Serotonin syndrome associated with the use of escitalopram

Escitalopram is the newest selective serotonin reuptake inhibitor (SSRI) available for use in the United States. It has been approved for the treatment of major depression and generalized anxiety disorder. It is the S-enantiomer of the SSRI citalopram and is highly serotonin specific as it has minimal effect on the reuptake of dopamine or norepinephrine. It is also a well-tolerated medication, with a side-effect profile comparable to the other SSRIs. While a number of side effects have been seen during escitalopram therapy, such as insomnia, nausea, and increased sweating, there are no reported cases of serotonin syndrome associated with escitalopram therapy to date. We present the case of a 24-year-old woman who developed serotonin syndrome after an increase in her escitalopram to 30 mg/day. We will review the diagnostic criteria of serotonin syndrome and the clinical scenarios in which serotonin syndrome can develop. We will also discuss the proposed treatments and role that polypharmacology may play in the development of this clinical entity.     

Cognitive-behavior therapy for discontinuation of SSRI treatment of panic disorder: a case series

In this report we describe the outcome of eight outpatients with panic disorder and agoraphobia who discontinued their treatment with a selective serotonin reuptake inhibitor (SSRI) in the context of a structured, group program of cognitive-behavior therapy. All patients successfully discontinued their SSRI medication while demonstrating clinical improvement. These results were maintained at 3-month follow-up. This case series suggests that manualized CBT for discontinuation of benzodiazepine treatment for panic disorder may be successfully applied to SSRI discontinuation as well.     

Effect of treatments for depression on quality of life: a meta-analysis*

Cognitive-behavioral therapy (CBT) and selective serotonin reuptake inhibitors (SSRIs) are the two first-line treatments for depression, but little is known about their effects on quality of life (QOL). A meta-analysis was conducted to examine changes in QOL in adults with major depressive disorder who received CBT (24 studies examining 1969 patients) or SSRI treatment (13 studies examining 4286 patients) for their depression. Moderate improvements in QOL from pre to post-treatment were observed in both CBT (Hedges’ g = .63) and SSRI (Hedges’ g = .79) treatments. The effect size remained stable over the course of the follow-up period for CBT. No data were available to examine follow-ups in the SSRI group. QOL effect sizes decreased linearly with publication year, and greater improvements in depression were significantly associated with greater improvements in QOL for CBT, but not for SSRIs. CBT and SSRIs for depression were both associated with moderate improvements in QOL, but are possibly caused by different mechanisms.     

Incremental validity of a measure of emotional intelligence

After the Schutte Self-Report Inventory of Emotional Intelligence (SSRI; Schutte et al., 1998) was found to predict college grade point average, subsequent emotional intelligence (EI)-college adjustment research has used inconsistent measures and widely varying criteria, resulting in confusion about the construct's predictive validity. In this study, we assessed the SSRI's incremental validity for a wide range of adjustment criteria, pitting it against a competing trait measure, the NEO Five-Factor Inventory (NEO-FFI; Costa & McCrae, 1992), and tests of fluid and crystallized intelligence. At a broad bandwidth, the SSRI total score significantly and uniquely predicted variance beyond NEO-FFI domain scores in the UCLA Loneliness Scale, Revised (Russell, Peplau, & Cutrono, 1980) scores. Higher fidelity analyses using previously identified SSRI factors and NEO-FFI item clusters revealed that the SSRI's Optimism/Mood Regulation and Emotion Appraisal factors contributed unique variance to self-reported study habits and social stress, respectively. The potential moderation of incremental validity by gender did not reach significance due to loss of power from splitting the sample, and mediational analyses revealed the SSRI Optimism/Mood Regulation factor was both directly and indirectly related to various criteria. We discuss the small magnitude of incremental validity coefficients and the differential incremental validity of SSRI factor and total scores.     

Hemispheric specialization for emotional word processing is a function of SSRI responsiveness

Vulnerability to depression and non-response to Selective Serotonin Reuptake Inhibitors (SSRIs) are associated with specific neurophysiological characteristics including greater right hemisphere (RH) relative to left hemisphere (LH) activity. The present study investigated the relationship between hemispheric specialization and processing of emotional words using a divided visual field paradigm administered to never-depressed and previously-depressed individuals, who were subdivided into SSRI responders and non-responders. SSRI responders and never-depressed participants were similar in their left hemispheric lateralization for evaluating emotional words. In contrast, SSRI non-responders showed a relative shift towards RH processing of negative words, and a strong bias toward negative evaluation of words presented to the RH. The results are discussed within the context of a biological-cognitive model of vulnerability to depression.     

