Withdrawal symptoms after graduated cessation of imipramine in children

Tricyclic antidepressant withdrawal syndrome

OBJECTIVE

To examine the evidence pointing to a withdrawal syndrome associated with the discontinuation of tricyclic antidepressants (TCAs).

DATA SOURCES

MEDLINE searches were conducted. References used in relevant articles were screened for additional published information.

STUDY SELECTION

Emphasis was placed on human trials and individual case reports.

DATA SYNTHESIS

Symptoms of gastrointestinal and somatic distress, sleep disturbance, and movement disorders and mania have been temporally linked to withdrawal of TCAs. Cholinergic and adrenergic overdrive after TCA discontinuation have been suggested as the proposed mechanism for this syndrome. Reported symptoms may be psychosomatic or related to underlying mental illness.

CONCLUSIONS

Clinicians should be aware that discontinuation of TCA therapy may produce a withdrawal syndrome in some patients.

Antidepressant treatments in children and adolescents: II. Anxiety, physical, and behavioral disorders

Part II of this review critically evaluates antidepressants' (AD) efficacy in children and adolescents with anxiety, physical, and behavioral disorders as well as AD's side-effect spectrum. AD are administered increasingly to youths with specific anxiety syndromes phenomenologically paralleling those in adults which are responsive to AD (e.g., panic, obsessive-compulsive disorders). While several trials have not substantiated earlier theoretical considerations suggesting their usefulness in separation anxiety, their recent success in ameliorating obsessive-compulsive symptoms is encouraging. Systematic drug treatment studies however are limited because of the common overlap of anxiety syndromes with each other and other prominent psychiatric disturbances. More consistent benefits with AD are seen in the physical (e.g., enuresis, bulimia nervosa) and behavioral disorders (e.g., attention deficit-hyperactivity disorder). The wide-ranging benefits of AD in nonaffective disorders suggest AD are more appropriately viewed as broad spectrum pharmacotherapeutics.

Heterocyclic antidepressant, monoamine oxidase inhibitor and neuroleptic withdrawal phenomena

1. The authors review the literature describing acute symptomatology produced by the gradual or abrupt withdrawal of heterocyclic antidepressants, monoamine oxidase inhibitors (MAOI) and neuroleptics. 2. Withdrawal of heterocyclic antidepressants and antipsychotic agents causes similar symptomatology. Symptoms produced by the discontinuation of these drugs include nausea, emesis, anorexia, diarrhea, rhinorrhea, diaphoresis, myalgias, paresthesias, anxiety, agitation, restlessness, and insomnia. 3. Psychotic relapse is often presaged by anxiety, agitation, restlessness, and insomnia. Prodromal symptoms are distinguished from the effects of neuroleptic withdrawal by a temporal relationship of the latter to reductions in the dosage or discontinuation of antipsychotic agents. 4. Withdrawal of MAOIs can result in severe anxiety, agitation, pressured speech, sleeplessness or drowsiness, hallucinations, delirium, and paranoid psychosis. 5. MAOI withdrawal phenomena resemble the symptoms produced by the discontinuation of chronically administered psychostimulants. 6. The capacity of MAOIs to exert amphetamine-like effects presynaptically and the propensity of somatic treatments for depression to subsensitize presynaptic receptors regulating the release of catecholamines provide a basis for the development of psychotic symptoms upon the withdrawal of MAOI. Evidence for this hypothesis is reviewed.

Psychopharmacology in patients with hepatic and gastrointestinal disease

Psychotropic drugs often need to be prescribed to patients who also have pre-existing gastrointestinal (GI) and/or hepatic disease. This paper addresses the effect of GI and hepatic disease on the pharmacokinetics of psychotropic drugs, the effect of psychotropic drugs on pre-existing GI and hepatic diseases, the adverse GI and hepatic effects of psychotropic medications, the effects of GI medications on mental status, and the potential drug interactions between commonly prescribed GI medications and psychotropic drugs. Drug selection and dosage modification based on these considerations should allow safe and effective psychotropic treatment for patients with pre-existing GI and/or hepatic disease.

