[Psychosis, Intoxication or Serotonin Syndrome? - A 20-Year Old Male with Ziprasidone und Sertraline]

A young male with schizophrenia, dependence syndrome (multiple drug use) and a severe depressive episode develops a serotonin syndrome with Sertraline and Ziprasidone. Making the correct diagnosis, although potentially challenging, remains vital.

[The interaction of Rhodiola rosea and antidepressants. A case report]

OBJECTIVE

Rhodiola rosea (Russian Rhodiola/Golden Root) is a high mountain plant from the arctic regions of Europe and Asia which has the active substance phenylpropanoide. It has sedative, anti-depressive, drive-enhancing and stress-modulated properties stimulating the distribution of dopamine and serotonin; in combination with other drugs, an increase of side effects and risk profile has to be expected.

METHODS

A case report is presented in order to illustrate the interaction between Rhodiola rosea and antidepressants.

RESULTS

We report the case of a 68-year-old female patient with recurrent moderate depressive disorder with somatic syndrome (ICD-10 F33.11) who developed vegetative syndrome, restlessness feeling and trembling since she began to ingest Rhodiola rosea in addition to paroxetine.

CONCLUSIONS

Prescribing Rhodiola rosea with paroxetine, pharmacokinetic and -dynamic interactions have to be assumed. The symptoms of the patient can be interpreted as a serotonergic syndrome. Because of its different effects, the plant is widely used. An increase of clinical relevant risks should be considered in the add-on treatments.

Ecstasy use and serotonin syndrome: a neglected danger to adolescents and young adults prescribed selective serotonin reuptake inhibitors

BACKGROUND

At present, there are scarce clinical and basic lab data concerning the risk of acute serotonin toxicity from selective serotonin reuptake inhibitors (SSRIs) and 3,4-methylenedioxymethamphetamine (MDMA, ecstasy) co-administration. The health care community can strongly benefit from efforts to address the high risks associated with serotonin syndrome from this specific drug combination.

OBJECTIVE

The aim of this work is to review the risk of serotonin syndrome in adolescents and young adults prescribed with SSRIs and are concurrently using ecstasy.

DATA SOURCES

An electronic search of the major behavioral science bibliographic databases (Pubmed, PsycINFO, Medline) was conducted to retrieve peer-reviewed articles, which detail the clinical characteristics, biological mechanisms and social implications of SSRIs, MDMA, and their potential synergism in causing serotonin syndrome in the pediatric and young adult population. Search terms included "serotonin syndrome", "ecstasy", "MDMA", "pediatric", and "SSRI". Additional references were incorporated from the bibliographies of these retrieved articles.

RESULTS

MDMA, in combination with the widely-prescribed SSRI antidepressant class, can lead to rapid, synergistic rise of serotonin (5-HT) concentration in the central nervous system, leading to the acute medical emergency known as serotonin syndrome. This review addresses such complication through an exploration of the theoretical mechanisms and clinical manifestations of this life-threatening pharmacological interaction.

CONCLUSION

The increasing incidences of recreational ecstasy use and SSRI pharmacotherapy among multiple psychiatric disorders in the adolescent population have made this an overlooked yet increasingly relevant danger, which poses a threat to public health. This can be curbed through further research, as well as greater health care provision and attention from a regulatory body owing.

Receptor mediation of exaggerated responses to serotonin-enhancing drugs in serotonin transporter (SERT)-deficient mice

