Double-blind naltrexone and placebo comparison study in the treatment of pathological gambling.

BACKGROUND: The authors' goal was to assess the efficacy and tolerability of naltrexone in the treatment of pathologic gambling disorder. METHODS: Eighty-three subjects who met criteria for DSM-IV pathologic gambling disorder were enrolled in a 1-week single-blind placebo lead-in followed by an 11-week double-blind naltrexone or placebo trial. Naltrexone was started at 25 mg/day and titrated upward until maximum symptom improvement or 250 mg/day was achieved. Gambling symptom change was assessed with the patient-rated Clinical Global Impression (PG-CGI-PT), clinician-rated CGI (PG-CGI-MD), and the Gambling Symptom Rating Scale (G-SAS). Side effects were monitored weekly and liver function tests biweekly. RESULTS: Data from 45 patients were analyzed. Using random regression analysis, significant improvement was noted in all three gambling symptom measures: patient-rated Clinical Global Impression, p <.001; clinician-rated CGI, p <.001; Gambling Symptom Rating Scale, p <.019. At study end, 75% of subjects taking naltrexone were much or very much improved on both the PE-CEI PT and the PG-CGI-MD, compared with only 24% of those on placebo. Elevated liver enzymes occurred in four subjects who were taking analgesics concurrently. Nausea was common during the first week of treatment. CONCLUSIONS: Results suggest that naltrexone is effective in reducing the symptoms of pathologic gambling. Until further studies corroborate the present findings, our report should be interpreted cautiously.

Weight loss during chronic, cervical vagus nerve stimulation in depressed patients with obesity: an observation.

Fourteen patients were treated over 2 years with cervical vagus nerve stimulation (VNS) for adjunctive therapy of severe, treatment-resistant depression. Here, we report the serendipitous observation that this treatment was associated with highly significant, gradual weight loss despite the patients' report of not dieting or exercising. The weight loss was proportional to the initial BMI, that is, the more severe the obesity, the greater the weight loss. Weight loss did not correlate with changes in mood symptoms. The vagus nerve carries visceral information to and from the brain; modulation of its activity may alter eating behavior. Chronic cervical VNS may merit controlled study for the treatment of severe obesity.

An unusual presentation of sertraline and trazodone overdose.

OBJECTIVE: To report an unusual and life-threatening presentation of an overdose of sertraline and trazodone. CASE SUMMARY: A patient with a history of depression ingested sertraline 6,000 mg and trazodone 1,300 mg in a suicide attempt. Twenty-four hours after antidepressant administration, the patient presented with symptoms of selective serotonin-reuptake inhibitor (SSRI) overdose and serotonin syndrome, and later developed an enlarged tongue consistent with angioedema. A compromised airway resulted and endotracheal intubation was necessary. After intubation, the symptoms subsided and the patient recovered. DISCUSSION: Although SSRIs and trazodone are generally considered to be relatively safe in single-agent overdose, serious delayed reactions can occur, especially if several agents are involved. In this case the patient initially presented with symptoms typical of an SSRI overdose that did not appear to be exceptionally dangerous. Over time, symptoms consistent with angioedema appeared that necessitated intubation. Although previous reports of angioedema have been reported with SSRIs, this is the first report, to our knowledge, of a presentation this severe. CONCLUSIONS: This case demonstrates that overdose with the newer antidepressants can result in unusual and delayed presentations and must be treated with caution.

The superior mesenteric artery syndrome and acute gastric dilatation in eating disorders: a report of two cases and a review of the literature.

OBJECTIVE: The pathophysiology and symptomatology of the superior mesenteric artery syndrome (SMA syndrome) is discussed. METHOD: A review of much of the available literature concerning the SMA syndrome and the associated condition acute gastric dilatation is offered. RESULTS: Two new cases of acute gastric dilatation in patients with eating disorders, one of whom was diagnosed with SMA syndrome, are presented, along with a discussion of these conditions in reference to the eating disorders. CONCLUSION: The SMA syndrome and gastric dilatation are rare but potentially a very serious complication of eating disorders, and clinicians who work with these patients should be aware of such problems.

The selectivity of inclusion and exclusion criteria in bulimia nervosa treatment studies.

OBJECTIVE: To examine the rates of exclusion and inclusion in various research studies for a series of 51 treatment-seeking patients. METHOD: The inclusion and exclusion criteria employed in a sample of 41 studies were applied to a series of 51 treatment-seeking bulimia nervosa patients. RESULTS: Of the sample of 51, 11, (21.6%) would have been excluded from 16 (39%) of the studies because of an age greater than 30; 13 (32%) of the studies would have excluded 8 (16%) of our patients because of weight > 110% ideal body weight. Thirteen (26%) would have been excluded from 22 (54%) of the studies because of active psychotropic drug use, despite the lack of response. DISCUSSION: Some of the patients who may be most difficult to work with may be excluded from treatment studies.

Potential drug-drug interactions on a tertiary-care hospital consultation-liaison psychiatry service.

Pharmacokinetic interactions involving the cytochrome P450 system have been a recent focus of clinical and research interest in psychopharmacology. The authors reviewed 100 consecutive patients seen on a consultation-liaison (C-L) psychiatry service for potential drug-drug interactions. The patients were taking a mean of 8.8 medications; for those undergoing organ transplantation the mean was 12.9. While both enzyme inhibitors (n = 87) and substrates (n = 89) were commonly used, only rarely were they used in the same patient (n = 14). The authors conclude that the potential for drug interactions on a C-L psychiatry service is significant, necessitating awareness of this potential complication.