Mental Health Clinician Volume 3: Issue 5

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Primary or secondary? What came first and how to treat?

Pharm.D., BCPP

Most of the literature regarding the importance of accurately and efficiently differentiating neuropsychiatric symptoms as secondary to medical conditions or as a primary psychiatric illnesses is found in the emergency department setting. It has been reported that 6 to 12% of patients presenting to the emergency department have psychiatric complaints or behavioral disturbances.¹ ² Patients with psychiatric or behavioral disturbances are generally “medically cleared” prior to transfer to psychiatric care.² Assessing if a patient is “medically cleared” helps to identify medical illnesses that could cause or contribute to psychiatric or behavioral symptoms which may make treatment

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Toolbox: Neuropsychiatric adverse effects of antimicrobial agents

Pharm.D.,

Pharm.D,

Pharm.D.,

Pharm.D., and

Pharm.D., BCPP

DOI: 10.9740/mhc.n179730

Antimicrobials are used to treat numerous infections. Despite their wide usage, they may cause neuropsychiatric complications which may be overlooked by healthcare providers. While the occurrence of these adverse events can be rare, they can make treatment very difficult. The toolbox provides a list of antimicrobials and their corresponding psychiatric and neurologic adverse events to assist health care practitioners in their practice.

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Pharmacist's guide to pseudotumor cerebri: A review of the condition and its management

Pharm.D. and

Pharm.D., BCPP, CGP, FASCP

DOI: 10.9740/mhc.n178413

INTRODUCTION

Pseudotumor cerebri is a rare neuro-ophthalmologic syndrome with an estimated incidence of 0.9 per 100,000 persons in the general population.¹ As its name implies, pseudotumor cerebri is a condition of increased intracranial pressure with a clinical presentation similar to that of a cerebral tumor, yet it is void of any intracranial masses.² Because the associated symptoms arise from increased intracranial pressure, but are not the result of structural changes, lesions, cerebral spinal fluid composition abnormalities, or hydrocephalus, the condition is often referred to as idiopathic intracranial hypertension (IIH).^2–5 While this name descriptively characterizes

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Antiphospholipid antibody syndrome presenting with psychosis

Pharm.D., BCPP,

Pharm.D. Student, and

DOI: 10.9740/mhc.n178893

We present a case in which a 66 year old man with a history of depression and mild obsessive compulsive disorder (OCD), recently diagnosed with positive lupus anticoagulant and heterozygous MTHFR mutation, exhibited worsening OCD symptoms, paranoia, aphasia, and psychosis. The patient's symptoms were thought to be a central nervous system manifestation of antiphospholipid antibody syndrome (APS). The patient was successfully treated with therapeutic anticoagulation, hydroxychloroquine, and risperidone.

CASE

JJ is a 66 year old male that presented to a neighboring facility after experiencing seizure-like activity with arrested speech. Behavioral changes of one week duration, including paranoia, anxiety, and tangential

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Psychiatric outcomes associated with citalopram dose reduction in veterans after food and drug administration warning

Pharm.D.,

Pharm.D., BCPS, BCPP,

Pharm.D., BCACP,

Pharm.D., BCPS, and

Pharm.D., BCPS

DOI: 10.9740/mhc.n178898

INTRODUCTION

On August 24, 2011, the Food and Drug Administration (FDA) released a Drug Safety Communication which warned that higher citalopram doses, particularly 60 milligrams, were affiliated with QTc-interval prolongation.¹ This abnormality can lead to a potentially fatal arrhythmia, Torsades de Pointes (TdP). Although there is considerable intra-individual and inter-individual variability, normal QTc length can be roughly defined as 400 milliseconds. The upper limit of normal is 450 milliseconds for men and 460 milliseconds for women. Intervals longer than 500 milliseconds are considered to be a major risk factor for the development of TdP.² Additionally, a

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Acute intermittent porphyria with psychiatric manifestations: A case report

Pharm.D., BCPP

DOI: 10.9740/mhc.n178915

The porphyrias are a group of eight genetic disorders of heme biosynthesis that result from the deficient activity of a certain enzyme in the biosynthesis pathway. These disorders are separated by symptom manifestation and classified as acute porphyrias and cutaneous porphyrias. One of the acute porphyrias, acute intermittent porphyria (AIP), is caused by a prophobilinogen deaminase deficiency and usually presents as abdominal pain, nausea, constipation, and confusion.¹

