Case Reports
The authors acknowledRe Donald Kornfeld. MD .. and Philip Muskin. MD .. ofthe Consulta-
tion-Liaison Service at Columhia-Preshyterian Medical Center for their advice and support.
References I. Downey J. Yingling S. McKinney M, et al: Mood disor-
2. 3.
4.
5.
6.
ders. psychiatric symptoms. and distress in women presenting for infenility evaluation. Fenil Steril 52:425-432. 1989 Menning BE: The emotional needs of infenile couples. FerriJ SteriJ 34:313-319.1980 Rosenfield DL. Mitchell E: Treating the emotional aspects of infenility: counseling services in an infenilily clinic. Am J Obstet Gynecol 135: 177-180. 1979 Seibel MM. Levin S: A new era in reproductive technologies: Ihe emotional stages of in vitro fenilization. Journal of In-Vitro Fertili;ation and Embryo Transfer 4:135-140.1987 Morse C. Dennerslein L: Infenile couples enrering an in vitro fenilization programme: a preliminary survey. Ann NY Acad Sci 4:207-219, 1985 Freeman EW. Boxer AS. Rickels K. el al: Psychological
evalualion and suppon in a program of in vitro fenilization and embryo transfer. FerriJ Steril 43:48-53. 1985 7. Haselline FP. Mazure C. DeL'aune W. el al: Psychological inrerviews in couples undergoing in vitro fenilizalion. Ann NY Acad Sci 422:504-516. 1985 8. Baram D. Tounelot E. Muechler E. et al: Psychological adjustment following unsuccessful in vitro fenilil.3lion. Journal of Psychosomatic Obstetrics and GynecoloKY 9:181-190.1988 9. Leiblum SR. Kemmann E. Colburn D. et al: Unsuccessful in vilro fenilization: a follow up sludy. Journal ofIn- Vitro FertiJi;ation and Embryo Transfer 4:46-50. 1987 10. Uvnas- Moberg K: The gastrointestinal tract in growth and reproduction. Sci Am July:78-83. 1989 II. Goshen-Gollstein ER: The mothering of twins. triplets and quadruplets. Psychiatry 43: 189-204. 1980
Pregnancy Complicated by Acute Mania and Preeclampsia LESLEY
R.
DICKSON, M.D.
WILLIAM H. MILLER, M.D. MARK
T
C.
HYATT, M.D.
he treatment of mania and psychosis during pregnancy has been reviewed by several authors.1.2 Most have focused on the teratogenic effects and potential toxicity of psychotropic medications on the neonate. There has also been some discussion of the need to alter dosage patterns of lithium due to altered renal clearance during pregnancy. Although the risk-benefit ratio of the use of psychotropic medications has been briefly discussed, there has been little mention of treating a patient with acute mania and complicated pregnancy. In addition. we could find only VOLUME 33· NUMBER 2· SPRING 1992
one case report that mentions development of preeclampsia during a pregnancy of a patient treated with lithium. J We report a case where most of these problems became treatment issues. Received September 18. 1990; revised January 31. 1991; accepted March 15. 1991. From the Department of Psychiatry. College of Medicine. University of Kentucky and Chandler Medical Center. Lexington. Address reprint requests to Dr. Dickson. Depl. of Psychiatry. Annex II. Universily of Kentucky College of Medicine. Lexington. KY 40536. Copyright © 1992 The Academy of Psychosomatic Medicine.