Administration of serotonin-enhancing drugs induces a distinctive behavioral syndrome in rodents. We previously reported that mice with a targeted disruption of the serotonin transporter (SERT) display some of these behaviors spontaneously, in the absence of drug. In the current studies, we assessed the drug-induced serotonin syndrome in SERT wildtype (+/+), heterozygous (+/-) and knockout (-/-) mice. In SERT -/- mice, the monoamine oxidase inhibitor (MAOI) tranylcypromine (1mg/kg) or the serotonin precursor 5-hydroxy-L-tryptophan (5-HTP; 80 mg/kg) led to markedly exaggerated serotonin syndrome behaviors relative to SERT +/+ mice, with an intermediate phenotype in SERT +/- mice. SERT +/+ mice developed significant serotonin syndrome behaviors only with the combination of the MAO-A/B inhibitor tranylcypromine (0.5 or 1 mg/kg) or the MAO-A-selective inhibitor clorgyline (1.2 mg/kg) plus 5-HTP. In evaluations of underlying mechanisms, pretreatment with the Htr1a receptor antagonist WAY 100635 (1 mg/kg), but not the Htr7 antagonist SB 269970 (3 mg/kg) or the Htr2a antagonist MDL 11,939 (5 mg/kg), markedly decreased the exaggerated 5-HTP-induced behaviors in SERT -/- mice. Subsequent experiments showed that the Htr1a agonist 8-OH-DPAT (1 or 2 mg/kg) elicited serotonin syndrome behaviors in a dose-dependent manner, blocked by WAY 100635 (1 mg/kg), in mice of all three genotypes, confirming the role of Htr1a receptors. The current data document markedly enhanced behavioral sensitivity to serotonin-enhancing drugs in SERT-deficient mice. These studies also show that the exaggerated behavioral responses observed in SERT +/- and -/- mice are mediated by postsynaptic Htr1a receptors, and suggest intact postsynaptic Htr1a function in SERT -/- mice.

Treatment of acute mania with ambient air anionization: variants of climactic heat stress and serotonin syndrome

High concentrations of ambient anions (O2-) were used to augment treatment for 20 acutely manic male patients. Anions were produced by an anion generator in a sealed room. A double-blind crossover design was used, and responses were evaluated with the Brief Psychiatric Rating Scale by 2 blinded raters. This produced a significant antimanic effect: total rating scores declined with anion treatment. Presham and postsham total scores for these 5 were 31.3 and 31.6, respectively. Pretreatment and posttreatment total scores were 31.6 and 26.3, respectively. Previous research indicates a role for serotonin in producing this antimanic effect.

Reversal of haloperidol-induced tardive vacuous chewing movements and supersensitive somatodendritic serotonergic response by buspirone in rats

Tardive dyskinesia (TD), a syndrome of involuntary hyperkinesias in the orofacial region that develops in patients chronically treated with neuroleptic agents is a major limitation of the therapy. Rats chronically treated with haloperidol exhibit vacuous chewing movements (VCMs) with the twitching of facial musculature and tongue protrusion. The syndrome is widely used as an animal model of TD. Evidence suggests a role of 5-hydroxytryptamine (5-HT; serotonin)-1A receptors in the pathogenesis and treatment of TD because repeated administration of haloperidol resulted in an increase in the effectiveness of 5-HT-1A receptors while drugs with agonist activity at 5-HT-1A receptors could attenuate haloperidol-induced VCMs. The present study was designed to test the hypothesis that a decrease in the responsiveness of somatodendritic 5-HT-1A receptors by the coadministration of buspirone could reverse the induction of VCMs and supersensitivity at 5-HT-1A receptors by haloperidol. Rats treated with haloperidol at a dose of 1 mg/kg twice a day for 2 weeks displayed VCMs with twitching of facial musculature that increased in a time dependent manner as the treatment continued to 5 weeks. Coadministration of buspirone attenuated haloperidol-induced VCMs after 2 weeks and completely prevented it after 5 weeks. The intensity of 8-hydroxy-2-di (n-propylamino) tetralin (8-OH-DPAT)-induced locomotion was greater in saline+haloperidol injected animals but not in buspirone+haloperidol injected animals. 8-OH-DPAT-induced decreases of 5-HT metabolism were greater in saline+haloperidol injected animals but not in buspirone+haloperidol injected animals. It is suggested that an impaired somatodendritic 5-HT-1A receptor dependent response is a major contributing factor in the pathophysiology of TD and a normalization of the somatodendritic response by drugs may help extending therapeutics in schizophrenia.

