Pimozide-induced depression in men who stutter

The Pharmacologic Treatment of Stuttering and Its Neuropharmacologic Basis

Stuttering is a DSM V psychiatric condition for which there are no FDA-approved medications for treatment. A growing body of evidence suggests that dopamine antagonist medications are effective in reducing the severity of stuttering symptoms. Stuttering shares many similarities to Tourette's Syndrome in that both begin in childhood, follow a similar male to female ratio of 4:1, respond to dopamine antagonists, and symptomatically worsen with dopamine agonists. In recent years, advances in the neurophysiology of stuttering have helped further guide pharmacological treatment. A newer medication with a novel mechanism of action, selective D1 antagonism, is currently being investigated in FDA trials for the treatment of stuttering. D1 antagonists possess different side-effect profiles than D2 antagonist medications and may provide a unique option for those who stutter. In addition, VMAT-2 inhibitors alter dopamine transmission in a unique mechanism of action that offers a promising treatment avenue in stuttering. This review seeks to highlight the different treatment options to help guide the practicing clinician in the treatment of stuttering.

Ziprasidone-associated depressive state in schizophrenic patients

OBJECTIVES

Although depression is a recognized side effect of many medications, the association of this condition with neuroleptics has received limited attention in the literature. Atypical antipsychotics may demonstrate a beneficial effect on affective symptoms. On the other hand, they may also cause depression both in those with and without a history of psychiatric illness. Although ziprasidone has been reported to have antidepressive properties, we are not aware of reports regarding ziprasidone-induced depression.

METHODS

We describe 3 cases of ziprasidone-associated depression in patients treated for schizophrenia who had no previous history of depressive illness. To the best of our knowledge, this is the first description of such an association.

CONCLUSIONS

This case series suggests that atypical antipsychotics may have a causal relationship in the development of depression in schizophrenic patients. This is noteworthy because these medications have been found in the past to have an antidepressant action. If neuroleptic-induced depression is mistaken for negative symptoms of schizophrenia, this condition may go untreated. Further data based on controlled studies are required.

Quetiapine-Associated Depression in a Patient With Schizophrenia

Depression has been reported as a side effect of a wide variety of drugs in clinical medicine. Neuroleptics may cause depression in persons with or without any past history of psychiatric illness. Clinically, these drug-induced depressions may go unnoticed and thus create therapeutic problems. The authors present a case of quetiapine-associated depression in a patient being treated for schizophrenia. To the best of our knowledge it is the first description of depression associated with quetiapine treatment. This case report suggests that atypical antipsychotics may be a cause of depression. This is noteworthy because these medications have been found in the past to have an antidepressant action. Further data based on controlled studies are needed.

Treatment with medications affecting dopaminergic and serotonergic mechanisms: effects on fluency and anxiety in persons who stutter

Medications with dopamine antagonist properties, such as haloperidol, and those with serotonin reuptake inhibitor properties, such as clomipramine, have been shown to improve fluency. To examine the degree to which each of these two pharmacological mechanisms might independently affect fluency, a selective serotonin reuptake inhibitor, paroxetine, and a selective dopamine (D-2) antagonist, pimozide, were evaluated. Both types of medications also affect mood and anxiety, factors that could influence fluency levels. Therefore, we also evaluated the medications' effects on generalized and speech-related anxiety and the relationships between changes in anxiety and changes in fluency in 11 subjects with a history of developmental stuttering. The randomized, double blind, placebo-controlled crossover study that was designed had to be terminated prior to completion due to severe side effects following withdrawal from paroxetine. Even with a reduced sample size (n=6), significant improvement in percent fluent speaking time (p=0.02) was found using a telephone task between baseline and pimozide (n=6), with average duration of dysfluencies significantly shorter (p=0.04) but no significant difference in the estimated number of dysfluencies per minute. This significant improvement was associated with non-significant increases in generalized anxiety, but non-significant decreases in speech-related anxiety. No significant differences were found in fluency between baseline and paroxetine (n=5). These preliminary results suggest that fluency improvement is more likely to be mediated by dopaminergic rather than serotonergic mechanisms. Due to its side effects, however, pimozide may be considered a risk for treatment of stuttering.

EDUCATIONAL OBJECTIVES

As a result of reading this paper the reader will describe and explain: (1) how medications may affect fluency and the rationale for selecting medications for treatment trials; (2) the interrelationship between fluency and anxiety; and (3) factors important in developing clinical trials using medications.

Neuroleptic dysphoria: towards a new synthesis

RATIONALE

Neuroleptic dysphoria (ND) is a subtle and under-recognized side effect of antipsychotic drugs. It is an all-inclusive descriptive phrase that encompasses a variety of unpleasant subjective changes in arousal, mood, thinking and motivation induced by neuroleptic drugs. Understanding this phenomenon has wide ranging clinical and research implications.

OBJECTIVE

The present review examined the themes identified in the original studies from the neuroleptic era in the light of recent findings from neuroimaging research, cumulative experience with second generation antipsychotic drugs, and new concepts such as pleasure responsivity, hedonic regulation and subjective tolerability.

METHODS

Empirical studies on neuroleptic drugs involving clinical populations treated for schizophrenia, Tourette's disorder and stuttering, studies performed on normal healthy volunteers and selected experimental studies in animals, are reviewed.

RESULTS

Dysphoric responses occur early during treatment and typically manifest as a dislike towards medication (drug aversiveness). Dysphoria persisting over time, may lead to adverse clinical consequences such as treatment non-adherence, substance abuse, poor clinical outcome, increased suicidality and compromised quality of life. Interference with the physiological processes of hedonic capacity by the neuroleptics due to their dopaminergic blocking action in the prefrontal cortex and the shell of nucleus accumbens is the putative mediating mechanism underlying the occurrence of dysphoric responses. Second generation antipsychotic drugs with an atypical receptor blocking profile are less likely to elicit dysphoric responses.

CONCLUSION

Viewing neuroleptic dysphoria within a broader spectrum of disorders of subjective tolerability and exploring its neurobiological mechanisms is relevant to addressing the nuances of antipsychotic therapy, and could help unravel the questions surrounding the pathophysiology of depression, substance abuse and other dysphoric clinical states.