LETIERS

TO ThE

depression,

EDITOR

recurrent.

psychotherapy,

and

I treated she

her with

responded

well.

desipramine After

and

(personal

communication

the response

termination

of her treatment, she was euthymic for 7 years, until she had a recurrence during the sixth week of a commercial weightreduction diet. This program involved a low-calorie diet and a food supplement but no appetite suppressants. Her weight had decreased by 20 ib, from 174 to 154 lb. She responded well to a therapeutic level of the antidepressant. Ms. B was a 31-year-old woman who had had five previous episodes of depression, treated elsewhere, dating back to age 22. Her diagnosis was major depression, recurrent. When she was 29 she experienced a depression that I treated with psychotherapy and perphenazine, which had previously been successful for her. Upon termination of this treatment, she remained euthymic for 20 months. Then she had a recurrence after 8 weeks of a self-structured, reducedcalorie diet in which she used no appetite suppressants. She had sustained a 27-lb weight loss, from 167 to 140 lb. Her depression responded well to perphenazine and psychotherapy.

),

20

1 . Smoller

a critical 2.

Wing RR, behavioral

Wadden TA, Stunkard AJ: Dieting and depression: review. J Psychosom Res 1987; 31:429-449 Epstein weight

LH, loss

Marcus programs.

MD,

J

et al: Mood Psychosom

changes in Res 1984;

20:189-196 ALAN

Cognitive

Dysfunction

Associated

With

M. KRAFT,

M.D.

Albany,

N.Y.

Fluoxetine

Sut: Cognitive impairment associated with tricyclic antidepressants has been attributed to sedative and/or anticholinergic effects (1). Accordingly, fluoxetine, with its low propensities for both, may be relatively free of adverse cognitive effects. Even so, cognitive dysfunction has been linked with fluoxetine

948

Lilly

and

treated

Company),

and

illustrates

this.

whose recurto fluoxetine,

mg/day,

prescribed along with conjugated estrogens, and L-thyroxine, 0.15 mg/day (for chronic hypothyroidism). She presented with a 9-month history of difficuities with memory and learning unaccompanied by depression, sedation, anticholinergic signs, sleep disturbance,

progesterone,

or current nesic

or prior

effects.

use of licit or illicit substances

Examples

of her difficulties

with

included

am-

forgetting

that she had made bank deposits, leaving out key ingredients in recipes, failing to learn piano pieces (which caused her to retire as a piano teacher), and inability to learn a foreign language in preparation for a trip. Although euthymic, alert, and oriented to person, place, and time on mental status examination, Ms. A, a college graduate, was able to recall only one of eight associative word pairs (four of eight is normal), only two of three items after S minutes, and only one president. Her fund of general was

poor,

and

she

made

several

errors

during

serial subtraction of sevens. Her interpretation of proverbs was concrete and personalized. Her thyroid functions were normal, as were the results of both medical and neurological evaluations. Fluoxetine was discontinued at Ms. A’s first visit, while her other medications remained constant. Over the ensuing week, she reported that her mind seemed clearer and her memory better. Then, since she reported recurrent depressive symptoms, she was started on a regimen of nortniptyline, 40 mg h.s. (which produced a 12-hour steady-state plasma level of 137 ng/mt) and responded well. Eighteen days after discontinuing fluoxetine, she returned for a fol-

low-up

functioning

was

significantly improved: she was now able to remember associative learning pairs, remember three of three after S minutes, perform serial subtraction of sevens

five items with-

visit,

during

which

her cognitive

out error, and recall five past presidents. When her nortniptyline dose was reduced to 30 mg h.s. because of weight gain, she became more depressed but experienced no cognitive

dysfunction.

Her

dose

of nortniptyline

was

then

in-

creased to 40 mg h.s. (producing a 12-hour steady-state plasma level of 97 ng/ml), and her depressive symptoms resolved. Over the ensuing 3 months, she reported no memory difficulties, and after successfully resuming hen household duties and her career as a piano teacher and learning the foreign language she had been unable to master while taking

