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MEDICATION-INDUCED SEIZURES
LETTERS TO THE EDITOR
secretion of antidiuretic hormone-associated hyponarremia, which developed while the patient was taking sertraline (Goldstein et aI., 1996). No reports of seizures developing in the context of sertraline-methylphenidate combination therapy were discovered. S.D., a 13-year-old white male with a history of ADHD and a depressive disorder not otherwise specified, has been followed by the first aurhor for approximately I year. S.D. had been treated with methylphenidate, which was gradually increased in dosage to 80 mg/day (I.8 mg/kg per day) as lower dosages failed to provide adequate improvement in core ADHD symptoms. S.D. had tolerated the methylphenidate well, without significant side effects for approximately 10 months, and had not required any dose adjustment in more than 7 months. He has also benefited from cognitive-behavioral and family interventions and was seen at monthly intervals. His depressive symptomatology remained well controlled until the eighth month of rreatment, when he became significantly more irritable and showed progressive decline and significant dysfunction in social and academic performance over the following 2month period. Because of the worsening of his mood disturbance, sertraline 25 mg/day was prescribed; the dosage was increased to 50 mg/day after 7 days. After approximately I week of treatment with methylphenidate 80 mg/day and serrraline 50 mg/day, S.D. experienced a tonicclonic ictal event (lasting a few seconds) witnessed by his father. Immediate evaluation in a local emergency room revealed a negative history for recent infection or fever, bur a diminished appetite and oral intake over the previous week was noted. Laboratory analysis revealed normal serum electrolyte levels (including normal serum calcium, phosphate, osmolarity, and toxicology screen) and a normal computed tomographic scan of the brain. The only abnormality noted was a serum pH of 7.2. The following day, the sertraline therapy was discontinued unril S.D. could undergo a full neurological evaluation. The patient's furrher workup included an EEG revealing normal findings. S.D. has remained off all antidepressants and has continued his methylphenidate regimen unchanged and without recurrence of seizures. This is, to the best of our knowledge, the first reported case of seizure activity in the presence of sernaline-methylphenidate rreatment in a pediarric patienr. It is possible that these medications altered the patienr's appetite so significantly that a metabolic/electrolyte derangemenr existed, precipitating the seizure event. It may also be the case that these mediations altered cytochrome P450 metabolism to an extent that much higher blood levels of sernaline, methylphenidate, or both existed, increasing the patienr's seizure risk. It is also possible that the patient's ictal event had no association with his medical regimen.
develop in patients receiving daily doses of more than 40 mg/day of prednisone or its equivalent (Hall et aI., 1979). The factors involved in individual susceptibility to corticosteroids remain obscure, and more documented cases are needed to search for a possible genetic predisposition. ipek Tiirkta~ KIVlIclm Giiciiyener Gazi University Faculty of Medicine Aykut Ozden Ankara University Faculty of Medicine Ankara, Turkey
Connet G. Lenney W (19') I), Inhaleo buoesonioe ano hehavioural Oistur· bances. Lanut .DH:6."\4-6Yi Golostein E'l~ Preskorn SH (l9R9), Mania triggereo by a sleroio nasal spray in a patient wilh slable bipolar oisoroer. Am J PsyclJitltry 146: 1076 Hall RCW, Popkin MK, Sonora MD el al. (1')7'», Presentalion of sreroid psychoses. J Nr", Mmt Dis 167:229-B6 Meyboom RH B, de Graal: Breeoervelo N (1988), Buoesonioe ano psychic side dIects. Ann Intrrl/ Mrd 109:683 Phelan MC (1989), Beclomerhasone mania. Br J Pryr!Ji"try J55:H7J-872
MEDICATION-INDUCED SEIZURES
To the Editor: This is a report of an ictal evenr occurring in a 13-year-old boy receiving rreatmenr with methylphenidate and sertraline. The patient had no previous history of seizures or other neurological disorders, and his family history was also negative for seizure disorders. Antidepressanrs and methylphenidate theoretically can lower the seizure threshold and increase seizure risk, hut such events are uncommon. Methylphenidate is considered safe in children with attenrion-deficit hyperactivity disorder (ADHD) who are seizure-free (Gross-Tsur et aI., 1997). The majority of antidepressant-related seizures occur in patients with predisposing factors, including a .~eizure history, alcohol or other substance withdrawal, and concomitant use of multiple medications. The risk of seizures with antidepressants increases with increasing dose. A seizure incidence range of 0.1 % to 1.1 %, depending on dosage, has been suggested for patients taking imipramine (Rosenstein et aI., 1993). The seizure risk with bupropion has been considered to be fourfold greater than with standard antidepressants. Serrraline and mher more recenrly marketed anridepressants are believed to have a lower seizure risk, but risk estimates for them are complicated by the lack of established effective doses and blood levels (Rosenstein et aI., 1993). Our review of the literature revealed only one case of seizures in an adult, believed to be caused by syndrome of inappropriate
1018
.I.
