-item self-report that measures quality of life and psychological well-being. It is easy to administer and score, and past research has revealed its utility, validity, and reliability with different samples (i.e., clinical and nonclinical) and in different clinical settings (i.e., inpatient, outpatient, nonpsychiatry medical settings). The present study looks to investigate the utility of the SOS-10 in measuring psychological well-being and quality of life with the 28-day inpatient chemical dependency sample. In addition, the current study looks to investigate its ability to be used as a treatment outcome measure for chemical-dependent inpatients. The results revealed that the SOS-10 was associated with aspects of interpersonal dependency and alexithymia in predicted ways. The SOS-10 was positively associated to "Healthy Dependence" and negatively related to alexithymia and "Destructive Overdependence" and "Dysfunctional Detachment." The results also showed that the SOS-10 showed healthy change from admission to discharge and that this change was paralleled by healthy change in interpersonal dependency and alexithymia.