REFERENCES

I recently

Ms. A was a 60-year-old Caucasian woman rent major depressive disorder had responded

information

studies of mood disorders following weightreduction dieting have yielded conflicting and inconclusive mesuits; some patients improve affectively and others become depressed. Smoller et al. (1 in an extensive review of the literature, found that the apparent conflict among studies mesulted from the ways in which mood changes were measured. Wing et al. (2) proposed that the more recent studies failed to find serious mood disorders because persons with preexisting psychopathology were excluded from these studies. I could find no references in the literature published since 1 986 that addressed the impact of such diets on previously depressed patients. While persons without previous depression may not be at risk as a result of a weight-reduction regimen, these cases indicate that persons with such a history are at risk of recurrence, particularly with a weight loss of 20 lb or more (1). It is possible that some psychological process, such as a concern for low self-esteem, may have been a precursor of the depression. Or the connection between the depression and the diet may have been coincidental, so that to conclude that dieting was the cause of the depression is unwarranted. Nonetheless, these cases suggest that previously depressed patients may be at risk and should be monitored carefully if they embark on a weight-reduction diet. Cumulatively,

Eli

from

of a patient

fluoxetine,

she departed

on her

trip.

Ms. A’s reversible cognitive dysfunction appeared to be related to fluoxetine treatment. Although depression has been associated with cognitive dysfunction, Ms. A was euthymic at the time of her first mental status examination and did not develop cognitive difficulties when she became more depressed

upon

discontinuing

fluoxetine

or upon

reducing

her

dose of nortniptyline. Moreover, she was not sedated, sleep deprived, or hypothyroid, nor did she have a fluoxetine-induced syndrome of inappropriate secretion of antidiuretic hormone or anticholinergic symptoms or signs. Although diminished performance on a coding task has been associated with fluoxetine in one study (2), two others (3, 4) have reported unchanged or improved cognitive function during fluoxetine treatment. The mechanism by may impair short-term memory or learning awaits further investigation.

Am

J

Psychiatry

which fluoxetine in some patients

1 48:7,

July

1991

LE1TERS

REFERENCES 1 . Deptula 2.

formance:

D, Pomara a review.

Nicholson

AN,

J

Clin

Pascoe

sleep-wakefulness take inhibitor. 3.

N: Effects

particularly

of antidepressants

tidepressants,

alone

27:597-602

and

in combination

with

Biol Psychiatry

diazepam.

1988;

SUSAN

MIROW,

Bleeding

2.

AC: The

in Medical

Physiology.

J.A. YARYURA-TOBIAS, H. KIRSCHEN, P. NINAN, H.J. MOSBERG,

M.D. M.D. M.D. D.O.

Mineola,

N.Y.

Disorder

Reactivation

and

of the Herpes

Simplex

Virus

Fluoxetine

We would suffering

like to report

from

patients

eight

cases

obsessive-compulsive

had

ever

noticed

of bleeding disorder.

any

bleeding

in patients

None

episodes

of these

before

they

fluoxetine.

The patients’ ages ranged from 1 6 to 75 years, of 35. 1 years. One patient was taking fluoxetine 20 mg/day,

one

patient

was

taking

40 mg/day,

with a mean at a dose of

and

six patients

were taking 80 mg/day. The duration of treatment ranged from 21 days to 1 year, with a mean of 150 days. There was one report of metena, the cause of which was undetermined because the patient refused to be tested. There were four reports of rectal bleeding, three caused by internal hemorrhoids and one due to unknown factors, all confirmed by rectosigmoidoscopy. One patient reported scattered bruises on arms enzymes. Another taxis; rhinoscopy

lowing

case

and

legs

and

had

an

elevated

level

of liver

patient suffered from mild bilateral episshowed mucosal vascular dilation. The folhelp to illustrate this report.

may

SIR: We

ms infection

colitis.

She

was

mg/day,

for

mg/day,

and

a

placed

on

month.

she took

a regimen

Then this

had a history heart disease, the

dose

dose

of concomiangina, and

of

fluoxetine,

was

raised

for 2 months,

until

20

to 40 she had

to be hospitalized because of constant generalized abdominal pain of sudden onset. The pathology report indicated a segment of the small bowel with moderate acute ulcerating inflammation and vascular dilation, recent hemorrhages, and submucosal edema consistent with vascular compro-

cases of reactivated herpes with fluoxetine treatment.

tions.

