No abstract

TO THE EDITOR: Schizophrenia is associated with heavy smoking. The replacement of tobacco by other forms of nicotine only occasionally achieves abstinence in persons with schizophrenia (1). The nicotinic agonist varenicline is a new alternative replacement agonist. There are no reports of its use in schizophrenia. We present the case of a patient with schizophrenia who received varenicline and experienced an activated psychotic relapse.A 42-year-old woman with schizophrenia had been treated for 17 years with 1015 mg of thiothixene. She had several brief psychotic episodes per year, which seldom lasted for more than 3 days. She had no overt psychotic symptoms during an office visit one month previously. Her usual symptoms during acute psychotic episodes were voices commenting on her behavior, confusion, and angry outbursts. She smoked one to two packs of cigarettes per day and had made several attempts to discontinue the use of nicotine chewing gum and trandermal nicotine patches. The patient's mother reported a 5-day psychotic episode that began with increased activity, primarily the discarding of financial statements. At day 4, the patient ordered her daughter out of the house, and she threw away her thiothixene, which her daughter had insisted that she continue to take. She spent the next day screaming in her closet. Her mother administered thiothixene (20 mg) on the fifth evening and fed her because she had stopped eating. She appeared well groomed the next morning, without psychotic symptoms. She had no explanation for her sudden relapse and remission, but she announced with pride that her internist had prescribed a new medication, varenicline (2 mg), to help her stop smoking. The patient had been receiving varenicline for 5 days, and her quit day was the following day. She was advised to continue thiothixene, to avoid varenicline, and to return to nicotine chewing gum as a smoking substitute. She had no further exacerbations, but she continued to smoke cigarettes.Nicotine activates several classes of brain cholinergic receptors. Many are high affinity presynaptic receptors, composed primarily of alpha4 and beta2 subunits, which cause the release of dopamine and other neurotransmitters. Nicotine produces profound tachyphylaxis at doses that are close to its agonist effect, which quickly ends its pleasurable effect. Heavy smokers, including persons with schizophrenia, respond by increasing their smoking to overcome the tachyphylaxis. Varenicline is principally an agonist at high affinity receptors, with a lower propensity to tachyphylaxis than nicotine (2). The more prolonged agonist effect of the drug was selected to increase its acceptance by smokers as a substitute for the briefer effects of cigarettes. Prolonged release of dopamine and norepinephrine may have resulted in the activated psychotic relapse in our patient. Her relatively low neuroleptic dose likely increased her vulnerability to this effect.In addition to its pleasurable effects, smoking is a possible self-medication for cognitive dysfunction i...

We report the successful treatment of an episode of major depression with psychotic features with electroconvulsive therapy (ECT) in a 78-year-old woman with advanced Parkinson disease who had a left subthalamic nucleus deep-brain stimulator (DBS) in place. Electroconvulsive therapy effectively and safely treated the patient's depression without harming the patient or damaging the DBS hardware. We offer additional evidence about the safety and efficacy of electroconvulsive therapy in patients with DBS.

Delusions, hallucinations and other psychotic symptoms can accompany a number of conditions in late life. As such, elderly patients are commonly prescribed antipsychotic medications for the treatment of psychosis in both acute and chronic conditions. Those conditions include schizophrenia, bipolar disorder, depression and dementia. Elderly patients are at an increased risk of adverse events from antipsychotic medications because of age-related pharmacodynamic and pharmacokinetic changes as well as polypharmacy. Drug selection should be individualized to the patient’s previous history of antipsychotic use, current medical conditions, potential drug interactions, and potential side effects of the antipsychotic. Specifically, metabolic side effects should be closely monitored in this population. This paper provides a review of aripiprazole, a newer second generation antipsychotic agent, for its use in a variety of psychiatric disorders in the elderly including schizophrenia, bipolar disorder, dementia, Parkinson’s disease and depression. We will review the pharmacokinetics and pharmacodynamics of aripiprazole as well as dosing, diagnostic indications, efficacy studies, and tolerability including its metabolic profile. We will also detail patient focused perspectives including quality of life, patient satisfaction and adherence.

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°. 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.