- Email: [email protected]
PRIAPISM ASSOCIATED WITH VENLAFAXINE USE
LETTERS TO T H E E D I T O R
Office of Technology Assessment (1990), Health Care in RuralAmerica (Publication OTA-H-434). Washington, DC: US Government Printing Office Preston J (1992), Using telemedicine to improve health care in distant areas. Hop Community Psychiatry 43:25-32
PRIAPISM ASSOCIATED WITH VENLAFAXINE USE
Ti the Editor: This letter is to alert clinicians to one possible side effect of venlafaxine (and possibly of selective serotonin reuptake inhibitors too) that has not been reported yet, to my knowledge. (A literature search did not reveal any reports). Venlafaxine was prescribed for a 16-year 8-month-old white male for a recurrence of depressive symptoms associated with alcohol abuse and intermittent cannabis abuse. He also had a history of attentiondeficidhyperactivity disorder. He had been off all psychotropic medications for more than a year, but before that had been in treatment for many years and had received a number of psychotropic medications, including clonidine, dextroamphetamine, Adderall@,imipramine, carbamazepine, and guanfacine; he had finally been stabilized on a combination of guanfacine, carbamazepine, and imiprarnine. With the recurrence of depressive symptoms, the patient was unwilling to go back to his previous combination, because he felt “drugged on them and had discontinuation reactions when he discontinued them independently. He did agree to the trial of venlafaxine (Effexor-XR@),which was titrated from 37.5 mglday to 150 mg/day with salutary results. Two and a half months later, at a follow-up visit, the patient reported the presence of prolonged erections on 4 separate occasions of sexual intercourse. He had not experienced this before talung venlafixine. He denied any drug or alcohol abuse and was not talung any other medication, apart from over-the-counter use of ibuprofen and guaifenesin (Robitussin@).At the time of the follow-up, his mood was euthymic and he was behaving better in his family, doing well academically, and holding a parttime job. The patient reported no problems with libido, erection, or ejaculation. However, even after ejaculating, he maintained an erection for at least 3 hours and on one occasion for about 8 hours (full erection for about 3 hours and partial erection for about 5 hours). He denied any pain associated with the erection. He reported loss of the erection upon micturition. He was advised to reduce the venlafixine to 112.5 mg/day, to obtain a urine drug screen, and to follow up to monitor the priapism. Unfortunately, the patient did not follow up as recommended and only returned to treatment 3 months later. At that point, he indicated that he had stopped takmg the venlafaxine 6 weeks previously. He reported having no prolonged erections after discontinuing the venlafaxine, except for one that lasted overnight 3 weeks after discontinuing the drug. He again denied drug or
16
alcohol abuse; although he reported he had obtained a urine drug screen as ordered, there was no record that he had ever done so at the hospital where he claimed to have had the test. I wonder whether other clinicians have noticed complaints of prolonged erections in individuals taking the serotonergic antidepressants. Any other thoughts on the possible etiology of this phenomenon would be helpful.
