Carbamazepine overdose recognized by a tricyclic antidepressant assay

Altered mental status in an adolescent presents a diagnostic challenge, and the clinician depends on clinical evaluation and laboratory studies to determine therapy and prognosis. We report the case of an adolescent with altered consciousness caused by carbamazepine overdose with a positive tricyclic antidepressant level to alert clinicians to the cross-reactivity of carbamazepine with a toxicology screen for tricyclic antidepressants.     

The use of methylphenidate in a depressed adolescent with AIDS

Stimulants once used to treat depression have been overshadowed by tricyclic antidepressants and monoamine oxidase inhibitors. Recently, their use has been reported in the treatment of depression in medically ill adults in whom tricyclics are contraindicated, or for whom a rapid response is critical. This report documents the successful use of methylphenidate in a depressed adolescent with AIDS.     

Acrocyanosis as a side effect of tricyclic antidepressants: a case report

Acrocyanosis is probably the most unusual side effect of tricyclic antidepressant drugs. In this paper, we report a 10-year-old boy with primary enuresis nocturna and attention deficit hyperactivity disorder who developed two episodes of acrocyanosis, the first of which was after imipramine treatment and the second after desipramine usage. We also review the possible pathogenesis of acrocyanosis. We suggest that physicians should be aware of this rare side effect of tricyclic antidepressants.     

Pharmacologic treatment of adolescent depression

Depression is a disease entity that causes significant morbidity and mortality in the adolescent population. It is important for primary care providers to recognize the signs and symptoms associated with depression in adolescents. This article discusses the current literature addressing the pharmacologic treatment of adolescent depression. A brief review of diagnosing depression is included. Diagnosis of depression in the adolescent with normal and abnormal development is examined, along with risk factors associated with increased incidence of depression in this population. Past and present clinical trials of tricyclic, monoamine oxidase inhibitor, and selective serotonin reuptake inhibitor classes of antidepressants are reviewed. In addition, adverse effects and toxicity are briefly discussed. Currently, the selective serotonin reuptake inhibitors are the first-line pharmacologic intervention for adolescent depression, although only selected drugs have undergone controlled clinical trials in this age group. The high toxicity profile of other classes of antidepressants makes their choice less optimal. Newer antidepressants have also been studied recently in the adolescent population. Further pharmacotherapy research in this vulnerable cohort is needed.     

Relationship between clinical features of tricyclic antidepressant poisoning and plasma concentrations in children.

Clinical features and drug plasma concentrations were studied in 13 children admitted to hospital with tricyclic antidepressant poisoning. Patients with plasma concentrations below 500 microgram/l had anticholinergic signs and increased reflexes but did not have convulsions or cardiac arrhythmias. Four patients with plasma concentrations above 1000 microgram/l suffered convulsions, cardiac arrhythmias, or prolonged coma. The diagnosis of poisoning in 2 of these cases was made only by toxicological analysis. Quantitative estimation of tricyclic antidepressants is useful in atypical or severe poisoning both to reach the diagnosis and to give an idea of the likely duration of symptoms.     

