Drug treatment of depression. Citalopram in overdose may result in serious morbidity and death

Exceptions to the rule of informed consent for research with an intervention

BACKGROUND

In specific situations it may be necessary to make an exception to the general rule of informed consent for scientific research with an intervention. Earlier reviews only described subsets of arguments for exceptions to waive consent.

METHODS

Here, we provide a more extensive literature review of possible exceptions to the rule of informed consent and the accompanying arguments based on literature from 1997 onwards, using both Pubmed and PsycINFO in our search strategy.

RESULTS

We identified three main categories of arguments for the acceptability of a consent waiver: data validity and quality, major practical problems, and distress or confusion of participants. Approval by a medical ethical review board always needs to be obtained. Further, we provide examples of specific conditions under which consent waiving might be allowed, such as additional privacy protection measures.

CONCLUSIONS

The reasons legitimized by the authors of the papers in this overview can be used by researchers to form their own opinion about requesting an exception to the rule of informed consent for their own study. Importantly, rules and guidelines applicable in their country, institute and research field should be followed. Moreover, researchers should also take the conditions under which they feel an exception is legitimized under consideration. After discussions with relevant stakeholders, a formal request should be sent to an IRB.

Reversal of Citalopram-Induced Junctional Bradycardia with Intravenous Sodium Bicarbonate

The cardiotoxicity of tricyclic antidepressants is a well-described phenomenon requiring serious consideration in patients who have taken an overdose. In patients who are at high risk for suicide attempts, selective serotonin reuptake inhibitors (SSRIs) were thought to constitute a safe alternative. However, evidence is accumulating that they, too, possess proarrhythmic properties, which must be reconciled in the setting of an overdose. An 82-year-old woman intentionally ingested citalopram 1.6 g. Several hours after presentation, she developed sinus arrest and junctional bradycardia that resolved after infusion of intravenous sodium bicarbonate solution. Thereafter, she demonstrated no further electrocardiographic abnormalities and was safely transferred to the psychiatry service without the need for a temporary transvenous pacemaker. The dramatic effect of the sodium bicarbonate on the arrhythmia represents a probable event according to the Naranjo probability scale. Intravenous sodium bicarbonate may serve as an effective antidote to SSRI-induced bradyarrhythmias.

'Atypical' antidepressants in overdose: clinical considerations with respect to safety

The 'atypical' antidepressants comprise a heterogenous class with wide variation in presentation and management during overdose, both when compared with each other and with more traditional agents.Further toxico-epidemiological data are required to make definitive predictions about the clinical effects of most of these agents in overdose. Here, however, we review the available information in a manner intended to benefit both prescribers and clinical toxicologists. Our conclusion is that there can be no generic response by medical practitioners as to the 'safety' of these new antidepressants. Though undoubtedly exhibiting fewer problems in specific areas than some of the older classes of agents (e.g. arrhythmias with tricyclic antidepressants) each nonetheless presents unique safety problems. We experienced great difficulty obtaining accurate information from the manufacturers about the animal toxicity data upon which their recommended human dose limits were set. This highlights the uncertainties involved with too readily making 'safety' claims about these agents. The decision to prescribe 'atypical' antidepressant medications alleged to be both efficacious and safe in overdose involves a medicolegal tension. This tension is between respecting patient autonomy through frank communication of the material risk of overdose and non-disclosure to avoid such harm.

Citalopram-induced bradycardia and presyncope

OBJECTIVE

To report a case of symptomatic bradycardia and hypotension that resulted from the therapeutic use of citalopram and to review any previous reports in the literature, from the manufacturer, and the Australian Drug Reaction Advisory Committee (ADRAC).

CASE SUMMARY

A 60-year-old white woman who had been taking citalopram 20 mg/d for two weeks presented to the hospital with a heart rate of 39 beats/min, mild hypotension (systolic BP 105 mm Hg), and a normal electrocardiogram (QTc < 440 msec), following a presyncopal episode. The patient was admitted for cardiac monitoring, and citalopram was discontinued. The bradycardia and hypotension resolved in the 48-hour period following cessation of citalopram. No other medical or pharmacologic cause was found for the adverse drug reaction.

DISCUSSION

Bradycardia has been reported rarely with citalopram in therapeutic doses, but this is the first detailed case with a dose of only 20 mg. The manufacturer reports bradycardia as an infrequent adverse effect (0.1-1%) of citalopram. There have been no reports to ADRAC or to the manufacturer in postmarketing surveillance. There is a case report of asymptomatic bradycardia in a patient whose dose was increased to 40 mg. In the case reported here, there was no QTc prolongation consistent with previous reports. The sinus bradycardia reported more often with therapeutic doses would appear to be distinct to QT abnormalities seen with citalopram overdose.

CONCLUSIONS

Citalopram should be used with care in the elderly and in persons with a history of heart disease. Heart rate and blood pressure should be monitored in the first week of therapy and when doses are modified.

Recruitment of frail older people to research: lessons learnt through experience

BACKGROUND

With the emphasis on the need for clinical governance and evidence-based practice in the healthcare industry there is increasing pressure on researchers to provide tangible research evidence of the effectiveness of new treatments, interventions and services. Recruiting an adequate size of sample is an important factor in the success or otherwise of a study to answer the research question. Difficulty in the recruitment of older people to research is widely acknowledged. However, much can be achieved to maximize the success of this process.

AIMS OF THE PAPER

This paper describes and explores our experience of recruiting frail, older people to research, with particular emphasis on ensuring quality in the process of research related to ethical practice.

CONCLUSIONS

Recruitment of frail older people to research can be a complex process in which the awareness and integrity of the researcher is key in upholding the principle of nonexploitation. It is important not to underestimate this difficulty and to ensure that the data collection period is sufficient to recruit adequate numbers. There is a need to continue to develop and refine recruitment skills and strategies to maximize the involvement of frail older people to research while protecting their right to refuse.

QTc interval prolongation associated with citalopram overdose: a case report and literature review

Citalopram is a member of the selective serotonin reuptake inhibitor class of antidepressants. In 1998, citalopram was approved by the US Food and Drug Administration for the treatment of major depression. Like the other selective serotonin reuptake inhibitors, citalopram enjoys a relatively benign side effect profile compared with the tricyclic antidepressants and the monoamine oxidase inhibitors. However, citalopram has been associated with electrocardiographic changes and seizures at doses greater than 600 mg per day. Fatalities have occurred with citalopram-only overdoses. We report the case of a healthy 21-year-old woman who developed QTc interval prolongation after ingestion of approximately 400 mg citalopram. We discuss the cardiac effects of citalopram, review previous cases of citalopram overdose, and discuss treatment recommendations.

Research and ethics: leaving exclusion behind

Research into mental disorders has continued to stimulate ethical debate during the past year. The urgent need for research in this field remains transparent, but the need for balance between enabling research and protecting patients continues to generate argument. Informed consent has been the subject of earnest debate in the United Kingdom, while attempts to protect incapacitated patients in the United States have attracted accusations of stifling research. From this baseline, a new movement is emerging, where there are few blanket bans or endorsements of specific types of research on specific groups of people. Instead, the emphasis is switching to patient participation in research and to the process of involving people in research projects.