221
Case Reports
Case Report A 39-year-old, gravida 3, para 0, abortion 2, white female with a history of bipolar affective disorder was admitted at 27 weeks gestation, as documented by early ultrasounds. She had been admitted previously at 22 weeks gestation to a hospital in another state with documented seizures and acute psychosis. An extensive workup at that time had revealed no neurological cause for the seizures, and she received a diagnosis of eclampsia and acute mania. The patient responded well to bed rest, phenytoin, and thiothixene. After 5 days, the patient was felt to be competent and, despite a recommendation for continued hospitalization, the patient was discharged against medical advice and was referred for care at our institution. She later discontinued the thiothixene but continued the phenytoin. On admission to our hospital, the patient had a blood pressure of 136/104, 2-3+ pitting edema in her lower extremities, 3~+ deep tendon reflexes, with 3 beats of clonus and 3+ proteinuria. She had exhibited delusional behavior for at least 3 days before admission. The patient was placed on bed rest, continued phenytoin, and was started on intravenous MgS04 • Preeclampsia was diagnosed, and an appropriate preeclamptic workup was performed. Her physical symptoms improved in the next 48 hours, with decreases in her blood pressure and hyperreflexia. The phenytoin was discontinued. The patient's behavior became increasingly agitated, with pacing, rapid speech, bizarre behavior and paranoid ideation. Ten days after admission, a psychiatric consultation was obtained, and an acute manic episode was diagnosed. Thiothixene (Navane, 5 mg bid) was initiated, with some improvement over 48 hours. The patient continued to exhibit some manic behavior and began refusing the thiothixene because it made her feel "slowed down." Because she expressed a preference for lithium, lithium carbonate (300 mg tid) was added on Day 12 of admission. Unknown to the Psychiatry Service, the Obstetrical Service also placed the patient on a sodium-restricted diet, as per their usual protocol. The Obstetrical Service requested the patient remain on the Obstetrical floor because her medical condition was deemed too precarious for transfer to the Psychiatry Service. During the next 48 hours, the patient's liver function studies, 24-hour urine protein, creatinine clearance, and platelet count all worsened. The patient's blood pressure increased to 140-150/98222
104, and the fetus began to have severe variable decelerations. Induction of labor was begun with oxytocin and prostaglandins on Day 15. See Table I for a summary of hospital course. A 91 O-g infant with Apgars of 6 and 8 was precipitously delivered on Day 16 of admission. The infant did well in the neonatal intensive care unit, but an increase in serum sodium required treatment with fluids. A lithium level obtained from the infant 5 days after birth was 0.37. The patient's lithium level on the day of delivery was 1.05. The patient's preeclamptic and manic symptoms resolved postpartum. On Day 21 the patient was discharged on lithium and thiothixene, with psychiatric follow-up.
Discussion This patient's case demonstrates several points to be considered when treating a patient with acute mania and a complicated pregnancy. First, manic symptoms such as delusions and hyperactivity can lead to noncompliance, resulting, as in this case, with pacing when bed rest is indicated, refusal of medications, and a discharge against medical advice. The lack of early psychiatric consultation probably alIowed her symptoms to reach serious proportions, which could have been avoided had the significance of her symptoms been recognized earlier. The need for close cooperation between the Obstetrical and Psychiatry services becomes obvious in reviewing this case. Second, the use of neuroleptics alone was probably more appropriate than in combination with lithium in this pregnancy, where signs of renal insufficiency and the need for an early delivery were a concern. This patient was initialIy treated with neuroleptics, but lithium was added because she was refusing doses of neuroleptics. As was expected, issues of compliance complicated this patient's treatment. IdealIy, it would be best to manage such a patient in the security of a psychiatric inpatient service without medications, but this was prevented by the precarious medical situation. Third, we must consider that lithium may have added to the renal insufficiency by direct effects on a kidney already functionally compromised by preeclampsia. There are four reported types of adverse effects of lithium on the kidney: PSYCHOSOMATtCS