Age effects on antidepressant-induced manic conversion

BACKGROUND: Antidepressant drug therapy can precipitate mania in vulnerable individuals, but little is known about the effects of age on this phenomenon. OBJECTIVE: To pharmacoepidemiologically evaluate the risk of conversion to mania by antidepressant class and patient age. DESIGN, SETTING, AND PATIENTS: Using an administrative national database of more than 7 million privately insured individuals, linked outpatient and pharmacy claims were analyzed for mental health users aged 5 to 29 years (N = 87,920). MAIN OUTCOME MEASURES: The proportion and cumulative hazard of manic conversion were analyzed by antidepressant class and subject age among children, adolescents, and young adults with an anxiety or nonbipolar mood disorder in the United States between January 1, 1997, and December 31, 2001. Manic conversion was defined as a new diagnosis of bipolar illness. RESULTS: During median follow-up of 41 weeks (range, 8-251 weeks), manic conversion occurred in 4786 patients (5.4%). Multivariate analyses using time-dependent Cox proportional hazards models indicated that an increased risk of manic conversion was associated with antidepressant category vs no antidepressant exposure (hazard ratios: 2.1 for selective serotonin reuptake inhibitors, P<.001; 3.8 for "other" antidepressants, P<.001; and 3.9 for tricyclic antidepressants, P =.002). Antidepressant x age interactions revealed inverse age effects for selective serotonin reuptake inhibitors and other antidepressants (beta = -.05; P<.001 for both) but not for tricyclic antidepressants (beta = -.02; P =.25). Peripubertal children exposed to antidepressants were at highest risk of conversion (number needed to harm: 10 [95% confidence interval, 9-12] among 10- to 14-year-olds vs 23 [95% confidence interval, 21-25] among 15- to 29-year-olds). CONCLUSIONS: Patient age is an effect modifier on the risk of antidepressant-associated manic conversion. Treatment with antidepressants is associated with highest conversion hazards among children aged 10 to 14 years.     

Practitioner Review: The Pharmacotherapy of Adolescent Depression

This paper is a review of the pharmacotherapy of adolescent depression. It begins with a brief discussion regarding the nature of adolescent depression and then critically evaluates the available evidence regarding the efficacy and tolerability of psychotropic intervention as it has, to date, been reported. As the available evidence suggests that tricyclic antidepressants have failed to show efficacy, yet demonstrate significant problems with tolerability and safety, the remainder of the article describes how clinicians should prescribe antidepressants using the serotonin reuptake inhibitors. Areas covered include assessment, treatment initiation, dosing, outcome evaluation, adverse events, and combinations. The review concludes with a discussion of long-term therapy with antidepressant medications.     

Therapeutic drug monitoring of psychotropic drugs in children

In several areas of medicine, therapeutic drug monitoring (TDM) has been proven to be a very useful tool for optimizing the therapeutic potential of various drugs and for minimizing the risk of adverse events. In pediatrics the value of TDM is generally accepted for drugs such as Theophylline and/or antiepileptics, but it is still strongly questioned for classes of drugs such as neuroleptic and tricyclic antidepressants. However, in the last 5 years evidence has been produced indicating that TDM may be a very useful tool in pediatric neuropsychiatry too. In fact, if on the one side therapeutic windows have been defined for major neuroleptics and tricyclic antidepressants, on the other side clear relationships between drug plasma concentrations and the incidence and severity of adverse reactions have been reported. Data derived from our own experience of 5 years of TDM in pediatric neuropsychiatry will be described together with data from the literature. It appears that at least for four major drugs, Haloperidol, Chlorpromazine, Imipramine, and Chlorimipramine, drug plasma levels monitoring during chronic treatment does help in a significant manner in optimizing the treatment.     

Neonate characteristics after maternal use of antidepressants in late pregnancy

BACKGROUND: Exposure to antidepressants during the third trimester of pregnancy has been associated with an increased risk for adverse birth outcomes, including preterm birth, respiratory distress, and hypoglycemia. OBJECTIVE: To investigate neonatal outcomes in 997 infants (987 mothers) after maternal use of antidepressants based on prospectively recorded information in antenatal care documents. RESULTS: An increased risk for preterm birth (odds ratio [OR], 1.96) and low birth weight (OR, 1.98) was verified, but the gestational week-specific birth weight was increased notably after exposure to tricyclic antidepressants. An increased risk for a low Apgar score (OR, 2.33), respiratory distress (OR, 2.21), neonatal convulsions (OR,1.90), and hypoglycemia (OR, 1.62) was found, the latter especially after exposure to tricyclic drugs, but no significant effect on the frequency of neonatal jaundice was seen (OR, 1.13). Most effects seemed not to be selective serotonin reuptake inhibitor drug specific, and outcomes after exposure to paroxetine hydrochloride were not worse than after exposure to other selective serotonin reuptake inhibitors. CONCLUSIONS: Neonatal effects after maternal use of antidepressant drugs during late pregnancy were seen. Selective serotonin reuptake inhibitors may be the drugs of choice during pregnancy.     

