The Association between Use of ICS and Psychiatric Symptoms in Patients with COPD—A Nationwide Cohort Study of 49,500 Patients

Psychiatric side effects are well known from treatment with systemic corticosteroids. It is, however, unclear whether inhaled corticosteroids (ICS) have psychiatric side effects in patients with COPD. We conducted a nationwide cohort study in all Danish COPD outpatients who had respiratory medicine specialist-verified COPD, age ≥40 years, and no previous cancer. Prescription fillings of antidepressants and risk of admissions to psychiatric hospitals with either depression, anxiety or bipolar disorder were assessed by Cox proportional hazards models. We observed a dose-dependent increase in the risk of antidepressant-use with ICS cumulated dose (HR 1.05, 95% CI 1.03–1.07, p = 0.0472 with low ICS exposure, HR 1.10, 95% CI 1.08–1.12, p < 0.0001 with medium exposure, HR 1.15, 95% CI 1.11–1.15, p < 0.0001 with high exposure) as compared to no ICS exposure. We found a discrete increased risk of admission to psychiatric hospitals in the medium and high dose group (HR 1.00, 95% CI 0.98–1.03, p = 0.77 with low ICS exposure, HR 1.07, 95% CI 1.05–1.10, p < 0.0001 with medium exposure, HR 1.13, 95% CI 1.10–1.15, p < 0.0001 with high exposure). The association persisted when stratifying for prior antidepressant use. Thus, exposure to ICS was associated with a small to moderate increase in antidepressant-use and psychiatric admissions.

High on steroids: manische episode na gebruik van corticosteroïden

High on steroids: manic episode after using corticosteroids This article describes a case of a severe manic episode with a patient using corticosteroids which were one of the precipitating factors. Since the first use of corticosteroids in medicine, psychiatric side effects as well as a myriad of somatic side effects have been known to occur. The neuropsychiatric side effects are situated within both the affective as well as the psychotic spectrum. While mostly mild and transient, these side effects can be severe, as glucocorticoids increase the risk of suicide to a significant degree. The risk of developing side effects is dose-dependent and a psychiatric history can be considered a risk factor. The HPA-axis and a potential inbalance between different glucocortoid receptors play a role in causing these side effects. While convincing evidence exists for the increased risk of psychiatric symptoms caused by systemic use of corticosteroids, far less scientific literature exists regarding the specific treatment. In addition, the case in this article demonstrates how psychiatric symptoms can severely interfere with the course and treatment of a pneumonia. Such cases remain a challenge in a hospital setting where departments (psychiatry or general medicine) are never completely tailored to the needs of these patients who thereby tend to fall between two stools.

Antibiomania: a case report of clarithromycin and amoxicillin-clavulanic acid induced manic episodes separately

Background Antibiomania is a rare but recognized side effect with yet unclear definite pathogenesis although multiple hypotheses have been proposed. The novelty of this case is the suspected pharmacodynamic drug-drug interaction between clarithromycin and amoxicillin-clavulanic acid. Case presentation We present the occurrence of a brief manic episode concerning a 50-year-old man with no psychiatric history, first started on amoxicillin-clavulanic acid therapy and then switched to clarithromycin for left basal pneumonia. Shortly after the antibiotic prescription, he presented psychiatric symptomatology (logorrhea, elevated mood, irritability, increase in physical activity and delusions). The antibiotic was stopped and the patient received lorazepam (2.5 mg p.o.) to treat psychomotor agitation. Approximately 12 h after clarithromycin cessation, amelioration was already observed, supporting the diagnosis of a clarithromycin-induced manic episode. Amoxicillin-clavulanic acid was then reintroduced because of the pneumonia and psychiatric symptoms reemerged. This second antibiotic was also stopped, and 1 week later, the patient was symptom-free. Conclusion The emergence of psychiatric side effects related to antibiotherapy, which is a common treatment, can greatly impact a patient’s quality of life. Early recognition and intervention could substantially influence the administered medical care and recovery. Moreover, given the widespread use of antibiotics including in combination, we thought our case report might be clinically useful as a clinical reminder relevant to the use of antibiotic combinations.

Seizures in palliative medicine: brivaracetam

Seizures occur in around 13% of patients with cancer and can be distressing for family members to witness. In those unable to manage regular antiepileptic medications, midazolam can be administered subcutaneously using a syringe driver, but this may cause sedation. Brivaracetam is a newer drug licensed as an adjunctive therapy in the treatment of partial-onset seizures with or without secondary generalisation and for restricted use in those with refractory epilepsy. It is associated with fewer behavioural or psychiatric side effects than levetiracetam, has a very low incidence of drug interactions and the maximal dose can be accommodated in a single syringe driver. We present three cases from 2019 to 2020 where subcutaneous brivaracetam has been successfully used in a Specialist Inpatient Palliative Care setting to manage seizures. Brivaracetam dosing is 1:1 conversion from oral:subcutaneous, with syringe driver doses ranging from 150 mg to 300 mg/24 hours being successfully used, with no adverse effects observed.

