Clinical Presentations of Bupropion Prescription Drug Misuse: A Systematic Review.

BACKGROUND: Among prescribers, bupropion is considered a substance of low misuse potential, with some studies showing lesser misuse potential than caffeine. However, several case reports exist of recreational bupropion misuse and diversion. Our goal is to understand at-risk populations, clinical courses, interventions, and outcomes after acute ingestion of bupropion via oral, intravenous route, and insufflation. METHODS: The systematic review was registered with PROSPERO on August 5, 2023. We conducted a systematic literature search on July 30, 2023, utilizing 8 databases with the help of the Medical Subject Headings (MeSH) term "Bupropion" in the context of misuse and abuse. Ultimately, we found 17 articles with qualitative synthesis relevant to our study objective and meeting our inclusion/exclusion criteria. RESULTS: Bupropion insufflation and intravenous injection occur almost exclusively in patients with a substance use disorder history, with a preponderance of patients with stimulant use disorder or multiple substance use disorders. Additionally, many were dual-diagnosis patients with a history of attention deficit hyperactivity disorder and stimulant use disorder, treated with bupropion. Patients describe the effects of bupropion insufflation/IV injection as a milder "cocaine-like" high that is brief, with less severe withdrawal effects of anxiety and agitation. The most common side effect at presentation was tachycardia, followed by seizures responsive to IV benzodiazepines. IV injection seems particularly insulting to the vascular system, with cellulitis, tissue necrosis, and digital ischemia as documented adverse effects. CONCLUSIONS: This systematic review highlights the bupropion misuse potential in certain patient populations and serves to increase awareness among clinicians. Additional patient screening, monitoring and follow-up, surveillance, and further research are needed to investigate and prevent bupropion misuse in at-risk patient populations entirely.

Transcultural Psychiatry in Medical Ethics: Assessing Decision-Making Capacity within the Lens of an East African Refugee.

AbstractA 29-year-old female East African refugee with no formal psychiatric history and a medical history significant for HIV was admitted for failure to thrive and concern for bizarre behavior in the context of abandonment by her husband and separation from her child. After psychiatric evaluation, it was determined that she did not have the capacity to care for herself independently; adult protective services then pursued and was awarded guardianship. While admitted, the patient repeatedly refused medical treatment, had a feeding tube placed for forced nutrition and medications (though she did at one point remove this tube herself), and received two electroconvulsive therapy (ECT) treatments. Soon thereafter, the patient's court-appointed guardian met with the primary medical, psychiatric, and ethics teams to discuss goals of care in the setting of complex social and cultural needs. It was collectively determined that the patient's choices to refuse care (including nutrition, lab work, medications, and ECT) and some repeated behaviors (e.g., denial of divorce, denial of HIV, denial of need for care) could be considered culturally appropriate in the context of the acute stressors leading up to hospitalizations. All teams concluded, therefore, that the patient had the capacity to refuse these interventions and that further forced intervention would pose a greater chance of exacerbating her already-significant trauma history than improving her outcomes. Ultimately, the patient was able to be discharged into the care of her guardian, who would assist her in receiving support from members of her community who share her language and culture.

Antiepileptics in Electroconvulsive Therapy: A Mechanism-Based Review of Recent Literature.

ABSTRACT: Although prior conventional wisdom strongly recommended complete discontinuation of medications increasing the seizure threshold before electroconvulsive therapy (ECT), more recent literature suggests that anticonvulsants should be considered a relative rather than an absolute contraindication to proceeding with therapy. Most literature regarding the use of use antiepileptic drugs in ECT focuses on antiepileptic mood stabilizers with which most psychiatrists are familiar. However, there is considerably less information available about the use of newer antiepileptics in conjunction with ECT, which may be prescribed to a patient with epilepsy or off-label for psychiatric reasons.In this article, we provide a mechanism-based review of recent available literature concerning the use of antiepileptics during ECT and discuss which medications have the most robust evidence supporting their continued use in select patients. Finally, we highlight important considerations for psychiatrists when deciding how to proceed with patients on antiepileptics who require ECT.

Updates in Consultation-Liaison Psychiatry: 2019.

