Successful management of prolonged gamma-hydroxybutyrate and alcohol withdrawal.

A 27-year-old man was admitted with tremulousness, diaphoresis, tachypnea (28 breaths/min), full-body rigidity, irritability, paranoia, and auditory and visual hallucinations 2 days after stopping long-term gamma-hydroxybutyrate (GHB) and 8 hours after stopping alcohol intake. He received intravenous fluids and tapering dosages of lorazepam to control agitation and rigidity, and recovered with no significant sequelae after 8 days. Abrupt cessation of GHB after high-dosage abuse can precipitate a clinically significant withdrawal syndrome. Lorazepam should be considered for treatment of GHB withdrawal. Concomitant alcohol abuse may mask early GHB withdrawal symptoms and exacerbate withdrawal.

Consumer use of St. John's wort: a survey on effectiveness, safety, and tolerability.

Despite its poorly described pharmacology, effectiveness, and safety, use of St. John's wort (SJW) is largely unsupervised and unexplored, and can potentially lead to adverse outcomes. We conducted a telephone survey of 43 subjects who had taken SJW to assess demographics, psychiatric and medical conditions, dosage, duration of use, reason for use, side effects, concomitant drugs, professional consultation, effectiveness, relapse, and withdrawal effects. Most subjects reported taking SJW for depression, and 74% did not seek medical advice. Mean dosage was 475.6+/-360 mg/day (range 300-1200 mg/day) and mean duration of therapy was 7.3+/-10.1 weeks (range 1 day-5 yrs). Among 36 (84%) reporting improvement, 18 (50%) had a psychiatric diagnosis. Twenty (47%) reported side effects, resulting in discontinuation in five (12%) and one emergency room visit. Two consumers experienced symptoms of serotonin syndrome and three reported food-drug interactions. Thirteen consumers experienced withdrawal symptoms and two had a depressive relapse. These data suggest the need for greater consumer and provider awareness of the potential risks of SJW in self-care of depression and related syndromes.

Antidepressant overdoses and resultant emergency department services: the impact of SSRIs.

Suicide is a major source of morbidity and mortality in patients with mental illness. The selective serotonin reuptake inhibitors (SSRIs) and other newer nontricyclic antidepressants appear to have less clinically significant toxicity in overdose, resulting in lower costs of treatment when compared with tricyclic antidepressant (TCA) overdoses. The resource utilization and cost of treatment for SSRI overdoses may not be less if (1) these agents are commonly ingested with other potentially toxic substances, or (2) health care practices have not changed in response to the apparent greater safety of SSRIs. This study evaluates demographic variables of antidepressant overdoses to determine whether differences exist in treatments and monitoring. Additionally, this study evaluates costs associated with care and the impact of co-ingestants on those same factors.

Longitudinal analysis of abnormal involuntary movements in long-term clozapine-treated patients.

As part of a prospective efficacy and safety monitoring system, patients receiving clozapine are assessed monthly for dyskinetic events (DE), using the Abnormal involuntary Movement Scale (AIMS). Longitudinal analysis of 45 patients revealed 20 with baseline DE, 7 who developed emergent DE after a negative baseline assessment, and 18 patients with no DE symptoms throughout treatment with clozapine. Eight of the 20 patients with baseline DE were assessed to resolution of symptoms, with an average time of 261 +/- 188 days; 5 were evaluated until complete resolution of symptoms (AIMS = 0), with an average time of 691 +/- 462 days. The average time to onset of DE in emergent DE patients was 238 +/- 179 days, and the average time to resolution was 347 +/- 179 days after diagnosis. Four patients attained complete resolution with an average time of 629 +/- 293 days after diagnosis. It appears this emergent type of dyskinesia is different from other currently described dyskinesias. Overall, of the 27 patients having DE at any point in treatment, 15 of 27 (56%) had resolution of symptoms and 10 of 27 (37%) had complete resolution of DE. Clinicians should be aware of the utility of clozapine in dyskinesia and the extended time frame of response.