Induction of a mixed depressive episode during rTMS treatment in a patient with refractory major depression

Repetitive transcranial magnetic stimulation (rTMS) is a non-invasive experimental technique which has mostly been investigated in the treatment of mood disorders with possible efficacy in depression. Among its potential side effects, there have been some reports of rTMS-induced (hypo)mania in the literature but none for rTMS-induced mixed episodes. We report the case of a 39-year-old woman suffering from refractory chronic major depression who developed a depressive mixed episode associated with a mild serotonin syndrome during her second week of rTMS treatment. She was receiving a combination of antidepressants, the doses of which were kept unchanged during rTMS treatment. Mixed as well as manic episodes may be induced by transcranial magnetic stimulation, complications already observed with antidepressants and electroconvulsive therapy. Therefore, caution should be exercised among clinicians using this experimental procedure, particularly in the treatment of bipolar depressed patients.

Serotonin syndrome in a case of depression with various somatic symptoms: the difficulty in differential diagnosis

A 65-year-old female patient with major depressive disorder suffered from clonus, shivering and impaired visual acuity after 20 mg/day of paroxetine administration. The symptoms were initially regarded as further manifestations of her somatic symptoms of depression, and paroxetine was increased to 30 mg/day resulting in frequent clonus, increased shivering, serious dysarthria, ongoing impairment in visual acuity and agitation. These symptoms subsided upon paroxetine discontinuation. Ten mg/day of paroxetine rechallenge provoked dysarthria, tremor and headache, but these symptoms improved again upon paroxetine discontinuation. These findings indicate that the patient's symptoms were not somatic in origin but were in fact the symptoms of serotonin syndrome. In conclusion, the present case suggests the difficulty in diagnosing serotonin syndrome in a patient with somatic symptoms.

Serotonin (1A) receptor involvement in acute 3,4-methylenedioxymethamphetamine (MDMA) facilitation of social interaction in the rat

The current study assessed whether various co-administered serotonin (5-HT) receptor antagonists could prevent some of the acute behavioral effects of 3,4-methylenedioxymethamphetamine (MDMA, "Ecstasy") in rats. In the social interaction test, MDMA (5 mg/kg) significantly increased the duration of total social interaction between two conspecifics meeting for the first time. Microanalysis showed that MDMA increased adjacent lying and approach behaviours while reducing anogenital sniffing. MDMA (5 mg/kg) also caused elements of the serotonin syndrome including low body posture and piloerection. In the emergence test, MDMA significantly increased hide time and emergence latency indicating increased anxiety-like behavior. Pretreatment with the 5HT 1A receptor antagonist, WAY 100635 (1 mg/kg), prevented MDMA-induced increases in social interaction and markers of the serotonin syndrome while the 5-HT 1B receptor antagonist GR 55562 (1 mg/kg) and 5-HT 2A receptor antagonist ketanserin (1 mg/kg) were ineffective. The 5-HT 2B/2C receptor antagonist, SB 206553 (2 mg/kg), prevented MDMA-induced prosocial effects but caused pronounced thigmotaxis (hyperactivity at the periphery of the testing chamber). The anxiogenic effect of MDMA on the emergence test was not prevented by pretreatment with any of the 5-HT receptor antagonists tested. These results indicate that prosocial effect of MDMA may involve 5-HT 1A and possibly 5-HT 2B/2C receptors. In contrast, MDMA-induced generalised anxiety, as measured by the emergence test, seems unlikely to involve the 5-HT 1A, 5-HT 1B or 5-HT 2A, 5-HT 2B or 5-HT 2C receptors.