Case Reports
have likely caused decreased perfusion of various organ systems such as the hepatic and renal systems, which were already compromised by the preeclampsia.5 The other problem that deserves consideration was the effect of the sodium-restricted diet. When the amount of sodium reaching the proximal tubules is decreased, lithium is preferential1y resorbed. 4 This can cause rapid escalations in lithium levels and probably explains the level of 1.05 on first measurement. This level could have added to the renal toxicities already discussed and might also have complicated the function of other organ systems, thus confusing the picture in detennining how the patient's preeclampsia was progressing. In summary, lithium could have contributed to fluid loss, decreased intravascular volume, mildly toxic lithium levels. and increased proteinuria. All of these may have contributed to the rapid worsening of the patient's hypertension, renal function, and neurological irritability, ne-
vasopressin or antidiuretic honnone (ADH)-resistant nephrogenic diabetes insipidus, acute renal failure, which is usual1y associated with lithium toxicity, tubulointerstitial nephropathy, and lithium-induced nephrotic syndrome. 4 This patient did not experience acute renal failure, and we have no evidence of nephropathy because a biopsy was not done. The clinical significance of the nephropathy remains unclear and does not appear to be regularly associated with renal problems. The nephrotic syndrome is rare, and, in this patient, proteinuria clearly predated the addition of lithium, although the lithium could certainly have contributed to it. The most likely deleterious effect of lithium for this patient was the possible inhibition of ADH action on the distal convoluted tubules of the nephron. This leads to a decrease in resorption of water and resultant polyuria. In this patient, the fluid loss may have caused decreased intravascular volume which could have rapidly led to increased lithium levels. In addition, the decrease of intravascular volume would
TABLE I. Medications and laboratory values during hospital stay Day
3
5
Medications MgS04 --I (2 grams!hour) Thiothixine (Navane). (5 mg bid) Lithium (300mg tid) Sodium restriction Lab Values Lithium 2.4 2.5 Albumin Protein 5.6 5.9 27 SGPT 53 42 SGOT 65 Platelels, x 1,000 193 190 102 erCl Protein, mg loss/day 368 Urinary protein 1+ 3+ Blood pressure Systolic 136 104 128 Diastolic 104 70 78
7
1.9 4.7 103 82 114 989 2+
9
10
II
12
13
14 15
2.3 5.4 130 105 75 105 93.6 116 118 2.8844,130 4.130 1+ 2+ 2+ 2+
130 130 130 80 80 80
130 130 80 70
16
17
18
19 20 21
1.05 2.0 5.3 167 183
1.02 2.2 1.7 2.3 5.9 4.7 5.8 107 76 186 92 44 193
76
71
82
2+
0.88 0.81
97 95 1,170
2,520 2+
22 23
2+
132 142 140 151 132 128 128 75 74 98 87 85 70 84
Note: Induction was on Day 15; delivery was on Day 16. SGPT =serum glUlamic pyruvic transaminase; SOOT =serum glutamic-oxaloacetic transaminase
VOLUME 33· NUMBER 2· SPRING 1992
223
Case Reports
cessitating early delivery. Continued study of the effects of both lithium and pregnancy on the function of the kidney will prove useful in the management of acute mania in a pregnant patient. In considering treatment of a patient who has a pregnancy complicated by both preeclampsia and mania. it would be wise to avoid lithium.
Low-dose, high-potency neuroleptics to control the psychotic symptoms would appear to be most useful. Addition of a low dosage of a benzodiazepine such as lorazepam to help control agitation can be considered. Finally, close cooperation and monitoring by both the Obstetrics and Psychiatry Services are essential.
References I. Sitland-Marken PA. Rickman LA. Wells BG. et al: Pharmacological management of acute mania in pregnancy. J elin PsycllOpharmam/9:78-87. 1989 2. Numberg HG: An overview of somatic lreatment of psychosis during pregnancy and post-panum. Gen Hosp Psychiatry 11:328-338. 1989 3. Burgess HA: When a patienl on lithium is pregnant. Am
J Nursing 79: 1989-1990. 1979 4. Lazarus JH: Effect of lithium on the kidney. in Endocrim' and Metaholic Efji'cts of Lithium. New York. Plenum. 1986 5. Davison JM. Lindheimer MD: Hypenension in pregnancy. in Gynem/ogy and Ohstl'trics. edited by Sciarra JJ. Philadelphia. Lippincoll. 19119
Auoxetine and Organic Mood Syndrome F. BESSETTE, D.O. LINDA G. PETERSON, M.D.
