Massive sertraline overdose.

Selective serotonin reuptake inhibitor medications are considered relatively safe even in overdose. We report a massive overdose of sertraline with the highest serum sertraline concentration reported to date. Clinical features of this patient were confusion, agitation, myoclonus, hyperreflexia, fever, and creatine kinase elevation. This case may represent serotonin syndrome caused by sertraline overdose alone.

Attitudes toward DSM-IV dissociative disorders diagnoses among board-certified American psychiatrists.

OBJECTIVE: The authors assessed the opinions of American psychiatrists regarding the diagnostic status and scientific validity of the DSM-IV categories of dissociative amnesia and dissociative identity disorder. METHOD: A one-page questionnaire was mailed to a random national sample of 367 board-certified American psychiatrists. RESULTS: Three hundred one responses were received-a rate of 82%. Only about one-third of respondents replied that dissociative amnesia and dissociative identity disorder should be included without reservations in DSM-IV; a larger proportion replied that these categories should be included only as proposed diagnoses. Only about one-quarter of respondents felt that diagnoses of dissociative amnesia and dissociative identity disorder were supported by strong evidence of scientific validity. CONCLUSIONS: Among board-certified American psychiatrists, there currently appears to be little consensus regarding the diagnostic status or scientific validity of dissociative amnesia and dissociative identity disorder.

Effect of video self-observation on development of insight in psychotic disorders.

Many patients with psychotic disorders lack awareness of being ill. This often presents a serious impediment to treatment compliance. We hypothesized that exposing partially remitted patients to videotapes of themselves, made while they were acutely psychotic, might increase their insight into the nature of their illness. Eighteen acutely psychotic inpatients were assigned randomly to a control or experimental group and interviewed on videotape 24 to 48 hours after admission, using scales that measure insight (Insight and Treatment Attitudes Questionnaire [ITAQ]) and psychopathology (Brief Psychiatric Rating Scale [BPRS]). One to six weeks later, when judged to be significantly improved, subjects were shown either a videotape of their initial interview (experimental group) or a placebo videotape (control group) and then reinterviewed 24 to 48 hours later on videotape, using the BPRS and ITAQ scales. Evaluation of initial and final ITAQ and BPRS scores revealed significantly greater improvement in insight scores and in delusionality in the experimental group. However, no significant difference in overall psychopathology was seen for the two groups. These results suggest that exposure of hospitalized patients to videotapes of their own psychotic behavior may be a cost-effective therapeutic tool for developing personal insight into psychotic illness.

Questionable validity of 'dissociative amnesia' in trauma victims. Evidence from prospective studies.

BACKGROUND: We reviewed evidence from prospective studies to test whether individuals can develop amnesia for traumatic experiences, a process variously termed 'repression', 'dissociative amnesia' or 'psychogenic amnesia'. METHOD: Using specified criteria, we selected and analysed studies which prospectively assessed memory in victims of documented traumatic experiences. RESULTS: In studies in which people were asked directly about a past traumatic experience, they consistently reported memories. Non-reporting occurred only in studies where subjects were not asked directly about the experience. This latter design leaves open the well-documented possibility that subjects simply did not disclose events that they actually remembered. Some prospective studies were also limited by incomplete documentation of trauma and failure to rule out other more ordinary causes of amnesia. CONCLUSIONS: Prospective data as yet fail to demonstrate that individuals can develop dissociative amnesia for traumatic events.

Combining serotonin reuptake inhibitors and bupropion in partial responders to antidepressant monotherapy.

BACKGROUND: Many patients with affective illness show partial or otherwise unsatisfactory responses to standard treatments, encouraging trials of combinations of pharmacologically dissimilar antidepressants. METHOD: Records of consecutive outpatients with affective disorders only partially responsive to treatment with a serotonin reuptake inhibitor (SRI) or bupropion, alone, were reviewed for changes in specific symptoms and risks of adverse events when an SRI and bupropion were combined. RESULTS: Greater symptomatic improvement was found in 19 (70%) of 27 subjects during a mean +/- SD of 11 +/- 14 months of combined daily use of bupropion (243 +/- 99 mg) with an SRI (31 +/- 16 mg fluoxetine-equivalents) than with either agent alone. Adverse effect risks were similar to those associated with each monotherapy, with a > 10% incidence of sexual dysfunction (N = 11, 41%), insomnia (N = 6, 22%), anergy (N = 4, 15%), and tremor (N = 3, 11%) during combined therapy; there were no seizures. CONCLUSION: With conservative dosing and close monitoring, combinations of SRIs with bupropion in this uncontrolled clinical series appeared to be safe and often more effective than monotherapy.

Treatment of negative symptoms in schizophrenia and schizoaffective disorder by selegiline augmentation of antipsychotic medication. A pilot study examining the role of dopamine.