Implications of naturalistic use of pharmacotherapy in CBT treatment for panic disorder

This study examined naturalistic medication use and cognitive behavioral therapy (CBT) treatment outcomes in 105 patients meeting DSM-IV criteria for panic disorder (PD), assessed by structured clinical interview. The association between pre- and post-treatment use of SSRIs, benzodiazepines (BZs), and any anti-anxiety or anti-depressant (A/D) medication were investigated for three indicators of treatment outcome (PD severity, presence of agoraphobia (AG), anxiety sensitivity) at post-treatment and 6-month follow-up. Controlling for pre-treatment severity, pre-treatment SSRI use was associated with worse outcomes for AG (p=.04) and anxiety sensitivity (p=.047); post-treatment SSRI use was associated with delayed improvements in PD severity (p=.05). Pre-treatment use of A/D was associated with poorer PD severity outcomes (p=.04). Post-treatment use of A/D was associated with higher anxiety sensitivity scores across post-treatment and 6-month follow-up (p=.03). BZ use was not associated with significantly worse outcomes. However, there was a decrease in the number of patients using BZs from pre-treatment to post-treatment (p=.06) and follow-up (p=.006). In conclusion, controlling for pre-treatment severity, pre- and post-treatment use of SSRIs and A/D was associated with poorer outcomes, particularly for PD severity and anxiety sensitivity.     

Hemispheric specialization for emotional word processing is a function of SSRI responsiveness

Vulnerability to depression and non-response to Selective Serotonin Reuptake Inhibitors (SSRIs) are associated with specific neurophysiological characteristics including greater right hemisphere (RH) relative to left hemisphere (LH) activity. The present study investigated the relationship between hemispheric specialization and processing of emotional words using a divided visual field paradigm administered to never-depressed and previously-depressed individuals, who were subdivided into SSRI responders and non-responders. SSRI responders and never-depressed participants were similar in their left hemispheric lateralization for evaluating emotional words. In contrast, SSRI non-responders showed a relative shift towards RH processing of negative words, and a strong bias toward negative evaluation of words presented to the RH. The results are discussed within the context of a biological–cognitive model of vulnerability to depression.     

Development of an inventory of teachers' attitudes towards sex-role stereotyping and knowledge of sex differences

The Scott Sex-Role Inventory (SSRI) is a 37-item questionnaire of teachers' knowledge of sex differences and attitudes toward sex-role stereotyping. Norms, reliability, and validity were developed on a suburban southeastern school system. Responses of male and female teachers were comparable on both sections of the test. The SSRI offers an index of teachers' knowledge and attitudes toward sex roles which may help to assess (1) needs for attitude change and (2) the effectiveness of intervention programs.     

Serotonin syndrome in elderly patients treated for psychotic depression with atypical antipsychotics and antidepressants: two case reports

We report two cases of serotonin syndrome in elderly patients during treatment of psychotic depression with atypical antipsychotics and antidepressants. The first case is a 69-year-old man who was admitted for depression with psychosis and treated with trazodone, risperidone, and sertraline. Subsequently, he developed myoclonus, tremor, cogwheel rigidity, and diaphoresis. The second case is a 72-year-old female initially admitted to a medical inpatient unit for a change in mental status that presented as increased confusion, lethargy, slurred speech, and a fever of 101.5 degrees. She had been on phenelzine and quetiapine. In both cases, all symptoms resolved within 24 hours of the psychotropics being stopped. In both cases, we believe that serotonin syndrome was produced by a combination of an antidepressant and an atypical antipsychotic. There have been several case reports of serotonin syndrome from similar combinations of antidepressant and atypical antipsychotic treatment. Clinicians treating elderly patients with a combination of serotonergic antidepressants and atypical antipsychotics for psychotic depression should be aware of the potential for serotonin syndrome.     

Effects of trazodone on sleep in patients diagnosed with post-traumatic stress disorder (PTSD)

Trauma victims frequently report nightmares with experiences of reliving the stressful event in catastrophic dreams. The following day there are exaggerated startle responses and psychic numbing, followed that evening by a reluctance to go to sleep and insomnia. This study found trazodone to be effective in veteran patients with a diagnosis or symptoms of PTSD including sleep disturbance. Among this group of veterans, 20 of the 21 under 60 and 24 out of 27 over 60 had positive responses to bedtime trazodone doses, in that they slept better, including going to sleep more quickly, having fewer nightmares,and had less anger the next day. These benefits may be due to deepened non-REM sleep early in the night as well as delayed REM-sleep onset.     