BACKGROUND: The scientific literature in consultation-liaison psychiatry continually expands, and remaining familiar with the most current literature is challenging for practicing clinicians. The Guidelines and Evidence-Based Medicine Subcommittee of the Academy of Consultation-Liaison Psychiatry writes quarterly annotations of articles of interest to help Academy members gain familiarity with the most current evidence-based practices. These annotations are available on the Academy Website. OBJECTIVE: We identify the 10 most important manuscripts for clinical practice in consultation-liaison psychiatry from 2019. METHODS: Sixty-four abstracts were authored in 2019. Manuscripts were rated on clinical relevance to practice and quality of scholarship. The 10 articles with the highest aggregate scores from 19 raters are described. RESULTS: The resulting articles provide practical guidance for consultation psychiatrists on several topic areas including the treatment of substance use disorders. CONCLUSION: We suggest that these clinical findings should be familiar to all consultation-liaison psychiatrists regardless of practice area. Regular article reviews and summaries help busy clinicians deliver cutting-edge care and maintain a high standard of care across the specialty.

Rhabdomyolysis in the Context of Designer Benzodiazepine Misuse.

Designer benzodiazepines belong to a class of lab-created psychoactive compounds, with limited federal regulation, no toxicity testing, and reported high potency, leading to substantial overdose risk and harmful clinical syndromes. Benzodiazepine misuse has been previously documented to be associated with rhabdomyolysis, with elevated creatine kinase (CK) during and after acute episodes of intoxication. Here, we present a case of profound rhabdomyolysis and associated acute kidney injury (AKI) after acute designer benzodiazepine intoxication. A 26-year-old male with a history of poly-substance misuse, including alcohol, psychedelics, opiates, kratom, and benzodiazepines, presented to the emergency department with altered mental status and agitation after an accidental overdose on liquid flubromazolam and clonazolam, designer benzodiazepines purchased online. He went on to develop seizure-like activity. Additional labs revealed AKI with creatinine 2.22 mg/dL (reference 0.74-1.35 mg/dL, baseline 0.88 mg/dL). He was discovered to have severe rhabdomyolysis that peaked at 131,920 U/L (reference 55-170 U/L) on the fourth day of admission. This case demonstrates the potential deleterious effects of the designer benzodiazepine class, including prolonged sedation, AKI, and severe rhabdomyolysis. In addition, seizure-like manifestations may occur during the intoxication or withdrawal phase. Designer benzodiazepines may produce rhabdomyolysis; however, the mechanism is unknown. Direct myotoxicity or prolonged immobilization may be contributors to rhabdomyolysis. More research is needed to elucidate the consequences of designer benzodiazepine misuse. Clinicians should be aware of their use given the ease of availability online and rising popularity.

Identifying the Most Important Consultation-Liaison Psychiatry Publications in 2020 Using a Novel Literature Assessment Instrument.

BACKGROUND: As the science of consultation-liaison psychiatry advances, the Academy of Consultation-Liaison Psychiatry's Guidelines and Evidence-Based Medicine Subcommittee reviews articles of interest to help academy members remain familiar with the latest in evidence-based practice. OBJECTIVE: We identify the 10 most important articles for clinical practice in consultation-liaison psychiatry from 2020 using the new Importance and Quality instrument for assessing scientific literature. METHODS: The subcommittee published annotated abstracts for 97 articles on the academy website in 2020. Reviewers then rated all articles on clinical importance to practice and quality of scholarship using the Importance and Quality instrument. We describe the 10 articles with the highest aggregate scores and analyze the reliability of Importance and Quality instrument. RESULTS: Twenty-four raters identified the top 10 scoring articles of 2020. These articles provide practical guidance on key areas of consultation-liaison psychiatry including management of COVID-19, lithium treatment for complex patients, medical risks among patients with severe mental illness, and substance use disorders in medical settings. The assessment instrument demonstrated good to excellent interrater reliability. CONCLUSION: These articles offer valuable guidance for consultation-liaison psychiatrists regardless of their practice area. Collaborative literature reviews with standardized assessments help clinicians deliver evidence-based care and foster a high standard of practice across the specialty.

Myocarditis in a Patient on Clozapine: What did it?

We are presenting the case of a 37-year-old male with schizoaffective disorder who developed myocarditis within three weeks of starting on clozapine for his treatment-resistant psychosis. The patient also had a positive titer for Influenza A, which makes it a diagnostic dilemma regarding the cause of his myocarditis. It may be possible that the myocarditis was caused by the Influenza A virus or synergistically exacerbated the clozapine's propensity to cause it. Currently, there are no studies establishing the link between the two etiologies. As clozapine can be the only option for patients resistant to treatment of their psychiatric illness, and there being some evidence for successful rechallenge of clozapine, we consider that this patient could have benefited from a trial of a rechallenge; however, he was lost to follow-up.