AM. ACAD. CHIl.D ADOl.ESC. PSYCHIATRY..~(':8. AliClIST 1997
LETTERS TO THE EDITOR
More research is needed regarding the use of this combination of medications in pediatric patients, including possible side effects and medication interactions. Daniel J. Feeney, M.D. William M. Klykylo, M.D. Wright State University School of Medicine Dayton,OH Goldstein I.. Barker M. Segall F et al. (1')%). Seizure and transient SIADH associated with senraline. Am] Psychiatry 153:732 Gross-Tsur V, Manor O. van der Meere J. Joseph A. Shalev RS (1'>')7), Epilepsy and :mention-deficit hyperactivity disorder: is methylphenidate safe and effective' ] Pediatr 1.10:40-44 Rosenstein DL, Nelson JC. Jacobs SC (1')'>3), Seizures associated with antidepressants: a review.] Gin Psychiatry 54:28'>-2'>'>
MORE ON NONAFFECTIVE SEASONALITY To the ttlitor: This is a note to expand upon Harrison's (1997) letter regarding nonaffectivc seasonality in which he noted the importance of asking adolescents about this. Recently, after hearing Dr. Norman Rosenthal (the author of articles on this subject) speak on seasonal affective disorder, I began asking adolescents about symptoms associated with this disorder.
J.
AM. ACAD. CIII LD ADOLESC. PSYCHIATRY, .H,:H, AUC C ST 1')<)7
Somewhat to my surprise, two depressed adolescents reported such symptoms. One obtained a light box and within 2 weeks reported significant improvement. While certainly there may be a placebo effect (it was very helpful for him and his family to focus on this to explain his symptoms), there is no question that this 14-year-old is better and does not seem to require further treatment. Alex Weintrob, M.D. New York Harrison SI (1')')7). Nonaffecrive seasonality (Iwer).] Am Amd Child Adolesc Psychiatry 36: 163-164
The Letters column is a corner of the journal that encourages opinion, controversy, and preliminary ideas, We especially invite reader comments on the anicles we publish as well as issues or interests of concern to child and adolescent psychiatry. The Editor reserves the right to solicit responses and publish replies. All statements expressed in this column are those of the authors and do not reflect opinons of the journal. Letters should not exceed 750 words. including a maximum of 5 references. They must be signed, typed doublespaced, and submitted in duplicate. All letters are subject to editing and shortening. They will be considered for publication blll may not necessarily be published nor will their receipt be acknowledged. Please direct your letters to John E McDermott, Jr., M.D .• Editor, journal of the AACAP, University of Hawaii School of Medicine, Kapiolani Medical Center. 1319 Punahou Street #635. Honolulu. HI 968261032.
1019
secretion of antidiuretic hormone-associated hyponarremia, which developed while the patient was taking sertraline (Goldstein et aI., 1996). No reports of seizures developing in the context of sertraline-methylphenidate combination therapy were discovered. S.D., a 13-year-old white male with a history of ADHD and a depressive disorder not otherwise specified, has been followed by the first aurhor for approximately I year. S.D. had been treated with methylphenidate, which was gradually increased in dosage to 80 mg/day (I.8 mg/kg per day) as lower dosages failed to provide adequate improvement in core ADHD symptoms. S.D. had tolerated the methylphenidate well, without significant side effects for approximately 10 months, and had not required any dose adjustment in more than 7 months. He has also benefited from cognitive-behavioral and family interventions and was seen at monthly intervals. His depressive symptomatology remained well controlled until the eighth month of rreatment, when he became significantly more irritable and showed progressive decline and significant dysfunction in social and academic performance over the following 2month period. Because of the worsening of his mood disturbance, sertraline 25 mg/day was prescribed; the dosage was increased to 50 mg/day after 7 days. After approximately I week of treatment with methylphenidate 80 mg/day and serrraline 50 mg/day, S.D. experienced a tonicclonic ictal event (lasting a few seconds) witnessed by his father. Immediate evaluation in a local emergency room revealed a negative history for recent infection or fever, bur a diminished appetite and oral intake over the previous week was noted. Laboratory analysis revealed normal serum electrolyte levels (including normal serum calcium, phosphate, osmolarity, and toxicology screen) and a normal computed tomographic scan of the brain. The only abnormality noted was a serum pH of 7.2. The following day, the sertraline therapy was discontinued unril S.D. could undergo a full neurological evaluation. The patient's furrher workup included an EEG revealing normal findings. S.D. has remained off all antidepressants and has continued his methylphenidate regimen unchanged and without recurrence of seizures. This is, to the best of our knowledge, the first reported case of seizure activity in the presence of sernaline-methylphenidate rreatment in a pediarric patienr. It is possible that these medications altered the patienr's appetite so significantly that a metabolic/electrolyte derangemenr existed, precipitating the seizure event. It may also be the case that these mediations altered cytochrome P450 metabolism to an extent that much higher blood levels of sernaline, methylphenidate, or both existed, increasing the patienr's seizure risk. It is also possible that the patient's ictal event had no association with his medical regimen.