CASE

Mr. G is a 55 year old Caucasian male with a past medical history significant for acute intermittent porphyria (AIP), chronic back pain, renal insufficiency, hypertension, and nicotine dependence. The patient

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Venlafaxine and duloxetine: A comparison of efficacy and tolerability for the treatment of depression in elderly patients

Pharm.D.,

MS, Pharm.D., and

Pharm.D., BCPP (corresponding)

DOI: 10.9740/mhc.n178920

The geriatric population has a disproportionally higher rate of depression and related suicide compared to the general population. While selective serotonin reuptake inhibitors are considered first line, serotonin norepinephrine reuptake inhibitors (SNRIs) are commonly used. Online databases including MEDLINE, EMBASE, International Pharmaceutical Abstracts, and CINAHL were searched (up to June 2013) to identify trials using SNRIs in the elderly. Results revealed 15 studies involving venlafaxine (n=10) and duloxetine (n=5) use in the elderly. Overall, venlafaxine and duloxetine appear to be similar in efficacy and tolerability in treating late life depression. However, venlafaxine has been more extensively studied in this particular population, appears to carry fewer drug interactions, and is available in generic forms for regular and extended-release formulations. Doses greater than 225 mg/day for venlafaxine or 60 mg/day for duloxetine appear to lead to greater discontinuation rates.

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On pens and needles: Treatment strategies for psychological insulin resistance in type 2 diabetes mellitus

Pharm.D.,

Pharm.D., BCACP, and

Pharm.D. Candidate, MBA

DOI: 10.9740/mhc.n179697

Background: Psychological insulin resistance (PIR) refers to psychological opposition towards insulin therapy. Although not a formal psychological diagnosis, PIR is an under-recognized issue clinicians may encounter when treating patients with diabetes requiring insulin therapy.

Methods: Review articles, clinical trials, and practice guidelines were located using online databases. A total of 39 abstracts were reviewed and 11 articles were included in the analysis.

Results: Eleven articles were included. Proposed strategies used to mitigate the occurrence of PIR include: identifying the patient's personal obstacles via administration of PIR questionnaires, use of insulin pens as opposed to conventional syringe and needle, education on the risk of hypoglycemia and continuous emphasis of the importance of self-monitoring of blood glucose (SMBG) readings.

Discussion: The management of type 2 diabetes mellitus (T2DM) in patients requiring insulin may present challenges such as PIR. Tailoring a patient's treatment plan to account for physiological, psychological, social and financial needs may thwart some of these challenges. Other factors to consider include the cost of the agent and/or devices required. Insulin-dependent patients with T2DM should be assessed for both physiological and psychological changes.

Conclusion: Current treatment strategies for clinicians treating T2DM patients with PIR include administering the PIR or BIT questionnaire, initiating lower doses of insulin, switching from insulin vials to insulin pens, including assessment results in individualized treatment plans and using clinical outcomes to screen patients who are at risk for refusing the use of insulin. Further research evaluating clinical outcomes associated with treatment strategies is necessary.

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Letter to the editor

Pharm.D. and

Pharm.D., BCPP

DOI: 10.9740/mhc.n178409

In reading a recent article titled, “Use of Antidepressants during Pregnancy and Lactation” we enjoyed the summary that Dr. Norris has written and published; however, upon reading we recalled a particular antidepressant missing from the review.

Approved December 1^st, 1980, maprotiline (Ludiomil), which is currently only available by Mylan Pharmaceuticals, is classified as a tricyclic antidepressant, though technically a tetracyclic in structure. The FDA has given maprotiline a pregnancy risk category rating of “B”, the only one in the class of antidepressants with this distinction. Adverse teratogenic effects were not seen in animal reproduction studies performed

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Book Review: The prescribers guide: Stahl's essential psychopharmacology

Pharm.D., BCPP

DOI: 10.9740/mhc.n177661

CPNP members maintain a suggested reading list to provide information on peer recommended resources and convenient access to the highest quality neuropsychopharmacology publications. A reminder that if you shop with CPNP, by following the links below to Amazon, a small commission will be paid to CPNP which helps to financially support our mission to improve the minds and lives of individuals with psychiatric and/or neurologic disorders.

