Associated mood changes with naloxegol therapy for opioid-induced constipation in a patient with psychiatric disease

The objective of this clinical case report is to highlight unusual adverse effects brought on by Naloxegol therapy in a patient with underlying psychiatric illness. The patient is a 68-year-old female, with a psychiatric history of bipolar disorder, who presented for chronic pain management and opioid-induced constipation. After failing other therapies, she was trialed on Naloxegol on three separate occasions. She experienced mood lability with symptoms including agitation, confusion, irritability, hysteria and unprompted crying spells on each occasion. Notably, the drug manufacturer does not describe mood lability, nor the profound psychiatric manifestations outlined in our case report, as side effects of Naloxegol. Clinicians may consider judicious prescription of Naloxegol when treating opioid-induced constipation in patients with pre-existing psychiatric co-morbidities.

Perampanel-Induced Cataplexy in a Young Male with Generalized Epilepsy

Perampanel is an anti-epileptic drug reported to exert its effects in the central never system (CNS) by inhibiting post-synaptic glutamate receptors. The most commonly reported neuropsychiatric side effects are affective dysregulation with some reports of psychosis. However, the precise therapeutic mechanism is unknown. We report on a 32-year-old African American male with recurring generalized tonic-clonic (GTC) seizures, who presented to our hospital with onset of mood lability for several months, subsequent to adding perampanel to his antiepileptic medications. On presentation, perampanel administration was temporarily withheld, and subsequently, noted to be coincident with neuropsychiatric symptomatology, including motor weakness in emotional contexts. The mechanisms underlying cataplexy are complex and, in our patient, most likely induced by an interaction between perampanel and the wakeful inhibition of the sublaterodorsal nucleus projections.

Characteristics Associated with Depression Severity in 270 Juveniles in a Major Depressive Episode

Introduction: Severe depression is prevalent in young persons and can lead to disability and elevated suicidal risk. Objectives: To identify clinical and demographic factors associated with the severity of depression in juveniles diagnosed with a major mood disorder, as a contribution to improving clinical treatment and reducing risk of suicide. Methods: We analyzed factors associated with depression severity in 270 juveniles (aged 6–18 years) in a major depressive episode, evaluated and treated at the Bambino Gesù Children’s Hospital of Rome. Depressive symptoms were rated with the revised Children’s Depression Rating Scale (CDRS-R) and manic symptoms with the Kiddie Schedule for Affective Disorders and Schizophrenia (K-SADS) Mania Rating Scale (K-SADS-MRS). Bivariate comparisons were followed by multivariable linear regression modeling. Results: Depression severity was greater among females than males (55.0 vs. 47.2), with the diagnosis of a major depressive disorder (MDD) vs. bipolar disorder (BD; 53.8 vs. 49.3), and tended to increase with age (slope = 1.14). Some symptoms typical of mania were associated with greater depression severity, including mood lability, hallucinations, delusions, and irritability, whereas less likely symptoms were hyperactivity, pressured speech, grandiosity, high energy, and distractibility. Factors independently and significantly associated with greater depression severity in multivariable linear regression modeling were: MDD vs. BD diagnosis, female sex, higher anxiety ratings, mood lability, and irritability. Conclusions: Severe depression was significantly associated with female sex, the presence of some manic or psychotic symptoms, and with apparent unipolar MDD. Manic/psychotic symptoms should be assessed carefully when evaluating a juvenile depressive episode and considered in treatment planning in an effort to balance risks of antidepressants and the potential value of mood-stabilizing and antimanic agents to decrease the severity of acute episodes and reduce suicidal risk.

Graves’ disease presenting with hypomania and paranoia to the acute psychiatry service

This manuscript describes the case of a young woman, with no prior psychiatric history, who developed hypomania and paranoia as the principal presenting features of Graves’ disease. After starting treatment with carbimazole and propranolol, symptoms resolved without the use of antipsychotic drugs. Close liaison between psychiatry and endocrinology services was essential. This demonstrates that treating underlying thyrotoxicosis in patients presenting with psychiatric symptoms may lead to recovery without the use of antipsychotic medication. While agitation, irritability and mood lability are well-recognised thyrotoxic symptoms, psychosis is a rare presenting feature of Graves’ disease. All patients with agitation, delirium or psychiatric symptoms should have thyroid function checked as part of initial tests screening for organic disease. In new or relapsing psychiatric conditions, it is important to ask patients, their carers or relatives about symptoms of hypothyroidism or thyrotoxicosis.

Pharmacotherapy of attention deficit/hyperactivity disorder in individuals with autism spectrum disorder: A systematic review of the literature

Aim: To assess the empirical evidence for the treatment of attention deficit/hyperactivity disorder (ADHD) in populations with autism spectrum disorder (ASD). Methods: A systemic PubMed, PsychINFO, Embase, and Medline database search of peer-reviewed literature was conducted. Included in the review were controlled trials published in English with sample sizes ⩾10 participants examining the safety and efficacy of anti-ADHD medication in ASD populations. Data was extracted on relevant variables of study design, demographics, associated psychopathology, medication dose, efficacy, and tolerability. Results: Nine controlled trials met the inclusion and exclusion criteria: five with methylphenidate, three with atomoxetine, and one with guanfacine. Sample sizes ranged from 10 to 128 with 430 children participating across all the trials. In all the trials, treatment response was significantly superior to placebo. However, almost all trials assessed only hyperactivity, and most included only participants with intellectual disability with high levels of irritability. None of the trials distinguished agitation from hyperactivity. The response on hyperactivity for methylphenidate and atomoxetine was less than that observed in the neurotypical population; however, the response for guanfacine surpassed results observed in neurotypical populations. Treatment-emergent mood lability (i.e. mood dysregulation and mood-related adverse events) was frequently associated with methylphenidate and guanfacine treatments. Worse treatment outcomes were associated with individuals with lower intellectual capability compared with those with higher IQs. Conclusions: here is a scarcity of controlled trials examining ADHD treatments in ASD populations, particularly in intellectually capable individuals with ASD and in adults. Response to ADHD medications in ASD were adversely moderated by the presence of intellectual disability and mood lability.

Why sleep matters for young people who may get depressed

Depression and anxiety are negative emotional states familiar to us all through personal experience. Less familiar are severe states of depression, in particular, which can actually shorten the lives of sufferers by over a decade. The relationship of these very severe states of illness to the milder cases more common earlier in development is important. Most patients who have suffered from depression will suffer from further episodes during their lifetime, and an early onset may make recurrence more likely. A number of factors increase the risk for depression, including family history, stressful life events, early life experiences, personality (particularly the traits of neuroticism and perfectionism) and mood lability (marked ups and downs). Sleep disturbance may both provoke and/or signal the onset of mood disorder. Sleep is therefore doubly important as a gateway to treatment. Understanding more about how sleep interacts with the established risk factors would allow vulnerable young people to be identified earlier for more effective intervention. Early identification of sleep disorder and depression allows psychological treatments to be used, which are less effective once a full depressive episode and a cascade of neurobiological and psychological effects have occurred.