Preliminary comparison of predictive and empiric lithium dosing: impact on patient outcome.

OBJECTIVE: To evaluate whether initiating lithium with predictive dosing compared with empiric dosing improves outcome in patients with manic symptoms. DESIGN: The study was a randomized, single-blind design and used the Modified Slattery predictive method. SETTING AND PARTICIPANTS: Eighteen inpatients at an urban psychiatric hospital with a Mania Rating Scale (MRS) score greater than or equal to 24 were enrolled. OUTCOME MEASURES: The study endpoint was defined as an MRS rating less than or equal to 14 or discharge from the hospital. Assessments (MRS, Brief Psychiatric Rating Scale, Clinical Global Impression, Systematic Assessment for Treatment of Emergent Events Scale, quality of life measures) were completed at baseline, on days 3 or 4 and 7 or 8, and weekly thereafter. RESULTS: The predictive group achieved a therapeutic concentration significantly sooner than did the empiric group (p = 0.004); however, the mean serum lithium concentration at discharge did not differ between the groups. The predictive group was taking significantly higher dosages of antipsychotics in chlorpromazine equivalents on day 3 or 4 (p = 0.05). Significantly fewer gastrointestinal/genitourinary adverse effects on day 3 or 4 were reported by patients in the predictive group (p = 0.04). No difference was found between groups with any rating scale or other pharmacokinetic or medication item. Even though the difference did not meet statistical significance, the predictive group's length of stay in the acute unit was three days shorter than that of the empiric group, which may represent significant cost savings. CONCLUSIONS: The preliminary data do not suggest that patient outcome is improved by using Modified Slattery predictive dosing; however, the suggestion of a shorter length of stay in a restrictive unit merits further evaluation.

Profile of a sample of subjects admitted to an acute care psychiatric facility with manic symptoms.

A prospective survey was conducted on 155 consecutive subjects with manic symptoms admitted to an inpatient psychiatric facility to identify possible reasons for rehospitalization. Approximately one third were previously hospitalized at the same facility within the past month. Over half (57%) of the sample were admitted because of aggressive episodes. On admission, 80 percent were receiving carbamazepine or lithium for a mood disorder, and 52.3 percent were receiving multiple medications, of which antipsychotics accounted for over half. Forty-four percent of the sample had comorbid substance use on admission, with marijuana and stimulants accounting for the majority of illicit drug use. Medication noncompliance in 64 percent, and identifiable psychosocial stressors in 55 percent, were also likely contributors to rehospitalization. The data highlights specific treatment issues in the care of patients with a manic component to their illness, and suggests the need for individualized discharge planning with careful followup and continual patient education to assist in the transition from inpatient to society.

A longitudinal analysis of factors associated with morbidity in cocaine abusers with psychiatric illness.

We conducted a study to characterize a population of cocaine users who were referred to a state psychiatric institution, identify treatment problems including reasons for relapse, and develop strategies to improve treatment outcome. Using a data base system from a tertiary-care hospital emergency department, we identified a sample of 80 patients with a cocaine-related presentation who came to the emergency department and were referred to the psychiatric facility. Forty-six percent had consumed crack cocaine, and 65% reported ingesting cocaine with other drugs, half of them with alcohol. Suicidal ideation or attempt was the most common reason for referral. A retrospective review of 58 of the 80 referrals to the psychiatric facility showed that over half of the patients were given a concurrent psychiatric diagnosis and required hospitalization on an acute-care psychiatric unit. Sixty-two percent of those admitted had prior hospitalizations at the psychiatric facility, yet only five patients had received treatment for substance abuse. Seventy-four percent were readmitted to the psychiatric facility within 1 year of their index episode, with a higher rate of relapse among persons with dual diagnoses compared to cocaine users without dual diagnoses (p less than 0.05). Possible reasons for relapse included lack of referral for substance abuse treatment, nonintegrated treatment of psychiatric illness and substance abuse, lack of psychosocial support, and unresolved financial or job-related stressors. The data support increased funding to facilities that treat persons with dual diagnoses, and suggest the need to develop comprehensive treatment approaches involving a multidisciplinary team to address issues of mental illness and substance abuse concomitantly, and to identify and resolve stressors leading to relapse.

