Journal of Psychiatric Practice最新文献

This column reviews 4 psychiatric combination products: Contrave (bupropion + naltrexone), Lybalvi (olanzapine + samidorphan), Auvelity (dextromethorphan + bupropion), and Cobenfy (xanomeline + trospium). All have been approved in the last 11 years. These medications are all based on planned and therapeutic drug interactions involving pharmacokinetics and/or pharmacodynamics. In each case, the second drug in the combination enhances the efficacy and/or reduces the adverse effects of the first drug. This review illustrates how basic science in pharmacokinetics and brain circuitry was fundamental to the development of these products, particularly in the case of Contrave and Cobenfy.

Objective: Women with bipolar disorder are at higher risk of complications during pregnancy, which may be associated with risky behaviors by the mother during acute episodes, as well as pharmacotherapy's inherent risks to mother and/or infant. The goal of this narrative review is to discuss the treatment of bipolar disorder during pregnancy and breastfeeding.

Methods: A literature search was conducted between October 2023 and July 2024 using the PubMed database, with MeSH terms "bipolar disorder" and "pregnancy" combined with the Boolean operator "AND." Publications from 2014 to 2024 were considered, resulting in the identification of 573 articles. After titles were reviewed, 84 papers were selected for full-text review, 33 of which were included in the study.

Results: Cardiopathies associated with lithium use during pregnancy in infants were reported in the 1970s, but more recent case-control and cohort studies have shown that this risk is much lower than was previously reported. However, maintaining lithium levels during pregnancy can be challenging due to physiological adaptations in renal function. Valproate exposure has been found to be associated with increased risk of neural tube defects, craniofacial, cardiac, genital, and musculoskeletal abnormalities in infants. There does not appear to be an increased risk of malformations associated with lamotrigine, and results of studies diverge concerning carbamazepine and oxcarbazepine. No statistically significant association has been reported concerning the risk of congenital malformations and prenatal exposure to antipsychotics as a group, as well as for the subgroup of atypical antipsychotics. However, it is possible that risperidone slightly increases the risk of cardiac malformations. Electroconvulsive therapy during pregnancy appears to be a relatively safe treatment; however, the small sample size reported in the literature limits more robust conclusions.

Conclusions: Pharmacotherapy during pregnancy and lactation requires careful discussion and documentation so that the prescriber and the patient can be aware of its risks and benefits.

Current guidelines recommend a washout period of 1 to 2 weeks when switching between monoamine oxidase inhibitors (MAOIs) to reduce the risk of serotonin toxicity or hypertensive urgency/emergency. However, the evidence for these concerns is extremely limited, and reports of successful MAOI direct switches exist. This paper adds 3 new cases of rapidly executed MAOI direct switches without evidence of serotonin toxicity or hypertensive urgency/emergency. Case 1: A 25-year-old female on selegiline for 2 months was switched to phenelzine with only 1 medication-free day, then switched to tranylcypromine 2 weeks later with 1 medication-free day. Patient denied any concerning side effects during both transitions. Case 2: A 44-year-old male on selegiline was switched to phenelzine over 2 days. After 4 months of treatment inefficacy, he was switched to tranylcypromine over 2 days with no concerning side effects. Case 3: A 41-year-old female on isocarboxazid was switched to phenelzine with a 1-day washout period. The switch was well tolerated without any adverse events. These findings suggest MAOIs can be safely switched with a washout period of 2 days or less, although this should be reserved for specific clinical situations where the expected benefits outweigh the potential risks associated with any direct antidepressant switch.

Catatonia in individuals with autism spectrum disorder (ASD) can present atypically. Symptoms of catatonia can be difficult to recognize if they are atypical, which can delay proper medical workup and treatment. Comorbid catatonia can occur in individuals with ASD, with reported prevalence rates reaching as high as 12% to 18% in certain studies. However, there is a paucity of research on the management of catatonia in this demographic group. What evidence we currently have indicates that catatonia in individuals with ASD is less responsive to treatment with benzodiazepines than catatonia in individuals without ASD. We present the case report of an adolescent female with ASD presenting with signs of excited catatonia whose treatment spanned multiple inpatient admissions and trials of medications, including antipsychotics, lorazepam, zolpidem, and eventually electroconvulsive therapy. The complexities of treating catatonia that displays atypical symptomatology and is resistant to oral benzodiazepines are discussed.