develop in patients receiving daily doses of more than 40 mg/day of prednisone or its equivalent (Hall et aI., 1979). The factors involved in individual susceptibility to corticosteroids remain obscure, and more documented cases are needed to search for a possible genetic predisposition. ipek Tiirkta~ KIVlIclm Giiciiyener Gazi University Faculty of Medicine Aykut Ozden Ankara University Faculty of Medicine Ankara, Turkey
Connet G. Lenney W (19') I), Inhaleo buoesonioe ano hehavioural Oistur· bances. Lanut .DH:6."\4-6Yi Golostein E'l~ Preskorn SH (l9R9), Mania triggereo by a sleroio nasal spray in a patient wilh slable bipolar oisoroer. Am J PsyclJitltry 146: 1076 Hall RCW, Popkin MK, Sonora MD el al. (1')7'», Presentalion of sreroid psychoses. J Nr", Mmt Dis 167:229-B6 Meyboom RH B, de Graal: Breeoervelo N (1988), Buoesonioe ano psychic side dIects. Ann Intrrl/ Mrd 109:683 Phelan MC (1989), Beclomerhasone mania. Br J Pryr!Ji"try J55:H7J-872
MEDICATION-INDUCED SEIZURES
To the Editor: This is a report of an ictal evenr occurring in a 13-year-old boy receiving rreatmenr with methylphenidate and sertraline. The patient had no previous history of seizures or other neurological disorders, and his family history was also negative for seizure disorders. Antidepressanrs and methylphenidate theoretically can lower the seizure threshold and increase seizure risk, hut such events are uncommon. Methylphenidate is considered safe in children with attenrion-deficit hyperactivity disorder (ADHD) who are seizure-free (Gross-Tsur et aI., 1997). The majority of antidepressant-related seizures occur in patients with predisposing factors, including a .~eizure history, alcohol or other substance withdrawal, and concomitant use of multiple medications. The risk of seizures with antidepressants increases with increasing dose. A seizure incidence range of 0.1 % to 1.1 %, depending on dosage, has been suggested for patients taking imipramine (Rosenstein et aI., 1993). The seizure risk with bupropion has been considered to be fourfold greater than with standard antidepressants. Serrraline and mher more recenrly marketed anridepressants are believed to have a lower seizure risk, but risk estimates for them are complicated by the lack of established effective doses and blood levels (Rosenstein et aI., 1993). Our review of the literature revealed only one case of seizures in an adult, believed to be caused by syndrome of inappropriate
1018
.I.
AM. ACAD. CHIl.D ADOl.ESC. PSYCHIATRY..~(':8. AliClIST 1997
LETTERS TO THE EDITOR
More research is needed regarding the use of this combination of medications in pediatric patients, including possible side effects and medication interactions. Daniel J. Feeney, M.D. William M. Klykylo, M.D. Wright State University School of Medicine Dayton,OH Goldstein I.. Barker M. Segall F et al. (1')%). Seizure and transient SIADH associated with senraline. Am] Psychiatry 153:732 Gross-Tsur V, Manor O. van der Meere J. Joseph A. Shalev RS (1'>')7), Epilepsy and :mention-deficit hyperactivity disorder: is methylphenidate safe and effective' ] Pediatr 1.10:40-44 Rosenstein DL, Nelson JC. Jacobs SC (1')'>3), Seizures associated with antidepressants: a review.] Gin Psychiatry 54:28'>-2'>'>
MORE ON NONAFFECTIVE SEASONALITY To the ttlitor: This is a note to expand upon Harrison's (1997) letter regarding nonaffectivc seasonality in which he noted the importance of asking adolescents about this. Recently, after hearing Dr. Norman Rosenthal (the author of articles on this subject) speak on seasonal affective disorder, I began asking adolescents about symptoms associated with this disorder.
J.
AM. ACAD. CIII LD ADOLESC. PSYCHIATRY, .H,:H, AUC C ST 1')<)7
Somewhat to my surprise, two depressed adolescents reported such symptoms. One obtained a light box and within 2 weeks reported significant improvement. While certainly there may be a placebo effect (it was very helpful for him and his family to focus on this to explain his symptoms), there is no question that this 14-year-old is better and does not seem to require further treatment. Alex Weintrob, M.D. New York Harrison SI (1')')7). Nonaffecrive seasonality (Iwer).] Am Amd Child Adolesc Psychiatry 36: 163-164
The Letters column is a corner of the journal that encourages opinion, controversy, and preliminary ideas, We especially invite reader comments on the anicles we publish as well as issues or interests of concern to child and adolescent psychiatry. The Editor reserves the right to solicit responses and publish replies. All statements expressed in this column are those of the authors and do not reflect opinons of the journal. Letters should not exceed 750 words. including a maximum of 5 references. They must be signed, typed doublespaced, and submitted in duplicate. All letters are subject to editing and shortening. They will be considered for publication blll may not necessarily be published nor will their receipt be acknowledged. Please direct your letters to John E McDermott, Jr., M.D .• Editor, journal of the AACAP, University of Hawaii School of Medicine, Kapiolani Medical Center. 1319 Punahou Street #635. Honolulu. HI 968261032.
1019