Differentiation of cocaine toxicity: role of the toxicology drug screen.

Fifteen cases of presumed cocaine intoxication were evaluated in the emergency room (ER) at a city hospital over a four-day period. This series is unique in that many of these patients were from a similar area of the city, in some cases had the same street address, were regular abusers of cocaine, and presented to the ER with similar symptoms of tachycardia, dilated pupils, marked confusion, bizarre and sometimes violent behavior, psychosis, and hallucinations. Many of these symptoms were present several hours after drug use. Samples of a white powder presumed by the patients to be cocaine were obtained from two patients and analyzed by gas-liquid chromatography. Neither sample contained cocaine, but rather revealed atropine, benzocaine, and procaine. The signs and symptoms of cocaine, amphetamine, and atropine intoxication are reviewed and the problems of drug analysis and differential diagnosis of drug intoxication are discussed.

Neuroleptic rechallenge after neuroleptic malignant syndrome: case report and literature review.

Neuroleptic malignant syndrome (NMS) is associated with essentially all of the currently available antipsychotic agents. The signs and symptoms associated with the syndrome are hyperpyrexia, defined by body temperature greater than 38 degrees C; extreme muscle rigidity, with or without elevated creatine phosphokinase or hyperreflexia; and other symptoms such as altered level of consciousness and/or autonomic dysfunction as manifested by labile blood pressure, tachycardia, tachypnea, urinary or fecal incontinence, pallor, or diaphoresis. This potentially fatal syndrome complicates the treatment of patients with recurrent psychotic symptoms because of the possibility for recurrence of the NMS. A case of recurrent NMS is presented in which the patient was rechallenged with an antipsychotic agent. In addition, 41 reported cases of antipsychotic rechallenge after NMS are reviewed. The results of the review suggest that neuroleptic rechallenge following NMS is associated with an acceptable risk of recurrence in most patients. However, close monitoring for NMS and careful selection of patients for antipsychotic rechallenge is mandatory. A minimal time period of five days before rechallenge may also reduce the risk of recurrent NMS. Recurrence was not associated with patient age or gender, nor the antipsychotic agent used.

Fluoxetine: a serotonin-specific, second-generation antidepressant.

Fluoxetine is a bicyclic antidepressant that is a specific and potent inhibitor of the presynaptic reuptake of serotonin. It has essentially no effect on the reuptake of norepinephrine or other neurotransmitters. Similarly, it has negligible binding affinity for neurotransmitter receptor sites. It is well absorbed after oral administration, with absolute bioavailability in dogs of approximately 72 +/- 27.6%. The mean Tmax is between 4 and 8 hours, and it is approximately 94% protein bound. After a single dose, the elimination half-life is 1-3 days. After long-term administration, the elimination half-life averages 4 days. Its pharmacokinetics appear nonlinear. It is metabolized to an active metabolite norfluoxetine, which is also specific for the inhibition of serotonin reuptake. Norfluoxetine's elimination half-life averaged 7 days after long-term administration. Little is known about potential drug interactions; however, fluoxetine appears to have minimal clinically relevant interactions. Fluoxetine is indicated in the treatment of major depression. Its efficacy is comparable to the tricyclics and it has a similar onset of action. Although doses as high as 80 mg/day have been used, the optimal dosage range appears to be 20-40 mg once daily. Fluoxetine has been used with success in obsessive-compulsive disorder and intention myoclonus, however, its use in these disorders remains investigational. The frequency of side effects is low and dose related; the most common effects are nausea, anxiety, insomnia, anorexia, diarrhea, nervousness, and headache. Eight reports of intentional overdose with fluoxetine alone resulted in no deaths and mild adverse effects. It will be marketed as 20-mg capsules under the brand name of Prozac. Although fluoxetine should be added to formularies, its use should be reserved for treatment of those who do not respond to or do not tolerate tricyclic agents.