Nitrous oxide (N2O), an anesthetic gas used for dental procedures, has recently become increasingly recognized as a potential drug of misuse and abuse, with an increasing number of case studies reporting serious adverse effects, including megaloblastic anemia, myelopathy, neuropathy, subacute combined degeneration, psychosis, and even death. There is also growing research support for the use of N2O in the treatment of several psychiatric disorders, including major depressive disorder. In this issue, we present the case of a 37-year-old man with no significant psychiatric history who presented with agitation, self-inflicted arm lacerations, paranoia, and hallucinations. The patient admitted to about 6 months of increasing recreational nitrous oxide use. He was found to have a low vitamin B12 level and anemia with results of other laboratory tests and head imaging within normal limits. His presentation suggested psychosis and delirium with withdrawal-like symptoms due to nitrous oxide abuse. He responded to treatment with olanzapine, a diazepam taper, and the addition of sertraline. The case highlights challenges with identifying and treating patients who misuse N2O, given the absence of a drug test for it and a lack of a consensus on how to classify and manage patients who abuse this drug. Further clinical research should be done, in parallel, on the risks of misuse and abuse of nitrous oxide, along with larger scale, yet measured, investigations of N2O as a treatment option in psychiatry.

Nitrous oxide (N2O) is a clear gas used in the food industry as well as in clinical settings as an analgesic and anesthetic agent. It is also a commonly used recreational drug due to its anxiolytic and euphoric effects. We discuss the case of a 37-year-old Samoan male with a long-standing history of N2O use who was brought to the emergency department for psychotic symptoms, which expanded to symptoms of delirium soon after his presentation. This case report adds to the literature about N2O-induced psychiatric presentations, particularly by focusing on a patient from an underrepresented population. We outline his clinical presentation, describe the presenting physical and psychiatric symptoms, and discuss management options based on existing literature and knowledge. The patient's information is adequately de-identified in this case report.

This systematic review examines the intersection of rickets and autism spectrum disorder (ASD), highlighting clinical insights from 10 studies involving 13 patients. Rickets, a pediatric bone disorder resulting from vitamin D, calcium, and/or phosphate deficiencies, often manifests through skeletal deformities, muscle weakness, and bone pain. ASD is a neurodevelopmental condition characterized by deficits in social communication and repetitive behaviors. The coexistence of these conditions, although uncommon, is notable due to overlapping factors such as selective eating habits and sensory sensitivities in children with ASD, which may exacerbate nutritional deficiencies. A comprehensive search across PubMed, Google Scholar, and Web of Science identified 65 relevant articles meeting the initial inclusion criteria, 10 of which (reporting on 13 patients) met the final review criteria for inclusion. All patients exhibited food selectivity, with most excluding dairy products and favoring potato-based foods. Musculoskeletal symptoms were predominant, with genu valgum, wrist widening, and metaphysis fraying being common findings. Seizures were the second most frequent reason for hospital admission, emphasizing the importance of monitoring neurological health in these patients. Calcium supplementation, primarily with calcium carbonate or calcium gluconate, was used in all cases, and the majority of patients experienced normalization of biochemical markers, including serum calcium levels. This review underscores the need for interdisciplinary care, focusing on nutritional and behavioral interventions to manage both rickets and ASD effectively. Future research should aim to explore larger and more diverse populations to better understand the clinical interplay between these conditions and inform more comprehensive treatment strategies.

This column presents the case example of a patient who was prescribed 3 different brand name drugs, all of which contain bupropion, which has a dose-dependent seizure risk. This case illustrates how such prescribing can result in a patient exceeding the recommended maximum daily dose of bupropion and having a seizure. This column also explains why prescribers should advise their patients to get their prescriptions filled by the same pharmacy or pharmacy chain.