ROBERT
ffective illness ~fter ~Iosed ~ead injury has been well descnbed In the hterature. ' -J Saran I has reported three hypotheses for the relationship between head injury and the development of affective symptoms. First, head injury may disrupt brain catecholamine and cholinergic metabolism directly. Second. it may produce neuroendocrine disturbances related to pituitary involvement. Finally, it may disrupt the arousal effects of the mesencephalic formation. I Based on these hypotheses. it might be expected that organic mood syndrome secondary to closed
A
Received October 19. 1990: revised February 5. 1991: accepled March 15. 1991. From Ihe Depanment of Psychiatry. University of Massachusells Medical Center. Worcester. Address reprint requests to Dr. Pelerson. Dept. of Psychiatry. University of Massachusells Medical Center. 55 Lake Ave. Nonh. Worcester. MA 01605. Copyrighl © 1992 The Academy of Psychosomatic Medicine.
224
head injury would respond to antidepressant treatment because the primary effects of most antidepressants are on the monoaminergic systems noted above. It might also be expected, however. that there would be particular difficulty with the anticholinergic side effects of the tricyclic antidepressants because of the cholinergic disturbance in these patients. F1uoxetine is a bicyclic antidepressant that is a potent inhibitor of the presynaptic reuptake of serotonin. 4 Fluoxetine is indicated for the treatment of major depression with efficacy comparable to the tricyclic antidepressants; the frequency of side effects. however. is low and dose related. The most common side effects of fluoxetine are nausea. anxiety, insomnia, anorexia, diarrhea. nervousness, and headache. There is no report on the usefulness of tluoxetine for treating organic mood syndrome after closed head injury. The following is the report of a case PSYCHOSOMATICS
The authors acknowledRe Donald Kornfeld. MD .. and Philip Muskin. MD .. ofthe Consulta-
tion-Liaison Service at Columhia-Preshyterian Medical Center for their advice and support.
References I. Downey J. Yingling S. McKinney M, et al: Mood disor-
2. 3.
4.
5.
6.
ders. psychiatric symptoms. and distress in women presenting for infenility evaluation. Fenil Steril 52:425-432. 1989 Menning BE: The emotional needs of infenile couples. FerriJ SteriJ 34:313-319.1980 Rosenfield DL. Mitchell E: Treating the emotional aspects of infenility: counseling services in an infenilily clinic. Am J Obstet Gynecol 135: 177-180. 1979 Seibel MM. Levin S: A new era in reproductive technologies: Ihe emotional stages of in vitro fenilization. Journal of In-Vitro Fertili;ation and Embryo Transfer 4:135-140.1987 Morse C. Dennerslein L: Infenile couples enrering an in vitro fenilization programme: a preliminary survey. Ann NY Acad Sci 4:207-219, 1985 Freeman EW. Boxer AS. Rickels K. el al: Psychological
evalualion and suppon in a program of in vitro fenilization and embryo transfer. FerriJ Steril 43:48-53. 1985 7. Haselline FP. Mazure C. DeL'aune W. el al: Psychological inrerviews in couples undergoing in vitro fenilizalion. Ann NY Acad Sci 422:504-516. 1985 8. Baram D. Tounelot E. Muechler E. et al: Psychological adjustment following unsuccessful in vitro fenilil.3lion. Journal of Psychosomatic Obstetrics and GynecoloKY 9:181-190.1988 9. Leiblum SR. Kemmann E. Colburn D. et al: Unsuccessful in vilro fenilization: a follow up sludy. Journal ofIn- Vitro FertiJi;ation and Embryo Transfer 4:46-50. 1987 10. Uvnas- Moberg K: The gastrointestinal tract in growth and reproduction. Sci Am July:78-83. 1989 II. Goshen-Gollstein ER: The mothering of twins. triplets and quadruplets. Psychiatry 43: 189-204. 1980
Pregnancy Complicated by Acute Mania and Preeclampsia LESLEY
R.
