May 2012

Vol. 24. No. 2


Recovery of cognitive functioning in patients with co-occurring bipolar disorder and alcohol dependence during early remission from an acute mood episode

Boaz Levy, PhD | Emily Manove, JD | Roger D. Weiss, MD

OBJECTIVE: This study aimed to examine cognitive recovery in patients with co-occurring bipolar disorder (BD) and alcohol dependence (AD) during remission from an acute mood disturbance.

METHOD: Fifty-five adult inpatients with bipolar I disorder (BD I) completed a neuropsychological battery, mood measures, and substance abuse measures upon discharge from the hospital and at a 3-month follow-up. Analyses provided group comparisons on these measures between patients who presented with co-occurring AD (n = 21) in the year prior to hospital admission and patients without a substance use disorder (SUD; n = 34).

RESULTS: Multivariate analyses of variance detected group differences on measures of visual memory, verbal memory, and executive functioning, using previous number of psychiatric admissions and age of onset of BD as covariates. These differences occurred both at discharge and follow-up. Between discharge and follow-up, the group without SUD exhibited more substantial gains than the group of dually diagnosed patients on free recall of verbal and visual materials and on a measure of cognitive flexibility.

CONCLUSIONS: Patients with co-occurring BD and AD may suffer from more severe cognitive dysfunction and less favorable recovery of cognitive deficits than patients without SUD over the course of remission from a mood episode.



Serotonin syndrome vs neuroleptic malignant syndrome: A contrast of causes, diagnoses, and management

Paul J. Perry, PhD | Courtney A. Wilborn, PharmD

BACKGROUND: Serotonin syndrome (SS) and neuroleptic malignant syndrome (NMS) are uncommon but potentially life-threatening adverse reactions associated with psychotropic medications. Polypharmacy and the similar presentation of SS and NMS make diagnosis of the 2 syndromes problematic.

METHODS: A MEDLINE search was performed for the period 1960 to 2011 for case reports, review articles, and studies pertaining to SS and NMS.

RESULTS: The majority of available literature on SS and NMS consists of case reports, case-control studies, and retrospective reviews. In addition, diagnostic criteria have been developed to aid in the diagnosis and management of SS and NMS.

CONCLUSIONS: SS presents as mental status changes, autonomic nervous system disturbances, neurologic manifestations, and hyperthermia. Similarly, NMS presents as muscle rigidity, hyperpyrexia, mental status changes, and autonomic instability. However, the clinical laboratory profile of elevations in creatine kinase, liver function tests (lactate dehydrogenase, aspartate transaminase), and white blood cell count, coupled with a low serum iron level, distinguishes NMS from SS among patients taking neuroleptic and serotonin agonist medications simultaneously. For both SS and NMS, immediate discontinuation of the causative agent is the primary treatment, along with supportive care. For NMS, dantrolene is the most effective evidence-based drug treatment whereas there are no evidence-based drug treatments for SS. A 2-week washout of neuroleptic medication minimizes the chance of recurrence.


Managing medical and psychiatric comorbidity in individuals with major depressive disorder and bipolar disorder

Roger S. McIntyre, MD, FRCPC | Michael Rosenbluth, MD, FRCPC | Rajamannar Ramasubbu, MD, FRCPC, MSc | David J. Bond, MD, FRCPC | Valerie H. Taylor, MD, PhD, FRCPC | Serge Beaulieu, MD, PhD, FRCPC | Ayal Schaffer, MD, FRCPC

BACKGROUND: Most individuals with mood disorders experience psychiatric and/or medical comorbidity. Available treatment guidelines for major depressive disorder (MDD) and bipolar disorder (BD) have focused on treating mood disorders in the absence of comorbidity. Treating comorbid conditions in patients with mood disorders requires sufficient decision support to inform appropriate treatment.

METHODS: The Canadian Network for Mood and Anxiety Treatments (CANMAT) task force sought to prepare evidence- and consensus-based recommendations on treating comorbid conditions in patients with MDD and BD by conducting a systematic and qualitative review of extant data. The relative paucity of studies in this area often required a consensus-based approach to choosing and sequencing treatments.

RESULTS: Several principles emerge when managing comorbidity. They include, but are not limited to: establishing the diagnosis, risk assessment, establishing the appropriate setting for treatment, chronic disease management, concurrent or sequential treatment, and measurement-based care.

CONCLUSIONS: Efficacy, effectiveness, and comparative effectiveness research should emphasize treatment and management of conditions comorbid with mood disorders. Clinicians are encouraged to screen and systematically monitor for comorbid conditions in all individuals with mood disorders. The common comorbidity in mood disorders raises fundamental questions about overlapping and discrete pathoetiology.



Lorazepam withdrawal-induced catatonia

James J. Amos, MD

TO THE EDITOR: Catatonia can be associated with a number of medical and psychiatric disorders including sedative-hypnotic withdrawal. The mechanism is unclear but may involve γ-aminobutyric acid (GABA) transmission changes. I report a case of lorazepam withdrawal-induced catatonia in a postsurgical patient who had been taking lorazepam at home as prescribed by her psychiatrist. This case begs the question of whether to continue previously prescribed benzodiazepines in the intensive care unit (ICU) postoperatively in light of a recent study showing that lorazepam administration in this context is an independent risk factor for delirium…


Delayed response to repetitive transcranial magnetic stimulation treatment for intractable auditory hallucinations in schizoaffective disorder

David Kelly, BM, BS, FRANZCP, FaChAM | Shane Gill, BMBS, FRANZCP, Dip. Psychother | Patrick Clarke, MBBS, FRANZCP | Cassandra Burton, B Psych. (Hons) | Cherrie Galletly, MBChB, DPM, FRANZCP, PhD

TO THE EDITOR: There have been a small number of treatment trials of low frequency repetitive transcranial magnetic stimulation (rTMS) to the left temporoparietal cortex for chronic, intractable auditory hallucinations (AHs).1 We report a possible “delayed response” to rTMS. rTMS has been demonstrated to be an effective treatment for major depressive disorder (MDD).2 The availability of rTMS varies considerably in different countries. In 2008 the FDA approved the marketing of the NeuroStar TMS therapy device for treating adults with MDD who have failed to achieve satisfactory improvement with prior antidepressant medication.3 The use of rTMS to treat other conditions or symptoms, such as AHs, generally is regarded as experimental…