Serotonin Syndrome Induced by a Combination of Bupropion and SSRIs

Serotonin syndrome (SS) is a potentially fatal complication of the combined use of agents that enhance serotonin activity. Bupropion inhibits noradrenaline and dopamine reuptake with milder effects on serotonergic activity. Although regarded as a potential causative agent for SS, no cases have been reported in the medical literature. A 62-year-old woman treated with therapeutic dosages of bupropion and sertraline for depression for the previous 3 weeks presented with upper extremity myoclonic jerks, clumsiness, and gait difficulties with fluctuating symptoms of confusion, forgetfulness, and the alternation of agitation and lethargy. Symptoms were interpreted as an aggravation of depression and venlafaxine was added. The clinical picture progressed to alteration of consciousness and dysautonomia. After admission, medications were discontinued and she was started on cyproheptadine and clonazepam with gradual improvement and complete resolution of symptoms. This is a rare report of SS related to the association of bupropion and selective serotonin reuptake inhibitors (SSRIs). It also illustrates the potential for misinterpretation of the earliest manifestations of SS as signs of aggravation of the patient's underlying condition. The role of bupropion in SS is possibly related to its well-established specific inhibition of the cytochrome P450 2D6 pathway, increasing blood levels of SSRIs and tricyclic antidepressants.

Neuroleptic withdrawal versus serotonergic syndrome in an 8-year-old child

There appears to be considerable symptomatic overlap between neuroleptic withdrawal reactions and the serotonin syndrome. This case report is of an 8-year-old boy who developed symptoms compatible with both conditions while discontinuing pimozide and starting fluoxetine. It illustrates how the use of neuroleptic medication in young children is not without the risk of serious adverse drug events and can complicate diagnostic issues. This case report supports the suggestion that adverse drug reactions related to neuroleptics and serotonergic agents could be part of the same clinical and neurophysiological spectrum.

Some physiological manifestations of the activity of the gene controlling the predisposition to pendulum-like movements in rats

The physiological actions of the gene controlling the predisposition to stereotypic hyperkinesia in the form of pendulum-like movements (PM) and, probably, a form of spontaneous nystagmus in rats with albinism are manifest as a number of behavioral characteristics (total motor activity, emotionality, startle reflex intensity, sensitivity to serotonin 5-HT2 receptors as assessed in terms of the intensity of head twitching, and predisposition to cataleptic responses). A number of parameters showed differences between hybrids of gray handling-tolerant rats and carriers of the PM gene on the one hand, and between gray rats and animals not carrying the PM gene on the other. Some behavioral characteristics of rats with PM were closer to those of Wistar rats than to those of rats without PM. This, as well as the high frequency of PM in Wistar rats, indicates that the gene responsible for the manifestations of PM is not pathological, but controls a variety of adaptive features of the nervous system. The interaction between PM and the predisposition to catalepsy is biphasic in nature and is described by a curve in the form of an inverted U.

Possible serotonin syndrome associated with clomipramine after withdrawal of clozapine

OBJECTIVE

To report on the possible development of serotonin syndrome in a patient receiving clomipramine after clozapine was withdrawn from the treatment regimen.

CASE REPORT

A 44-year-old white man with a 23-year history of undifferentiated schizophrenia and obsessive-compulsive behavior had been treated with clozapine and clomipramine for several years. He tolerated both agents together well, with the exception of experiencing chronic constipation. Clomipramine was tapered and reduced to 50 mg over a period of 10 days. A worsening of ritualistic behavior was noted, and the clomipramine dosage was increased to 150 mg/d over 14 days. Simultaneously with the clomipramine dosage increase, clozapine was tapered and stopped ever a period of 19 days. The day after clozapine was stopped, while he was still receiving clomipramine 150 mg/d, he began behaving oddly, started sweating profusely, shivering, and became tremulous, agitated, and confused. He was diagnosed with possible serotonin syndrome; his symptoms resolved after clomipramine was stopped but before clozapine was restarted eight days later.

DISCUSSION

There are similarities in symptoms between serotonin syndrome and clozapine withdrawal. This article discusses the reasons why this case may represent serotonin syndrome rather than clozapine withdrawal and the possible pharmacologic mechanisms involved.

CONCLUSIONS

Clinicians should be aware that removing a serotonin-2a (S-HT2a) antagonist 1mm a treatment regimen including an agent that increases serotonin in the synaptic cleft may worsen clozapine withdrawal or potentially result in serious adverse drug reactions, such as serotonin syndrome.