DICKSON, M.D.
WILLIAM H. MILLER, M.D. MARK
T
C.
HYATT, M.D.
he treatment of mania and psychosis during pregnancy has been reviewed by several authors.1.2 Most have focused on the teratogenic effects and potential toxicity of psychotropic medications on the neonate. There has also been some discussion of the need to alter dosage patterns of lithium due to altered renal clearance during pregnancy. Although the risk-benefit ratio of the use of psychotropic medications has been briefly discussed, there has been little mention of treating a patient with acute mania and complicated pregnancy. In addition. we could find only VOLUME 33· NUMBER 2· SPRING 1992
one case report that mentions development of preeclampsia during a pregnancy of a patient treated with lithium. J We report a case where most of these problems became treatment issues. Received September 18. 1990; revised January 31. 1991; accepted March 15. 1991. From the Department of Psychiatry. College of Medicine. University of Kentucky and Chandler Medical Center. Lexington. Address reprint requests to Dr. Dickson. Depl. of Psychiatry. Annex II. Universily of Kentucky College of Medicine. Lexington. KY 40536. Copyright © 1992 The Academy of Psychosomatic Medicine.
221
Case Reports
Case Report A 39-year-old, gravida 3, para 0, abortion 2, white female with a history of bipolar affective disorder was admitted at 27 weeks gestation, as documented by early ultrasounds. She had been admitted previously at 22 weeks gestation to a hospital in another state with documented seizures and acute psychosis. An extensive workup at that time had revealed no neurological cause for the seizures, and she received a diagnosis of eclampsia and acute mania. The patient responded well to bed rest, phenytoin, and thiothixene. After 5 days, the patient was felt to be competent and, despite a recommendation for continued hospitalization, the patient was discharged against medical advice and was referred for care at our institution. She later discontinued the thiothixene but continued the phenytoin. On admission to our hospital, the patient had a blood pressure of 136/104, 2-3+ pitting edema in her lower extremities, 3~+ deep tendon reflexes, with 3 beats of clonus and 3+ proteinuria. She had exhibited delusional behavior for at least 3 days before admission. The patient was placed on bed rest, continued phenytoin, and was started on intravenous MgS04 • Preeclampsia was diagnosed, and an appropriate preeclamptic workup was performed. Her physical symptoms improved in the next 48 hours, with decreases in her blood pressure and hyperreflexia. The phenytoin was discontinued. The patient's behavior became increasingly agitated, with pacing, rapid speech, bizarre behavior and paranoid ideation. Ten days after admission, a psychiatric consultation was obtained, and an acute manic episode was diagnosed. Thiothixene (Navane, 5 mg bid) was initiated, with some improvement over 48 hours. The patient continued to exhibit some manic behavior and began refusing the thiothixene because it made her feel "slowed down." Because she expressed a preference for lithium, lithium carbonate (300 mg tid) was added on Day 12 of admission. Unknown to the Psychiatry Service, the Obstetrical Service also placed the patient on a sodium-restricted diet, as per their usual protocol. The Obstetrical Service requested the patient remain on the Obstetrical floor because her medical condition was deemed too precarious for transfer to the Psychiatry Service. During the next 48 hours, the patient's liver function studies, 24-hour urine protein, creatinine clearance, and platelet count all worsened. The patient's blood pressure increased to 140-150/98222
104, and the fetus began to have severe variable decelerations. Induction of labor was begun with oxytocin and prostaglandins on Day 15. See Table I for a summary of hospital course. A 91 O-g infant with Apgars of 6 and 8 was precipitously delivered on Day 16 of admission. The infant did well in the neonatal intensive care unit, but an increase in serum sodium required treatment with fluids. A lithium level obtained from the infant 5 days after birth was 0.37. The patient's lithium level on the day of delivery was 1.05. The patient's preeclamptic and manic symptoms resolved postpartum. On Day 21 the patient was discharged on lithium and thiothixene, with psychiatric follow-up.