Efficacy of magnesium sulfate for treatment of ventricular tachycardia in amitriptyline intoxication

In our country, tricyclic antidepressants are usually present in most of the homes. Myocardial depression and ventricular arrhythmia are the severe side effects in tricyclic antidepressant overdose. A 4-year-old boy was brought to our hospital after taking 70 mg/kg of amitriptyline. On arrival, the patient was comatose (Glasgow Coma Score was 3), had a shallow breathing pattern with bradycardia (HR <30/min), and hypotension. He was intubated and resuscitated with multiple doses of adrenaline and sodium bicarbonate. He was infused with a bolus of 20 mg/kg of normal saline for hypotension. After 30 minutes, ventricular fibrillation was detected. Lidocaine and bicarbonate were not effective in converting the rhythm to normal, therefore, synchronized cardioversion was used. After cardioversion, the rhythm converted to ventricular tachycardia. Because ventricular tachycardia did not resolve, we administered a load of less than 2 g of magnesium sulfate for 30 minutes followed by a continuous infusion of 3 mg/min. After magnesium sulfate infusion, a normal cardiac rhythm was achieved. Magnesium sulfate is a very effective treatment in intractable arrhythmias caused by high-dose amitriptyline intoxication.     

Prescribing practices and knowledge of tricyclic antidepressants among physicians caring for children

We did not find any significant difference between pediatricians and family practitioners with regard to their knowledge of the potentially serious toxicities of the tricyclic antidepressants. One of this group, imipramine, is in widespread use for the treatment of enuresis. A large proportion of the pediatricians (40%) and family practitioners (50%) surveyed use this drug as the first or only approach to enuresis. It is disquieting to discover that, of those physicians choosing to use the drug, one third appear to be unaware of its toxic potential. Other effective treatment modes are available, and it is to be hoped that more physicians will explore them before turning to the more hazardous pharmacologic alternatives. Pediatricians, although not more knowledgeable than family practitioners, exhibited more careful prescribing practices.     

Hypertension in neuroblastoma induced by imipramine

Hypertension is a well-known finding in some patients with neuroblastoma. However, it has not previously been described in association with the use of Imipramine. We report the occurrence of severe hypertension (blood pressure 190/160) in a 4-year-old girl with neuroblastoma who was given Imipramine to control a behavior disorder. It was determined later that this patient's tumor was recurring at the time of her hypertensive episode. Since she had no blood pressure elevation at initial diagnosis and none following discontinuation of the Imipramine (when she was in florid relapse), we believe that this drug rather than her underlying disease alone caused her hypertension. The mechanism for this reaction is believed to be increased levels of vasoactive catecholamines due to interference of their physiologic inactivation by Imipramine. From this experience, we urge extreme caution in the use of tricyclic antidepressants in children with active neuroblastoma.     

Newer antidotal therapies for pediatric poisonings

Specific antidotal therapy is essential for the successful management of a limited number of intoxications. Newer antidotes have emerged in the last 10 years that target specific life-threatening poisonings. These newer therapies, including hormones, drug antagonists, enzyme inhibitors, and antibodies against drugs and venoms, illustrate the spectrum of mechanisms by which an antidote can reverse toxicity of a poison. This report focuses on seven newer antidotes: glucagon (β-blocker and calcium channel blocker toxicity), insulin/glucose (calcium-channel blocker toxicity), octreotide (sulfonylurea toxicity), new crotalid antivenom (crotalid snake bit envenomation), antibody therapy for tricyclic antidepressants, fomepizole (ethylene glycol toxicity), and nalmefene (opiod toxicity). The antidotes' mechanisms of action, expected therapeutic actions, indications for use, adverse effects, dosing, and limitations are discussed.     

