Two cases of deep vein thrombosis associated with a combined paroxetine and zotepine therapy

Psychological and Psychopharmacological Interventions in Psychocardiology

Patients with mental disorders have an increased risk to develop cardiovascular disease (CVD), and CVD are frequently comorbid with especially adjustment, anxiety and depressive disorders. Therefore, clinicians need to be aware of effective and safe psychological and pharmacological treatment strategies for patients with comorbid CVD and mental disorders. Cognitive behavioral therapy and third-wave of cognitive-behavioral therapy are effective for patients with CVD and mental disorders. Internet-based psychological treatments may also be considered. In more severe cases, psychopharmacological drugs are frequently used. Although generally well tolerated and efficacious, drug- and dose-dependent side effects require consideration. Among antidepressants, selective serotonin reuptake inhibitors, selective serotonin and noradrenalin reuptake inhibitors, and newer antidepressants, such as mirtazapine, bupropion, agomelatine, and vortioxetine, can be considered, while tricyclic antidepressants should be avoided due to their cardiac side effects. Mood stabilizers have been associated with arrhythmias, and some first- and second-generation antipsychotics can increase QTc and metabolic side effects, although substantial differences exist between drugs. Benzodiazepines are generally safe in patients with CVD when administered short-term, and may mitigate symptoms of acute coronary syndrome. Laboratory and ECG monitoring is always recommended in psychopharmacological drug-treated patients with CVD. Presence of a heart disease should not exclude patients from necessary interventions, but may require careful risk-benefit evaluations. Effectively and safely addressing mental disorders in patients with CVD helps to improve both conditions. Since CVD increase the risk for mental disorders and vice versa, care providers need to screen for these common comorbidities to comprehensively address the patients' needs.

Direct and indirect effects of psychopharmacological treatment on the cardiovascular system

Background Severe mental disorders, i.e. psychotic disorders, unipolar and bipolar disorders are associated with increased morbidity and mortality from cardiovascular and metabolic disorders. The underlying cause of this association is complex and comprises disorder specific alterations such as dysfunctions of immunological and hormonal systems, body-composition changes and health associated behaviors (smoking, sedentary lifestyle, alcohol intake and treatment compliance). Furthermore, some psychopharmacological drugs may exert unwanted side effects that impact the cardiovascular system. Methods This paper reviews studies concerning commonly used antidepressant and antipsychotics drugs with a particular focus on direct and indirect cardiovascular side effects. Results Newer antidepressant drugs have a favorable cardiovascular safety profile compared to tricyclic antidepressants. However, QTc prolongation, increased blood pressure and potentially higher risks of bleeding have been observed in some newer antidepressants. Some second generation (atypical) antipsychotics have raised concern because of indirect cardiovascular, metabolic side effects such as weight gain and disturbances in lipid and glucose metabolism. Conclusions Psychiatrists need to be aware of potential direct and indirect cardiovascular side effects and to include them in the risk/benefit assessment when choosing a specific individualized treatment.

Drug-Induced Thrombosis—Experimental, Clinical, and Mechanistic Considerations

Awareness of the dangers of drug-induced thrombosis has recently been heightened and led to demand for improved testing methodology. For example, reports indicating that some selective inhibitors of cyclooxygenase-2 (COX-2) increase the risk of myocardial infarction and atherothrombotic events caused the withdrawal of rofecoxib from global markets and the issuance of warnings concerning the usage of other COX-2 inhibitors. Drugs may exert a prothrombotic state by a variety of mechanisms–those affecting the vessel wall, the blood flow, and/or different blood constituents. Our review serves as an update to that of Gerhard Zbinden published in 1976 by presenting recently acquired data that more fully elucidate the different mechanisms by which drugs are believed to induce thrombogenic effects and discussing new methods used to detect these without losing sight of the classical pathology of thrombosis. We offer correlations between experimental findings and clinical data and conclude that, because drugs may induce a prothrombotic state by a variety of mechanisms, they should be tested for these using appropriate experimental methods and animal models.

Depression and risk of venous thromboembolism: a population-based retrospective cohort study

OBJECTIVE

This study investigated the relationship between depression and the risk of subsequent venous thromboembolism (VTE) development.