Moderne Antidepressivatherapie

In den letzten drei Jahrzehnten ist es, mit der Entwicklung der so genannten selektiven Serotonin-Wiederaufnahmehemmer (SSRI), zu einer Revolution in der Behandlung der Depression gekommen. Mit dieser Produktgruppe war es erstmals m?glich, depressive Erkrankungen mittels einfacher Strategien (1 × 1 Dosierung) bei hoher Effektivit?t durchzuführen. So haben die Antidepressiva einen Siegeszug um die Welt angetreten und geh?ren heute zu den am h?ufigsten verschriebenen Medikamenten überhaupt. Gerade dadurch wurde eine neue ?ra moderner, antidepressiver Pharmakotherapie eingeleitet. Einer der wesentlichen Effekte dürfte darin liegen, dass in den industrialisierten Staaten seit der Einführung der SSRI die Suizidraten rückl?ufig sind - was eine sensationelle Entwicklung moderner Behandlungsstrategien in der Psychiatrie reflektiert.     

Influence of adjuvant mindfulness-based cognitive therapy (MBCT) on symptoms of post-traumatic stress disorder (PTSD) in veterans – results from a randomized control study

Even 30 or more years after the end of a war, veterans can suffer from post-traumatic stress disorder (PTSD). In the present study, we explored the influence on symptoms of PTSD among Iranian veterans of the Iran–Iraq war of mindfulness-based cognitive therapy (MBCT) as add-on to a standard treatment with citalopram. Forty-eight male veterans with PTSD (mean age: 52.97 years) took part in this eight-week intervention study. Standard treatment for all patients consisted of citalopram (30–50 mg/day at therapeutic dosages). Patients were randomly assigned either to the treatment or to the control condition. Treatment involved MBCT delivered in group sessions once a week. Patients in the control condition met at the hospital with the same frequency and duration for socio-therapeutic events. At baseline and at study completion, patients completed questionnaires covering symptoms of PTSD, depression, anxiety, and stress. At study completion after eight weeks, scores for PTSD (re-experiencing events, avoidance, negative mood and cognition, hyperarousal), depression, anxiety, and stress were lower, but more so in the intervention than the control group. Data suggest that, as adjuvant to standard SSRI medication, MBCT is an effective intervention to significantly reduce symptoms of PTSD, depression, anxiety, and stress among veterans.     

Cardiac Disorders and Antidepressant Medications

Tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs) have been associated with an increase in cardiovascular disorders, especially in depressed patients who have pre-existing cardiac disease. These disorders are less likely to occur when a therapeutic dosage is administered. Injuries because of falls are more likely in elderly depressed patients, and orthostatic hypotension occurs with the use of TCAs. Selective serotonin reuptake inhibitor (SSRI) antidepressants differ structurally and in side effects from TCAs and MAOIs. They appear to be effective for treatment of depression, and their side-effect profiles appear safer than those of earlier approved antidepressants used by depressed patients with cardiovascular disorders.     

Cardiac disorders and antidepressant medications

Tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs) have been associated with an increase in cardiovascular disorders, especially in depressed patients who have pre-existing cardiac disease. These disorders are less likely to occur when a therapeutic dosage is administered. Injuries because of falls are more likely in elderly depressed patients, and orthostatic hypotension occurs with the use of TCAs. Selective serotonin reuptake inhibitor (SSRI) antidepressants differ structurally and in side effects from TCAs and MAOIs. They appear to be effective for treatment of depression, and their side-effect profiles appear safer than those of earlier approved antidepressants used by depressed patients with cardiovascular disorders.     

Increased brain serotonin turnover in panic disorder patients in the absence of a panic attack: reduction by a selective serotonin reuptake inhibitor