Discussion This patient's case demonstrates several points to be considered when treating a patient with acute mania and a complicated pregnancy. First, manic symptoms such as delusions and hyperactivity can lead to noncompliance, resulting, as in this case, with pacing when bed rest is indicated, refusal of medications, and a discharge against medical advice. The lack of early psychiatric consultation probably alIowed her symptoms to reach serious proportions, which could have been avoided had the significance of her symptoms been recognized earlier. The need for close cooperation between the Obstetrical and Psychiatry services becomes obvious in reviewing this case. Second, the use of neuroleptics alone was probably more appropriate than in combination with lithium in this pregnancy, where signs of renal insufficiency and the need for an early delivery were a concern. This patient was initialIy treated with neuroleptics, but lithium was added because she was refusing doses of neuroleptics. As was expected, issues of compliance complicated this patient's treatment. IdealIy, it would be best to manage such a patient in the security of a psychiatric inpatient service without medications, but this was prevented by the precarious medical situation. Third, we must consider that lithium may have added to the renal insufficiency by direct effects on a kidney already functionally compromised by preeclampsia. There are four reported types of adverse effects of lithium on the kidney: PSYCHOSOMATtCS
Case Reports
have likely caused decreased perfusion of various organ systems such as the hepatic and renal systems, which were already compromised by the preeclampsia.5 The other problem that deserves consideration was the effect of the sodium-restricted diet. When the amount of sodium reaching the proximal tubules is decreased, lithium is preferential1y resorbed. 4 This can cause rapid escalations in lithium levels and probably explains the level of 1.05 on first measurement. This level could have added to the renal toxicities already discussed and might also have complicated the function of other organ systems, thus confusing the picture in detennining how the patient's preeclampsia was progressing. In summary, lithium could have contributed to fluid loss, decreased intravascular volume, mildly toxic lithium levels. and increased proteinuria. All of these may have contributed to the rapid worsening of the patient's hypertension, renal function, and neurological irritability, ne-
vasopressin or antidiuretic honnone (ADH)-resistant nephrogenic diabetes insipidus, acute renal failure, which is usual1y associated with lithium toxicity, tubulointerstitial nephropathy, and lithium-induced nephrotic syndrome. 4 This patient did not experience acute renal failure, and we have no evidence of nephropathy because a biopsy was not done. The clinical significance of the nephropathy remains unclear and does not appear to be regularly associated with renal problems. The nephrotic syndrome is rare, and, in this patient, proteinuria clearly predated the addition of lithium, although the lithium could certainly have contributed to it. The most likely deleterious effect of lithium for this patient was the possible inhibition of ADH action on the distal convoluted tubules of the nephron. This leads to a decrease in resorption of water and resultant polyuria. In this patient, the fluid loss may have caused decreased intravascular volume which could have rapidly led to increased lithium levels. In addition, the decrease of intravascular volume would
TABLE I. Medications and laboratory values during hospital stay Day
3
5
Medications MgS04 --I (2 grams!hour) Thiothixine (Navane). (5 mg bid) Lithium (300mg tid) Sodium restriction Lab Values Lithium 2.4 2.5 Albumin Protein 5.6 5.9 27 SGPT 53 42 SGOT 65 Platelels, x 1,000 193 190 102 erCl Protein, mg loss/day 368 Urinary protein 1+ 3+ Blood pressure Systolic 136 104 128 Diastolic 104 70 78
7
1.9 4.7 103 82 114 989 2+
9
10
II
12
13
14 15
2.3 5.4 130 105 75 105 93.6 116 118 2.8844,130 4.130 1+ 2+ 2+ 2+
130 130 130 80 80 80
130 130 80 70
16
17
18
19 20 21
1.05 2.0 5.3 167 183
1.02 2.2 1.7 2.3 5.9 4.7 5.8 107 76 186 92 44 193
76
71
82
2+
0.88 0.81
97 95 1,170
2,520 2+
22 23
2+
132 142 140 151 132 128 128 75 74 98 87 85 70 84
Note: Induction was on Day 15; delivery was on Day 16. SGPT =serum glUlamic pyruvic transaminase; SOOT =serum glutamic-oxaloacetic transaminase
VOLUME 33· NUMBER 2· SPRING 1992
223
Case Reports
cessitating early delivery. Continued study of the effects of both lithium and pregnancy on the function of the kidney will prove useful in the management of acute mania in a pregnant patient. In considering treatment of a patient who has a pregnancy complicated by both preeclampsia and mania. it would be wise to avoid lithium.