After

depression

with

Serotonin striction and

of fluoxetine, no further episodes by any of these eight patients.

is associated with the regulation dilation, notably that of mucosal

cause

large

(2)

a defective

doses

of fluoxetine vascular bed,

of

of vessel convessels (1 ). Be-

may cause hypersemotonemia as seen in our patients, an in-

crease in S-HT may serve as a mediator to precipitate the bleeding episode. When large doses of fluoxetine are prescnibed for the treatment of obsessive-compulsive disorder, potentially significant bleeding problems in some patients,

AmJPsychiatry

148:7,July

1991

vi-

8

months

of

fluoxetine

treatment,

major

has remitted. B was

major

a 64-year-old

depression

simplex.

She was

mg/day.

Approximately

and

white

woman

a remote

history

who

presented

of labial

herpes

started

on a regimen of fluoxetine, 20 2 weeks later, she developed yeslip that were typical of those she had had

ides on her lower in the past. Her regular

physician

diagnosed

herpes

simplex.

The patient discontinued fluoxetine and the lesions healed. Two weeks later she restarted fluoxetine, which she now has been taking for 2 months. There have been no further herpes outbreaks and her depression is well controlled.

etine,

discontinuation were reported

simplex

a 43-year-old white woman with recurrent and a history of genital herpes, quiescent a year. Within 1 month of her beginning to 20 mg/day, the herpes became reactivated. depression responded well, the patient beexacerbation of herpes was related to fluoxetine. Fluoxetine was replaced with desipramine, and there was partial relapse of the patient into depression but remission of the herpes. After 1 8 months on the desipramine regimen, Ms. A requested retreatment with fluoxetine. At 20 mg/day there was no improvement in her depression, so the dose was increased to 40 mg/day, and outbreaks of herpes began within 1 month. Because her depressive symptoms improved markedly with the dose of4O mg/day, she elected to continue fluoxetine and to control the herpes with oral acyclovir. She continues to experience the tingling of an imminent outbreak of herpes monthly. When the tingling begins, one to two doses of acyclovir prevent vesicular erup-

Mr. C was a 42-year-old

misc.

Upon bleeding

report three associated

Ms. A was major depression for more than take fluoxetine, Although her lieved that the

Ms. Ms. A, a 7S-year-old woman, tant emphysema, arteriosclerotic

in

circulation,

Utah

Fluoxetine

took

systemic

M.D.

City,

is a bicyclic antidepressant and a selective blocker of serotonin (S-HT) reuptake. Adverse vascular effects such as bruises, metrorrhagia, cerebrovascular accidents, hemoptysis, melena, hematemesis, hematuria, and vaginal bleeding after drug withdrawal have been sporadically reported (Dista Products Company, Fluoxetine Hydrochloride, Adverse Reactions, 1989). SIR:

should

Prog

PH.D.,

in Obsessive-Compulsive

conditions,

Philadelphia, WB Saunders, 1981 Steiner W, Fontaine R: Toxic reaction following combined administration of fluoxetine and L-tryptophan: five case reports. Biol Psychiatry 1986; 21:1067-1 071

12:783-792

Salt Lake

and

predisposing

REFERENCES 1. Guyton

MJ, et al: A comparison of the effect on the cognitive functioning of de-

Affective Disord 1990; 18:275-280 M: The effects on performance of two an-

Neuropsychopharmacol

Fluoxetine

have

1 990; 10:105-111 the modulation of the by fluoxetine, a S-HT up-

Fudge JS, Perry PJ, Garvey of fluoxetine and trazodone

J

per-

who

EDITOR

be considered.

Psychopharmacol PA: Studies on

continuum in man Neuropharmacology 1988;

pressed outpatients. 4. Moskowitz H, Burns

on human

those

TO THE

20

mg/day,

for

had recurrent

genital

herpes

of his genitals.

After

beginning

herpes changed resolved

white

recurrent

man who was given major

involving fluoxetine,

depression.

fluoxHe

also

the skin on one side the

frequency

of

outbreaks to involve with

the increase

remained the same, but the pattern both sides of his genitals. His depression fluoxetine, and he continues to take it despite in herpetic lesions.

Recurrences of herpes simplex are thought to be related to lapses in cell-mediated immunity. After primary infection the virus lies dormant in sensory ganglia, and under various cm-

949

Cognitive dysfunction associated with fluoxetine.

LETIERS TO ThE depression, EDITOR recurrent. psychotherapy, and I treated she her with responded well. desipramine After and (personal c...
451KB Sizes 0 Downloads 0 Views