A neurotoxic regimen of MDMA suppresses behavioral, thermal and neurochemical responses to subsequent MDMA administration

RATIONALE

3,4-Methylenedioxymethamphetamine (MDMA) produces a long-term depletion of serotonin (5-HT) in the rat brain; this depletion may have some functional consequences.

OBJECTIVE

The aim of the present study was to evaluate the acute effects of MDMA on the extracellular concentrations of dopamine and 5-HT, body temperature and the 5-HT behavioral syndrome in rats 7 days following a neurotoxic regimen of MDMA.

METHODS

One week after the rats were treated with a neurotoxic regimen of MDMA (10 mg/kg, i.p., every 2 h for a total of four injections), the rats were injected with a subsequent injection of MDMA. In vivo microdialysis combined with HPLC was utilized to measure the extracellular concentration of 5-HT and dopamine in the striatum. The increase in body temperature was determined by rectal temperature measurements, and the 5-HT behavioral syndrome was scored using a rating scale following the administration of MDMA.

RESULTS

The neurotoxic regimen produced a 45% reduction in brain 5-HT concentrations. The magnitude of the MDMA-induced increase in the extracellular concentration of 5-HT, but not dopamine, in the striatum produced by an acute injection of MDMA (7.5 mg/kg, i.p.) was reduced in rats treated previously with the neurotoxic regimen of MDMA when compared with that in control animals. In addition, the magnitude of the 5-HT behavioral syndrome, as well as the hyperthermic response, produced by MDMA was markedly diminished in rats that had previously received the neurotoxic regimen of MDMA.

CONCLUSIONS

It is concluded that the long-term depletion of brain 5-HT produced by MDMA is accompanied by impairments in 5-HT function, as evidenced by the deficits in the neurochemical, thermal and behavioral responses to subsequent MDMA administration.

Production of serotonin syndrome by 8-OH DPAT in Cryptotis parva

We have previously shown that the 5-HT2A/C agonist, DOI, potently and in a dose-dependent manner produces the head-twitch response in the least shrew (Cryptotis parva) via the activation of serotonergic 5-HT2A receptors. The purpose of the present study was to determine whether activation of 5-HT1A receptors by its selective agonist, 8-OH DPAT, can induce the serotonin syndrome (SS) in this species. In the rat, the symptoms of SS include: forepaw splaying, hindleg abduction, forepaw treading, flat body posture, tremor, and straub tail. Intraperitoneal (i.p.) administration of 8-OH DPAT produced four classic symptoms (forepaw splaying, hindleg abduction, forepaw treading, and straub tail) of SS in the least shrew in a dose-dependent manner in the 30-min observation period. The mean total cumulative score for all components of SS also significantly increased in intensity in a dose-dependent fashion. Administration of selective 5-HT1A antagonists [S(-)UH 301 or NAN-190] potently blocked the 8-OH DPAT-induced mean total SS score in a dose-dependent manner. Moreover, these antagonists had similar potencies as indicated by their identical ID50 values (0.5 and 0.52 mg/kg respectively). However, unexpectedly and unlike the published findings in the rat, the nonselective 5-HT1A antagonist with b-blocking activity, propranolol, failed to attenuate the induced response in this species. As was expected, the selective 5-HT2A/C antagonist, SR 46349B, did not affect the intensity 8-OH DPAT-induced symptoms. Overall, these data suggest that the SS produced by 8-OH DPAT in the least shrew is mediated via the activation of serotonergic 5-HT1A receptors. In addition, propranolol is not a useful 5-HT1A antagonist in this species.

Ayahuasca preparations and serotonin reuptake inhibitors: a potential combination for severe adverse interactions

The Amazonian psychoactive plant beverage ayahuasca has attracted increasing interest in recent years. Little attention has been given, however, to potentially dangerous interactions with other drugs. In particular, the interaction between the potent monoamine oxidase-inhibiting harmala alkaloids in ayahuasca and the selective serotonin reuptake inhibitor (SSRI) class of antidepressants may induce a serotonin syndrome with potentially grave outcome. Caution is advised when combining ayahuasca with certain pharmaceutical drugs.