[Major depression in the child: validation of the syndrome and pharmacologic treatment]

The concept of childhood depression has been the object of controversies over many years. Recent developments have permitted rapid progress in many areas of research. The author offers an update on the validity of the diagnosis of major depression in childhood and on pharmacological treatment. He then attempts to delineate the uses and limitations of this therapeutic approach. In the latter part, practical advice on the use of drugs in childhood depression is given.

Antidepressant withdrawal syndromes: phenomenology and pathophysiology

The literature reporting signs and symptoms produced by the abrupt or gradual withdrawal of antidepressants is reviewed. Patients with antidepressant withdrawal syndromes are presented and principles governing their care are highlighted. Finally, the author summarizes evidence that antidepressant-induced supersensitivity of central and peripheral muscarinic cholinergic mechanisms may account for commonly observed antidepressant withdrawal phenomena.

Clinical consequences of abrupt drug withdrawal

Syndromes due to the abrupt withdrawal of drug treatment occur mainly with adrenal corticosteroids and agents with an action on either the cardiovascular system or central nervous system. The abrupt withdrawal of antihypertensive therapy typically results in symptoms of overactivity in the sympathetic nervous system. Clonidine and beta-adrenoceptor antagonists are clinically the most important of these agents, but numerous other drugs have been implicated. Overall, the problem is small when viewed in the context of the huge scale of prescribing of antihypertensive medicines. A more serious problem is the occurrence of crescendo angina following the abrupt withdrawal of beta-adrenoceptor antagonists. Although other factors may be involved, adaptive up-regulation of beta-adrenoceptor density is the most likely cause of crescendo angina, and renders the patient more susceptible to sympathetic nervous stimulation following withdrawal of treatment. Besides leading to a recrudescence of the disease being treated, the withdrawal of corticosteroids can cause a variety of syndromes. In particular, problems can arise as a result of treatment-induced suppression of the hypothalamic-pituitary-adrenal (HPA) axis. Another steroid withdrawal syndrome of unknown aetiology, without significant abnormalities of the HPA axis occurring, has been described. Benign intracranial hypertension may rarely follow steroid withdrawal in children. The syndromes associated with withdrawal of drugs which have an action on the CNS are poorly understood. Withdrawal of neuroleptic drugs can be followed by symptoms that resemble those described following withdrawal of anticholinergic drugs, and those agents with the greatest muscarinic-receptor-blocking properties are those which are most frequently implicated. However, the less common withdrawal dyskinesias are thought to reflect up-regulation of dopaminergic receptors during long term treatment. Gastrointestinal symptoms predominate following the abrupt withdrawal of antidepressants but hypomania and an 'akathisia-like' syndrome have been reported. Barbiturates are no longer recommended as hypnotics because of severe effects of withdrawal and the existence of safer alternatives. Short acting barbiturates can be withdrawn by replacement with either phenobarbitone (phenobarbitol) or diazepam and subsequent gradual reduction in dose. The recognition of dependency on benzodiazepines has been slow because of the similarity of mild withdrawal symptoms to the original problem which led to treatment being offered.(ABSTRACT TRUNCATED AT 400 WORDS)

Differential effects of antidepressant drugs on [3H]dihydroalprenolol and [3H]imipramine ligand recognition sites in olfactory bulbectomized and sham-lesioned rats

In the olfactory bulbectomy rat model of major depression, the binding of [3H]imipramine is increased by 60% in the midbrain, reduced by 30% in the pons and by 20% in the hippocampus, and unchanged in the hypothalamus 6 weeks after the bulbectomy. Binding of [3H]dihydroalprenolol is unchanged in the midbrain but is increased by 30% in the pons and 15% in the hippocampus. The i.p. administration of the antidepressants amitriptyline, mianserin, tranylcypromine (all at a dose of 10 mg/kg) or iprindole (25 mg/kg) for 28 days followed by a 5-day drug washout period, alters brain part [3H]imipramine and [3H]dihydroalprenolol binding in a manner that is a function of the particular drug, brain part and lesion effect. Only in the hippocampus did the lesion increase beta-binding that was reduced by all four antidepressant drugs.