Since the brain neurotransmitter changes characterising panic disorder remain uncertain, we quantified brain noradrenaline and serotonin turnover in patients with panic disorder, in the absence of a panic attack. Thirty-four untreated patients with panic disorder and 24 matched healthy volunteers were studied. A novel method utilising internal jugular venous sampling, with thermodilution measurement of jugular blood flow, was used to directly quantify brain monoamine turnover, by measuring the overflow of noradrenaline and serotonin metabolites from the brain. Radiographic depiction of brain venous sinuses allowed differential venous sampling from cortical and subcortical regions. The relation of brain serotonin turnover to serotonin transporter genotype and panic disorder severity were evaluated, and the influence of an SSRI drug, citalopram, on serotonin turnover investigated. Brain noradrenaline turnover in panic disorder patients was similar to that in healthy subjects. In contrast, brain serotonin turnover, estimated from jugular venous overflow of the metabolite, 5-hydroxyindole acetic acid, was increased approximately 4-fold in subcortical brain regions and in the cerebral cortex (P < 0.01). Serotonin turnover was highest in patients with the most severe disease, was unrelated to serotonin transporter genotype, and was reduced by citalopram (P < 0.01). Normal brain noradrenaline turnover in panic disorder patients argues against primary importance of the locus coeruleus in this condition. The marked increase in serotonin turnover, in the absence of a panic attack, possibly represents an important underlying neurotransmitter substrate for the disorder, although this point remains uncertain. Support for this interpretation comes from the direct relationship which existed between serotonin turnover and illness severity, and the finding that SSRI administration reduced serotonin turnover. Serotonin transporter genotyping suggested that increased whole brain serotonin turnover most likely derived not from impaired serotonin reuptake, but from increased firing in serotonergic midbrain raphe neurons projecting to both subcortical brain regions and the cerebral cortex.     

Beyond the family; using network meetings with statutory child care cases

This article describes and discusses the use of network meetings in child care cases. It draws on the literature of network therapy and family therapy and adapts it to a new setting. It describes two cases in detail and raises questions about the limitations of family therapy to the development of systemic thinking. It also includes a practical guide to the use of network meetings.     

患者异常心理致阴茎尿道异物伤诊治体会

分析各种类型阴茎尿道异物伤的治疗原则及治疗方法,并结合病例就非正常酊慰相关心理因素问题进行探讨。回顾性分析11例不同类型阴茎尿道异物伤患者临床资料,其中阴茎异物嵌顿伤7例,尿道异物伤3例,阴茎内异物植入1例。11例均成功取出异物,随访无明显异常。不同类型阴茎尿道异物伤通过选择适当的治疗方法,大多可获得满意的结果。此类阴茎尿道异物伤属非正常自慰行为,患者大多伴有心理障碍,术后需要进行必要的心理疏导。     

发热伴阵发性呼吸困难——感染继发肺栓塞4例临床治疗观察并文献复习

为总结感染继发肺栓塞的临床特点和处理,回顾性分析4例感染继发肺栓塞患者的诊治经过。结果4例患者在强力有效抗感染治疗基础上溶栓并序贯抗凝治疗后均获得康复。提示有明确肺梗塞病灶及明显低氧血症存在的感染继发肺栓塞患者,在充分抗感染治疗基础上进行抗凝治疗的同时,必要时可以慎重溶栓治疗。     

Brief therapy in the Israeli kibbutz

Analysis of results of therapy in an unselected sample of 211 kibbutz patients seen over a three year period by the author in his capacity as kibbutz member and psychiatrist indicated that over 70% of the identified patients responded very satisfactorily to brief therapy. About one-third of the clients did not need more than a single comprehensive therapy session to achieve continuous improvement. In a minority of the cases more than 10 sessions were required. The results were significantly better in cases treated by brief therapy than in the sample treated by long-term therapy, where the pre-treatment severity was determined to be greater. The paper describes the unique aspects of brief therapy in the kibbutz setting, giving an outline of the author's model of intervention, using all components of the individual, family, and community ecosystem.     

Management der Parkinson-Demenz und Demenz mit Lewy-Körperchen

Idiopathisches Parkinson-Syndrom mit Demenz (PDD) und Demenz mit Lewy-K?rperchen (DLB) sind partiell unterschiedliche Manifestationen des Spektrums der Lewy-K?rperchen- und Alzheimer-Erkrankungen. Die Kombination von motorischer Parkinsonsymptomatik mit Demenz, affektiven St?rungen (Depression, Angst), Verhaltensst?rungen (wie REM-Sleep Behaviour Disorder) und psychotischen Episoden (Halluzinationen, Wahn, Delir) neben einer Reihe vegetativer Symptome und zunehmendem Nebenwirkungsrisiko erfordern eine ma?geschneiderte, sorgf?ltige, kombinierte Pharmakotherapie (L-Dopa mit Decarboxylasehemmer, gegebenenfalls Entacapone oder Tolcapone, neuere Antidepressiva wie SSRI, NaSSA, SNRI, Clozapin, Clonazepam, Therapie vegetativer St?rungen) und engmaschige klinische Kontrollen.