Anabolic-androgenic steroid administration increases self-reported aggression in healthy males: a systematic review and meta-analysis of experimental studies

Rationale Aggression and irritability are notable psychiatric side effects of anabolic-androgenic steroid (AAS) use. However, no previous study has systematically reviewed and quantitatively synthesized effects reported by experimental studies on this topic. Objective We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) investigating the effect of AAS administration on self-reported and observer-reported aggression. Methods Twelve RCTs comprising a total of 562 healthy males were identified through systematic searches of MEDLINE, PsycInfo, ISI Web of Science, ProQuest, Google Scholar, and the Cochrane Library. Results After excluding one outlier, AAS administration was associated with an increase in self-reported aggression under a random-effects model, albeit small (Hedges’ g = 0.171, 95% CI: 0.029–0.312, k = 11, p = .018), and when restricting the analysis to the effect of acute AAS administration on self-reported aggression under a fixed-effect model (g = 0.291, 95% CI: 0.014–0.524, p = .014). However, the above effects were neither replicated in the analysis of observer-reported aggression nor after restricting the analysis to the effects of the administration of higher (over 500 mg) and long-term (3 days to 14 weeks) doses. Conclusions The present meta-analysis provides evidence of an increase, although small, in self-reported aggression in healthy males following AAS administration in RCTs. Ecologically rational RCTs are warranted to better explore the effect of AAS administration on aggression in humans.

The Endocannabinoid System and Alcohol Dependence: Will Cannabinoid Receptor 2 Agonism be More Fruitful than Cannabinoid Receptor 1 Antagonism?

: Alcohol-use disorder (AUD) remains a major public health concern. In recent years, there has been a heightened interest in components of the endocannabinoid system for the treatment of AUD. Cannabinoid type 1 (CB1) receptors have been shown to modulate the rewarding effects of alcohol, reduce the abuse-related effects of alcohol, improve cognition, exhibit anti-inflammatory, and neuroprotective effects, which are all favorable properties of potential therapeutic candidates for the treatment of AUD. However, CB1 agonists have not been investigated for the treatment of AUD because they stimulate the motivational properties of alcohol, increase alcohol intake, and have the tendency to be abused. Preclinical data suggest significant potential for the use of CB1 antagonists to treat AUD; however, a clinical phase I/II trial with SR14716A (rimonabant), a CB1 receptor antagonist/inverse agonist showed that it produced serious neuropsychiatric adverse events such as anxiety, depression, and even suicidal ideation. This has redirected the field to focus on alternative components of the endocannabinoid system, including cannabinoid type 2 (CB2) receptor agonists as a potential therapeutic target for AUD. CB2 receptor agonists are of particular interest because they can modulate the reward pathway, reduce abuse-related effects of alcohol, reverse neuroinflammation, improve cognition, and exhibit anti-inflammatory and neuroprotective effects, without exhibiting the psychiatric side effects seen with CB1 antagonists. Accordingly, this article presents an overview of the studies reported in the literature that have investigated CB2 receptor agonists with regards to AUD and provides commentary as to whether this receptor is a worthy target for continued investigation.

Suicidal thoughts in a patient after administration of infliximab

Infliximab (IFX) is a chimeric monoclonal antibody biologic drug that works against tumor necrosis factor alpha (TNF-α) and is used to treat autoimmune diseases. This is case of a 45year old female patient who had suicidal thoughts after receiving infusions with IFX. She did not report any family psychiatric history. She was diagnosed with ulcerative colitis. She had many relapses and she was treated with azathioprine and prednisolone. After many incidents of diarrhea, she started therapy with infliximab infusions. She had totally 13 infusions during a period of 13 months. The last year and in particular during the time of Infliximab intake, she reported suicidal ideation. Due to lack of improvement in her physical symptoms, she voluntarily discontinued medication and resorted to a nutritionist and a mental health counselor, where she followed cognitive and behavioral interventions. Treatment of autoimmune disorders with infliximab raise an awareness among medical and paramedical staff involved in the care of these patients about the psychiatric side effects of the drug.

Psychiatric side effects induced by chloroquine and hydroxychloroquine: a systematic review of case reports and population studies

Chloroquine and hydroxychloroquine are commonly used drugs in the treatment of malaria as well as chronic diseases, such as rheumatoid arthritis, and systemic lupus erythematosus. Although various reports on possible psychiatric side effects of these drugs exist, the nature and extent of these effects remain poorly understood. Moreover, the relevance of these drugs in the treatment of early stages of COVID-19 necessitates a careful estimation of their side effects. Here, we provide a systematic review of the psychiatric side effects associated with chloroquine and hydroxychloroquine. We used PubMed, Scopus, and Web of Science platforms to identify relevant literature published between 1962 and 2020. Search terms included chloroquine, hydroxychloroquine, psychiatry, psychosis, depression, anxiety, bipolar disorder, delirium, and psychotic disorders. Only case reports and clinical trials were included. All studies included records of psychiatric side effects induced by either chloroquine or hydroxychloroquine or both. Both retrospective and prospective, randomized as well as non-randomized population studies were included. Overall, the psychiatric side effects are dose- and sex-independent. The most common psychiatric side effects reported are increased speech output/ excessive talking, increased psychomotor activity, irritable mood, auditory hallucinations, delusion of grandiosity, and suicide attempts, likely due to brain intoxicationbe of chloroquine or hydroxychloroquine. The symptoms can develop in a few hours to 11 weeks after drug intake and are normally reversed within a week after the drug withdrawal. We conclude that CQ and HCQ have the potential to induce psychiatric side effects. This study calls for further investigation of psychiatric symptoms induced by these drugs in the short and long term.