Misuse of dothiepin

Abuse and misuse of antidepressants

BACKGROUND

Rates of prescription drug abuse have reached epidemic proportions. Large-scale epidemiologic surveys of this under-recognized clinical problem have not included antidepressants despite their contribution to morbidity and mortality. The purpose of this review is to look specifically at the misuse of antidepressants and how this behavior may fit into the growing crisis of nonmedical use of prescription drugs.

METHODS

We conducted a comprehensive search on PubMed, Medline, and PsycINFO using the search terms "antidepressant", "abuse", "misuse", "nonmedical use", "dependence", and "addiction", as well as individual antidepressant classes (eg, "SSRI") and individual antidepressants (eg, "fluoxetine") in various combinations, to identify articles of antidepressant misuse and abuse.

RESULTS

A small but growing literature on the misuse and abuse of antidepressants consists largely of case reports. Most cases of antidepressant abuse have occurred in individuals with comorbid substance use and mood disorders. The most commonly reported motivation for abuse is to achieve a psychostimulant-like effect. Antidepressants are abused at high doses and via a variety of routes of administration (eg, intranasal, intravenous). Negative consequences vary based upon antidepressant class and pharmacology, but these have included seizures, confusion, and psychotic-like symptoms.

CONCLUSION

The majority of individuals prescribed antidepressants do not misuse the medication. However, certain classes of antidepressants do carry abuse potential. Vulnerable patient populations include those with a history of substance abuse and those in controlled environments. Warning signs include the presence of aberrant behaviors. Physicians should include antidepressants when screening for risky prescription medication use. When antidepressant misuse is detected, a thoughtful treatment plan, including referral to an addiction specialist, should be developed and implemented.

Abuse of dosulepin to induce mania

BACKGROUND

Tricyclic antidepressants sometimes trigger mania in bipolar patients, but little is known about their potential for abuse in this regard.

CASE DESCRIPTION

We describe a man with bipolar disorder and alcohol dependency who abused dosulepin repeatedly in order to induce manic episodes. This caused serious problems for treatment and long-term outcome. We mention two further cases in which dosulepin or clomipramine was used deliberately to induce bipolar mania.

CONCLUSIONS

Tricyclic antidepressants can be abused to induce mood elevation in bipolar patients. This should be considered in cases of treatment-resistant mania.

Do antidepressants have any potential to cause addiction?

Addiction/dependence is a syndrome in which the hallmark is a compulsive pattern of drug use. Most authorities do not regard antidepressants as causing addiction but this has been challenged. This debate is explored drawing on case reports and related clinical and pharmacological data. An extensive literature review identified 21 English language case reports of antidepressant addiction (DSM-IV 'substance dependence' criteria) published since 1963. Sixteen involved tranylcypromine or amineptine and may reflect their dopaminergic and stimulant properties. Subject characteristics included male sex (14/21), personality problems (10/21) and prior substance misuse (14/21). Withdrawal or discontinuation symptoms have long been recognized with antidepressants but other features of addiction such as tolerance and compulsive use are exceptionally rare. Common clinical problems are patients taking subtherapeutic dosages and prematurely stopping antidepressants. The pharmacodynamic profiles of most antidepressants and the absence of acute 'desirable' effects make addiction theoretically unlikely. It is concluded that, with the exception of tranylcypromine and amineptine, antidepressants do not have a clinically significant liability to cause addiction. Tranylcypromine and amineptine should be avoided in those with a history of substance misuse. Patients prescribed other antidepressants should be told that they are not addictive.

Antidepressants are not drugs of abuse or dependence

There is a view among both the lay and medical audience that antidepressants are addictive. Non-compliance may arise as a result, with fatal consequences in some cases. In spite of the fact that anti-depressants have not proved to be drugs of abuse or dependence, confusion exists in the literature, particularly regarding the definition of the terms misuse and abuse in opioid addicts. Here, antidepressants are used to treat the depressive component of the addictive syndrome and have proved effective. In some instances, however, misuse of antidepressants has been found in methadone-treated addicts, which may be due to an enhancement of the effects of methadone. These effects have led some people to believe, wrongly, that antidepressants are substances of abuse. Our findings, from a review of the literature, show that such use of antidepressants by methadone patients is by definition misuse and not abuse. Further, the known withdrawal symptoms which occasionally follow cessation of anti-depressant therapy are not, on their own, an indication of addictive potential. We therefore conclude that antidepressant drugs are not substances of abuse and dependence.