You can help grow this list of resources by suggesting a book.

Book: The Prescribers Guide: Stahl's Essential Psychopharmacology

FROM THE PUBLISHER

Now established as the indispensable formulary in

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Movie Review: Requiem

and

Pharm.D., FCCP, BCPS, CGP

DOI: 10.9740/mhc.n177663

STUDENT PERSPECTIVE AND REVIEW

Requiem is a German film directed by Hans-Christian Schmid, starring Sandra Hüller as the main character, Michaela Klinger. This film is based on the life and death of Anneliese Michel, a 23-year-old German woman diagnosed with epilepsy. Anneliese and her family were convinced that her seizures and hallucinations were due to demonic possession and she eventually died from starvation due to not eating as atonement during repeated exorcisms.

Requiem is set in the 1970s and tells the story of Michaela, a 21-year-old young woman with epilepsy who is accepted to her first year at

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Strategizing for success in neuropsychiatric pharmacy

Pharm.D., BCPP

DOI: 10.9740/mhc.n178689

CPNP members are bonded by a passion for improving the minds and lives of individuals affected by psychiatric and neurologic disorders. When our members are successful, our patients benefit. Realizing this, CPNP is retooling its strategic plan to ensure our laser focus on neuropsychiatric pharmacists and aspiring neuropsychiatric pharmacists (students, residents, other trainees). At a recent strategic planning retreat attended by the Board, we focused on defining CPNP's strengths and identifying the most important trends and resulting opportunities. Based on member needs assessments, satisfaction surveys and polling of the CPNP leadership, CPNP has assessed its core strengths as education, networking,

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CPNP Announcements

DOI: 10.9740/mhc.n179776

CPNP AT THE ASHP MIDYEAR MEETING

CPNP is once again playing a role in the ASHP Midyear Clinic Meeting taking place December 8–12, 2013 in Orlando, Florida.

Monday, December 9, 2013

Participate in the psychopharmacology/neurology section dialogue facilitated by Cherry W, Jackson, Pharm.D., BCPP, FASHP.

Psychopharmacy/Neurology

Networking Session Hosted by the Section of Clinical Specialists and Scientists

11:00 a.m. –12:30 p.m.

Room W311 B, Level 3, Orange County Convention Center

Facilitator: Cherry W, Jackson, Pharm.D., BCPP, FASHP, Professor of Pharmacy, Auburn University, Birmingham, AL

Discussion Topics:

Pharmacists' role(s) in prescription drug overdose prevention/treatment
TBI and depression among active duty

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Primary or secondary? What came first and how to treat?

Toolbox: Neuropsychiatric adverse effects of antimicrobial agents

Pharmacist's guide to pseudotumor cerebri: A review of the condition and its management

INTRODUCTION

Antiphospholipid antibody syndrome presenting with psychosis

CASE

Psychiatric outcomes associated with citalopram dose reduction in veterans after food and drug administration warning

INTRODUCTION

Acute intermittent porphyria with psychiatric manifestations: A case report

CASE

Venlafaxine and duloxetine: A comparison of efficacy and tolerability for the treatment of depression in elderly patients

On pens and needles: Treatment strategies for psychological insulin resistance in type 2 diabetes mellitus

Letter to the editor

Book Review: The prescribers guide: Stahl's essential psychopharmacology

FROM THE PUBLISHER

Movie Review: Requiem

STUDENT PERSPECTIVE AND REVIEW

Strategizing for success in neuropsychiatric pharmacy

CPNP Announcements

CPNP AT THE ASHP MIDYEAR MEETING

Pharmacist administration of long-acting injectable medications for substance use disorders: A scoping review

Transitions of care: Assessment of adherence to long-acting injectable antipsychotic treatment following discharge from inpatient psychiatry

Use of atypical antipsychotics in individuals with anorexia nervosa

Potential changes impacting psychiatric pharmacy by 2030

A model for timely dissemination of critical information: Clozapine toxicity during the COVID pandemic