Low-dose, high-potency neuroleptics to control the psychotic symptoms would appear to be most useful. Addition of a low dosage of a benzodiazepine such as lorazepam to help control agitation can be considered. Finally, close cooperation and monitoring by both the Obstetrics and Psychiatry Services are essential.
References I. Sitland-Marken PA. Rickman LA. Wells BG. et al: Pharmacological management of acute mania in pregnancy. J elin PsycllOpharmam/9:78-87. 1989 2. Numberg HG: An overview of somatic lreatment of psychosis during pregnancy and post-panum. Gen Hosp Psychiatry 11:328-338. 1989 3. Burgess HA: When a patienl on lithium is pregnant. Am
J Nursing 79: 1989-1990. 1979 4. Lazarus JH: Effect of lithium on the kidney. in Endocrim' and Metaholic Efji'cts of Lithium. New York. Plenum. 1986 5. Davison JM. Lindheimer MD: Hypenension in pregnancy. in Gynem/ogy and Ohstl'trics. edited by Sciarra JJ. Philadelphia. Lippincoll. 19119
Auoxetine and Organic Mood Syndrome F. BESSETTE, D.O. LINDA G. PETERSON, M.D.
ROBERT
ffective illness ~fter ~Iosed ~ead injury has been well descnbed In the hterature. ' -J Saran I has reported three hypotheses for the relationship between head injury and the development of affective symptoms. First, head injury may disrupt brain catecholamine and cholinergic metabolism directly. Second. it may produce neuroendocrine disturbances related to pituitary involvement. Finally, it may disrupt the arousal effects of the mesencephalic formation. I Based on these hypotheses. it might be expected that organic mood syndrome secondary to closed
A
Received October 19. 1990: revised February 5. 1991: accepled March 15. 1991. From Ihe Depanment of Psychiatry. University of Massachusells Medical Center. Worcester. Address reprint requests to Dr. Pelerson. Dept. of Psychiatry. University of Massachusells Medical Center. 55 Lake Ave. Nonh. Worcester. MA 01605. Copyrighl © 1992 The Academy of Psychosomatic Medicine.
224
head injury would respond to antidepressant treatment because the primary effects of most antidepressants are on the monoaminergic systems noted above. It might also be expected, however. that there would be particular difficulty with the anticholinergic side effects of the tricyclic antidepressants because of the cholinergic disturbance in these patients. F1uoxetine is a bicyclic antidepressant that is a potent inhibitor of the presynaptic reuptake of serotonin. 4 Fluoxetine is indicated for the treatment of major depression with efficacy comparable to the tricyclic antidepressants; the frequency of side effects. however. is low and dose related. The most common side effects of fluoxetine are nausea. anxiety, insomnia, anorexia, diarrhea. nervousness, and headache. There is no report on the usefulness of tluoxetine for treating organic mood syndrome after closed head injury. The following is the report of a case PSYCHOSOMATICS