METHODS

We conducted a population-based retrospective cohort analysis by using data for the period of 2000 to 2011 from the Longitudinal Health Insurance Database 2000 of Taiwan. A depression cohort comprising 35,274 patients and a nondepression cohort comprising 70,548 patients matched according to sex, age, and index year with no history of VTE were evaluated. Cox proportional hazard regression analysis was used to assess the effects of depression and comorbidities, and the Kaplan-Meier method was applied to estimate the cumulative VTE incidence curves.

RESULTS

Compared with individuals without depression, depressed patients had a 1.38-fold greater risk (95% confidence interval = 1.09-1.73) of developing VTE. This risk was significantly higher in male and younger (≤49 years) patients. In addition, patients with comorbidities such as hypertension, diabetes, heart failure, and cancer had a higher risk of depression-associated VTE that was attenuated, although nonsignificantly, by antidepressant use.

CONCLUSIONS

The incidence of VTE in Taiwan is higher in depressed patients than in nondepressed patients. Moreover, men, people 49 years or younger, and patients with comorbidities have a significantly greater risk of VTE after depression.

Antipsychotic drugs and venous thromboembolism

Since preliminary case reports suggesting a possible association between first generation of antipsychotics and venous thromboembolism (VTE), consistent epidemiological data is now available suggesting a moderate association between antipsychotics and VTE. However, despite several hypotheses, the underlying mechanisms remain unknown or uncertain. In addition, if the association between antipsychotics and VTE is plausible, the intensity of this risk and the dose effect relationship do not have yet been determined. Prospective data is therefore needed in order to confirm and to quantify this association. Because of the level of uncertainty, the clinical impact on the prevention and the treatment of VTE in patients with a psychiatric illness appears to be low.

Association between antidepressants and venous thromboembolism in Taiwan

OBJECTIVE

To investigate the association between venous thromboembolism (VTE) and antidepressant use in an Asian population.

METHODS

The authors conducted a nested case-control study of 1888 patients with VTE and 11,222 matched controls enrolled in the National Health Insurance Research Database in Taiwan from 2001 to 2009. The antidepressant exposure status and potential confounding factors were measured and included in the analyses. Conditional logistic regressions were applied to determine the effect of antidepressant use on VTE.

RESULTS

We found a significant association of current antidepressant use with VTE in the total study sample (adjusted odds ratio [aOR], 1.59; 95% confidence interval (CI), 1.27-2.00). With regard to antidepressant classes and potency, we found that tricyclic antidepressants (aOR, 1.56; 95% CI, 1.11-2.18), serotonin 5-HT2A receptor blockers (aOR, 2.03; 95% CI, 1.27-3.24), and antidepressants with a low potency of serotonin reuptake inhibition (aOR, 1.57; 95% CI, 1.18-2.08) were associated with a significantly increased risk of VTE. When further stratifying by age, sex, and comorbid conditions, the VTE risk with antidepressant use was elevated among young and middle-aged adults, but not among the elderly. In addition, an elevated risk of VTE was observed in women and subjects without severe comorbid conditions, but not in men and subjects with severe comorbid conditions.

CONCLUSIONS

There was a small increase in VTE risk with antidepressant use. The prescription of antidepressant drugs should be cautious, and especially, should be based on clinical evaluations of benefits and risks. The underlying mechanisms of the interaction between antidepressants and VTE warrant further investigation.

Association between antipsychotic medication and venous thromboembolism

OBJECTIVE

This study aims to identify and review available evidence in the literature to determine the strength of association between antipsychotic medications and thromboembolism as an adverse effect.

METHOD

Electronic databases were searched for evidence.

RESULTS

A total of 15 case reports, 14 case series, two observational studies and three case-control studies were found in the literature. Two case control studies found significantly increased risk of venous thromboembolism (OR 13.3 and 7.1 respectively). The risk was high for low potency antipsychotics. Studies were critically appraised to determine the strength of evidence.

CONCLUSION

The studies reviewed indicate a significant association between antipsychotics and venous thromboembolism. Patients using the antipsychotics and those who prescribe them should be aware of this association.