It has been suggested that schizophrenic negative symptoms may be manifestations of regionally deficient CNS dopaminergic activity. We sought to test this hypothesis by openly treating patients on chronic antipsychotic medication who showed prominent negative symptoms with low-dose selegiline (5 mg b.i.d.), a monoamine oxidase-B inhibitor that selectively enhances dopaminergic activity. Twenty-one patients meeting DSM-III-R criteria for chronic schizophrenia (N = 14) or schizoaffective disorder (N = 7) with prominent negative symptoms were studied. Subjects had been kept at their current antipsychotic and antiparkinsonian medication dose levels for at least a month before the study, which was continued unchanged throughout the trial. Over 6 weeks of selegiline treatment, a 34.7% reduction in negative symptoms was demonstrated on the Scale for the Assessment of Negative Symptoms. There were also reductions in depressive symptoms (21-item Hamilton Depression Scale dropped 36.8%) and extrapyramidal symptoms (Simpson-Angus Extrapyramidal Symptom Scale scores dropped 27.7%), but no change was observed in the severity of positive symptoms as measured by the Brief Psychiatric Rating Scale. Global clinical improvement was demonstrated, with mean Clinical Global Impressions Scale score rising 17.6%. These findings support the hypothesis that negative symptoms, as well as extrapyramidal symptoms and certain depressive symptoms, may be manifestations of regionally deficient dopaminergic activity.

Treatment orientation and associated characteristics of North American academic psychiatrists.

We present data showing the degree to which a "biological-psychotherapeutic" division persists in American psychiatry, and how psychiatrists' treatment orientation is associated with personal and professional characteristics. Almost two thirds of academic psychiatrists who responded to our survey (N = 435) could be classified as either biological (27%) or psychotherapeutic (37%) in orientation, according to the proportion of their caseload to which they provided psychotherapy (< or = 25% vs. > 75%). There appears to have been an increase over the last 35 years in the proportion of psychiatrists who can be classified as biologically oriented and a decrease in the proportion who can be classified as psychotherapeutically oriented, as well as the emergence of a large class of intermediate or "eclectic" practitioners (36%). Several personal and professional attributes were distributed differentially according to treatment orientation. Psychotherapeutically oriented respondents more frequently reported personal histories of psychiatric disorders than did biologically oriented respondents (64% vs. 39%) as well as greater satisfaction with clinical work (81% vs. 53% "very satisfied"). Differences were also found in age, gender, history of personal psychotherapy, family history of psychiatric disorder, history of marijuana use, degrees of involvement in research, teaching and clinical care of patients, and overall work satisfaction, as well as other characteristics.

Buprenorphine treatment of refractory depression.

Opiates were used to treat major depression until the mid-1950s. The advent of opioids with mixed agonist-antagonist or partial agonist activity, with reduced dependence and abuse liabilities, has made possible the reevaluation of opioids for this indication. This is of potential importance for the population of depressed patients who are unresponsive to or intolerant of conventional antidepressant agents. Ten subjects with treatment-refractory, unipolar, nonpsychotic, major depression were treated with the opioid partial agonist buprenorphine in an open-label study. Three subjects were unable to tolerate more than two doses because of side effects including malaise, nausea, and dysphoria. The remaining seven completed 4 to 6 weeks of treatment and as a group showed clinically striking improvement in both subjective and objective measures of depression. Much of this improvement was observed by the end of 1 week of treatment and persisted throughout the trial. Four subjects achieved complete remission of symptoms by the end of the trial (Hamilton Rating Scale for Depression scores < or = 6), two were moderately improved, and one deteriorated. These findings suggest a possible role for buprenorphine in treating refractory depression.

Emerging uses for high-potency benzodiazepines in psychotic disorders.

The author reviews the role of high-frequency benzodiazepines in the treatment of psychosis. Lorazepam and clonazepam are of established value in controlling acute psychotic agitation and catatonia. These agents have also been shown to be helpful in managing neuroleptic-induced akathisia. Recent data strongly support an adjunctive role for alprazolam in the treatment of neuroleptic-resistant symptoms in a subgroup of chronic schizophrenics. Separate, though overlapping, profiles of clinical efficacy are described for the three currently available agents. Alprazolam is suggested to be useful in depressive psychosis and clonazepam in manic psychosis. Lorazepam is suggested to be without specific "mood-normalizing" effects.

Antidepressant drug side effects.

A review of the range of side effects produced by the currently available antidepressants is presented. Frequently encountered adverse effects are emphasized, but some of the more serious rare ones are also considered. Where possible, guidelines for management of these effects are provided, although there are not invariably ways of avoiding them. Some of this discussion is based on a review of the literature; however, a large part of it grows out of the authors' personal experience in prescribing these medications. It is an unfortunate fact that the research literature does not treat these issues thoroughly, despite their great clinical importance.

Clonazepam in the treatment of obsessive compulsive disorder associated with panic disorder in one patient.

The authors present the case of a 21-year-old man with obsessive compulsive disorder (OCD) complicated by panic disorder, whose OCD and panic symptoms resolved during clonazepam treatment. Prior treatment with an equivalent dose of lorazepam had ameliorated his panic attacks without affecting his obsessions or compulsions. Clonazepam worked with a rapidity and completeness uncharacteristic of more established treatments for OCD.