Bulimia nervosa: an update and treatment recommendations.

Bulimia nervosa is a common eating disorder in adolescent women. Biological, psychological, and social factors are implicated in onset and important in treatment. Diagnosis of the syndrome, but not its subtypes, can be made well using the DSM-IV system. Screening tools, laboratory findings, and physical findings can be helpful in making the diagnosis. Comorbid disorders include affective disorders, addictive disorders, anxiety disorders, personality disorders, and anorexia nervosa. The etiology of bulimia nervosa is complex, with biologic, psychological, social, and family factors, which likely differ somewhat from patient to patient. Treatment, accordingly, should be comprehensive, individualized, and multifaceted. Many patients respond well to the use of an antidepressant, and cognitive-behavioral therapy is a useful approach for many patients. Combining these two treatments seems to be a good strategy. Environmental and family issues also need to be addressed. Many patients are treated insufficiently. More research on bulimia nervosa specific to adolescence is needed.     

Annotation: The use of psychotropic medications in children: an American view

BACKGROUND: Psychotropic medications have become an integral component in the treatment of children with mental illnesses. METHODS: Selective reviews of the empirical evidence for the efficacy of psychotropic medications and studies of their use patterns were reviewed. RESULTS: Very strong efficacy for at least the short-term benefits and safety of stimulant medications was found and some good efficacy and safety evidence for the treatment of anxiety and depressive disorders with seratonin reuptake inhibitors (SSRI) was also found. Efficacy for tricyclic antidepressants to treat attention deficit hyperactivity disorder was found but the presence of significant side effects makes them less the drugs of choice. Other medications are presented but with less rigorous evidence. Studies of use found that stimulant medications are extensively prescribed in the US by both psychiatrists and primary care physicians. SSRI are also prescribed extensively but not to the extent of stimulants and are more frequently prescribed by psychiatrists. CONCLUSIONS: There is now good evidence for the efficacy of some psychotropic agents and their use is an integral component in the management of childhood mental illnesses.     

Bulimia nervosa

Although there is a lot of information coming up to explain the pathogenesis of anorexia nervosa, yet little is know about bulimia nervosa in Indian literature. This case report highlights the typical presentation of a case of bulimia nervosa in an adolescent girl, where bulimia symptoms were preceded by anorexic behavior. Our case showed clinical similarity with the diagnostic criteria of the available classification system. The absence of self-evaluation for body weight and shape in this case be explained on the basis of cultural factors. To some extent, initial anorexic behavior could have played a role in etiopathogenesis of bulimia nervosa.     

Bulimia nervosa in adolescence

Investigations of bulimia nervosa have focused primarily on adult samples, although bulimia nervosa commonly has its onset in adolescence. Pediatricians are often questioned about its etiology, course, and treatment. In an attempt to provide pediatricians with answers, we integrate findings from recent epidemiological and treatment studies with a clinical report of 18 women who developed bulimia nervosa during their teens and sought treatment at our eating disorders clinic.     

Regurgitation in gorillas: possible model for human eating disorders (rumination/bulimia)

Regurgitation and reingestion behavior in gorillas is compared with two human disorders, rumination and bulimia. Eighty-four percent of captive gorillas that are more than 5 years old regurgitate and reingest. Comparisons are made on the basis of ontogeny, context, motor pattern, and intervention. There are more similarities between regurgitation and reingestion and rumination than between regurgitation and reingestion and bulimia. Regurgitation and reingestion resembles bulimia in parental/infant separation, lack of eating control, methods of induction, and some aspects of motor pattern. Regurgitation and reingestion resembles rumination in disrupted maternal/infant communication, context of the behavior (enjoy the taste of the regurgitant), several aspects of motor pattern, and treatment (increased food volume).