Risk of venous thromboembolism due to antipsychotic drug therapy

An increasing number of reports suggest a link between venous thromboembolism (VTE) and the use of antipsychotics. To better understand this association the available body of evidence has been critically scrutinised. Relevant articles were identified in the databases Scopus and PubMed. Several observational studies using different methodologies show an increased risk of VTE in psychiatric patients. This elevated risk seems to be related to the use of antipsychotic medication and in particular to the use of clozapine and low-potency first-generation drugs. Many studies investigating the association have, however, methodological limitations. The biological mechanisms involved in the pathogenesis of this possible adverse reaction are largely unknown but several hypotheses have been suggested such as drug-induced sedation, obesity, increased levels of antiphospholipid antibodies, enhanced platelet aggregation, hyperhomocysteinemia and hyperprolactinemia. The association may also be related to underlying risk factors present in psychotic patients. Physicians need to be aware of this possible adverse drug reaction. Although supporting evidence has not been published they should consider discontinuing or switching the antipsychotic treatment in patients experiencing VTE. In addition, although data is lacking, the threshold for considering prophylactic antithrombotic treatment should be low when risk situations for VTE arise, such as immobilisation, surgery and so on.

Association between antipsychotic drugs, antidepressant drugs and venous thromboembolism: results from the EDITH case-control study

Cohort studies suggest that exposure to antipsychotic agents may be associated with an increased risk of venous thromboembolism (VTE). Few data concerning antidepressant drugs are available. Using a different methodological approach, the aim of this study was to estimate the association between neuroleptic and antidepressant drug use and the risk of VTE. We report the results of a case-control study designed to evaluate interactions between acquired and inherited risk factors of VTE. We included 677 cases hospitalized with deep vein thrombosis and or pulmonary embolism with no major acquired risk factor for VTE, and 677 controls matched for gender and age. Drug exposure was defined as current use of drugs at admission. Neuroleptic exposure was associated with an increased risk of VTE (OR = 2.1, 95% CI 1.4-3.2). Among neuroleptics, antipsychotic agent use was associated with a 3.5-fold increased risk of VTE (OR = 3.5, 95% CI 2.0-6.2). No association was found between antidepressant drug exposure and the risk of VTE (OR = 1.1, 95% CI 0.9-1.5). In this hospital-based case-control study, exposure to antipsychotic drugs was associated with an increased risk of VTE. These results, added to previous results, suggest that clinicians should consider antipsychotic drug exposure as a potential risk factor of VTE. More studies are needed in order to further elucidate this adverse effect, and to determine the possible predisposing factors and the biological mechanisms involved.

Adverse Effects of Atypical Antipsychotics in the Elderly

Use of antipsychotic medication is very common in the elderly and often an essential therapy. However, successful treatment in the elderly requires appropriate multidimensional assessment of the patient, knowledge of possible multiple co-morbidities, and awareness of the complexities of polypharmacy, age-dependent changes in pharmacokinetics and pharmacodynamics, and drug-drug interactions in this age group. Antipsychotics are known to have a number of adverse effects. New antipsychotics, such as amisulpride, clozapine, olanzapine, risperidone, quetiapine, ziprasidone, zotepine and aripiprazole, may interact with both dopamine and serotonin receptors. However, compared with conventional antipsychotics, they are less likely to cause extrapyramidal symptoms and are better tolerated in the elderly. At the same time, consistent differences between atypical antipsychotics have been demonstrated. Use of clozapine, for example, is limited by the risk of agranulocytosis, whereas this is not a disadvantage of olanzapine, risperidone, quetiapine and, more recently, ziprasidone, which are being widely used with good results in schizophrenia. However, use of the latter agents to treat the behavioural and psychological symptoms of dementia has been restricted because of recent observations of increased cardiovascular events in patients taking risperidone and olanzapine treatment. Nonetheless, careful review of the literature suggests that the available evidence does not support any causal relationship between use of risperidone or olanzapine and cardiovascular events. This article focuses on some of the main adverse effects commonly reported during administration of atypical antipsychotics to elderly patients. Such effects may be partly explained by age-related changes in pharmacokinetics and pharmacodynamics, and partly by the characteristics of the drugs themselves and their different receptor binding profiles.

Psychotropic drugs and fatal pulmonary embolism

PURPOSE

To examine the association between the use of psychotropic drugs and fatal pulmonary embolism.

METHODS

We conducted a national case-control study of fatal pulmonary embolism. Cases were 75 New Zealand men and women aged 15-59 years who died between 1 January 1990 and 31 December 1998, where the underlying cause of death was certified as codes 415.1, 451 or 453 of the International Classification of Diseases (9th Revision). Four controls, matched for sex and age, were selected from the general practice to which each case had belonged. Information was abstracted from the records of general practitioners, family planning clinics and psychiatric services. Odds ratios and 95% confidence intervals (95% CI) were estimated using conditional logistic regression. The key analyses were restricted to cases (n = 62) and controls (n = 243) without major risk factors for venous thromboembolism.

RESULTS

Compared to non-use, the adjusted odds ratio for current use of antipsychotic drugs was 13.3 (95% CI: 2.3-76.3). Low potency antipsychotics appeared to carry the highest risk (odds ratio: 20.8 [95% CI: 1.7-259.0]). The main drug involved was thioridazine. The odds ratio for current use of antidepressants was also increased, at 4.9 (95% CI: 1.1-22.5).

CONCLUSIONS

Our results for conventional antipsychotics are consistent with previous studies of non-fatal venous thromboembolism. The finding for antidepressants needs to be replicated in other studies.

Antipsychotic-induced venous thromboembolism: a review of the evidence

Psychiatric disorders themselves and treatment with conventional antipsychotic medications have in a number of early studies been associated with venous thromboembolism. In general, information on the relationship between antipsychotics and this possible adverse effect is in the form of case reports and open cross-sectional studies. However, recently the association between conventional antipsychotics and venous thrombosis has been strengthened as a result of the publication of a large, nested, case-control study. In this study, low-potency antipsychotic drugs were more strongly associated with venous thrombosis than high-potency drugs. In addition, recent epidemiological data support an association between the atypical antipsychotic agent clozapine and venous thromboembolism. The risk for venous thromboembolism seems to be highest during the initial months of treatment with antipsychotics. The biological mechanisms responsible for this possible adverse drug reaction are unknown, but a number of hypotheses have been suggested. The increased risk may be the result of drug-induced sedation, obesity, hyperleptinaemia, antiphospholipid antibodies and increased activity in the coagulation system. The association could also be related to underlying risk factors present in patients with psychosis such as smoking. Despite the limitations of present knowledge, clinicians should be aware of this possible adverse drug reaction and should consider interrupting or changing the antipsychotic regimen in patients in whom this reaction is suspected. More studies are needed in order to further elucidate this adverse effect, particularly to determine the incidence rate, possible predisposing factors and the biological mechanisms involved.

Conventional and Atypical Antipsychotics in the Elderly

Psychoses are major mental disorders marked by derangement of personality and loss of contact with reality, and are common in the elderly. Various hypotheses suggest the pivotal role of abnormal neurotransmitter and neuropeptide systems in psychotic patients, the most studied of which are the dopaminergic, serotonergic and glutamatergic systems. In particular, long-term treatment with antagonists at dopamine (D) and serotonin (5-hydroxytryptamine; 5-HT) receptors and agonists at glutamate receptors may improve symptoms. Treatment with antipsychotics is very common in the elderly and often indispensable. However, for successful treatment it is essential to have an adequate multidimensional assessment of the geriatric patient and of his or her polypathology and polypharmacy, together with knowledge of age-dependent pharmacokinetics and pharmacodynamic changes and drug-drug interactions.Conventional antipsychotics such as haloperidol, chlorpromazine, promazine, tiapride and zuclopenthixol are D(2)-receptor antagonists and inhibit dopaminergic neurotransmission in a dose-related manner. They decrease the intensity of all psychotic symptoms, although not necessarily to the same extent and with the same time course. Negative symptoms may persist to a much more striking extent than delusions, hallucinations and thought disorders, and there is a dose-related incidence of extrapyramidal side effects (EPS). Newer antipsychotics, such as clozapine, olanzapine, risperidone, quetiapine and ziprasidone, have a different receptor-binding profile, interacting with both D and 5-HT receptors; they less frequently cause EPS and are better tolerated in the elderly. Their use is advantageous because they are effective both on positive and negative symptoms of schizophrenia and may also be used in the treatment of behavioural disturbances in elderly and/or demented individuals. The use of clozapine is limited by the onset of agranulocytosis, whereas olanzapine, risperidone, quetiapine and, more recently, ziprasidone are widely used, with good results in the above-mentioned diseases.