Roger Z. Samuel, M.D. Boca Raton Psychiatric Group, PA. Boca Raton, FL
Comment by Drs. Horrigan and Barnbill, at the invitation of the Editor: Drug-induced priapism comprises about 30% of cases (although most are idiopathic; medical disorders such as sickle cell anemia account for a small minority of cases) (Banos et al., 1989).Obviously, the case at hand does not make the tightest of arguments that venlafaxine (EffexorB) causes priapism in adolescents. Nonetheless, this report mirrors a growing series of case reports that have indicted the various selective serotonin reuptake inhibitors (SSRIs) as culprits behind a rash of priapism in both genders (Berk and Acton, 1997). In the meantime, this case also counters the more apparent trend of sexual dysfunction as a consequence of exposure to SSRIs (these agents can ostensibly prevent the initiation of an erection).The net result is a bit confusing. SSRIs seem to have an unpredictable and idiosyncratic effect on sexual responsivity-witness the various reports that emerged over the past decade concerning spontaneous orgasms while yawning (in those who were taking SSRIs) (Modell, 1989). In terms of a possible mechanism, a antagonism is frequently the key behind situations of blocked detumescence (it is worth noting, at this point, that emergent treatment is often necessary, as damage to the corpora can occur within 3-4 hours). Here is where the finger is more often pointed at older psychotropic agents such as the phenothiazines, and similarly at trazodone (Thompson et al., 1990). Olanzapinehas been implicated as well. There have also been case reports of atypical dystonic reactions to neuroleptics, beginning in the more reactive regions of the groin, with relief noted only when anticholinergic agents have been delivered. The story is not as simple as one would hope, though. Proper cholinergic tone is required for detrusor muscle responsivity, while adrenergic input to the bladder plays a key role in sphincter relaxation. Accordingly, timely resolution of an erection requires harmonious interplay of these various transmitter systems or circuits. To return to the present case, the disappearance of the priapism with micturition suggests that an adrenergic mechanism may be of primary importance here, although this is hard to fathom given venlafaxine’s capacity as a noradrenergic reuptake inhibitor (and thus as an indirect agonist). The haziest parts of the history involve the possible substance abuse by this young
J. A M . ACAD. C H I L D A D O L E S C . PSYCHIATRY, 3 9 : 1 , JANUARY 2000
L E T T E R S TO T H E EDITOR
man, tempered by his apparent appetite for sexual encounters. Topical cocaine as well as “Spanish fly” (cantharidin) have been credited with an ability to induce an unremitting erection, and it is likely that there is underreporting of such phenomena in both the emergency room and the medical literature (Karras et a]., 1996).Of course,marijuana and ethanol have also been known to caw priapism. The net result is that it is difficult in this case to sort out the possible offending agent or agents, although this first observation concerning venlafaxine may be a harbinger of more substantial reports to follow. Joseph t? Horrigan, M.D.
L.Jarrett Barnhill, M.D. Developmental Neuropharmacology Clinic University of North Carolina at Chapel Hill Banos JE, Bosch F, Farre M (1989), Drug-induced priapism: its etiology, incidence and treatment. Mrd Toxic01Advrnr Dnrg Erp 4:46-58 Berk M, Acton M (1997),Citalopram-associated clitoral priapism: a w series. Int Clin Psychophannarol12:121-122
b r a s DJ, Farrcll SE, Harrigan RA. Henretig FM. Gealt L (1996),Poisoning
from ”Spanish fly“ (cantharidin). Am J Emng Mcd 14:478-483 Modell JC (1989), Repeated observationsof yawning, clitoral engorgement, and orgasm associated with fluoxetinc administration. J Clin Psychopha-ol9:63-65 Thompson JW. Ware MR. Blashficld RK (19901, Psychotropic medication and priapism: a comprehensive review. 1Clin Pychiatry 51:410-433
The Letters column is a corner of the Journal that encourages opinion, controversy. and preliminary ideas. We especially invite reader comments on the articles we publish as well as issues or interests of concern to child and adolcscent psychiatry. The Editor rcscrvcs the right to solicit responses and publish replies. All statements expressed in this column are those of the authors and do not reflect opinions of the Journal Letters should not cxcecd 750 words, including a maximum of 5 references. They must be signed, typed double-spaced, and sub mined in duplicate. All letters are subject to editing and shortening. They will be considered for publication but may not necessarily bc published nor will their receipt be acknowledged. Please direct your letters to Mina K. Dulcan, M.D., Editor, Journal of the AACAP Editorial Office, Children’s Memorial Hospital, 2300 Children’s Plaza #156, Chicago, IL 60614-3394.
Children in Special Education Programs:Attention Deficit Hyperactivity Disorder, Use of Services, and Unmet Needs. Regina Bussing, MD, MSHS, Bonnie T. Zima, MD. MPH, Amy R. Pcrwien, BA, Thomas R. Belin, PhD, Me1 Widawski, MA 06jrm’ws:Atrention deficit hyperactivity disorder (ADHD), a common psychiatric condition, may impair a childi ability to learn and to form social relationships, tasks critical to healthy development. This study describe the prevalence of the disorder among children
in special education programs and identifies the extent and predictors of unmet service nccds. Mnhodr: A 2-stage screening protocol of a countywide population of second- through fourth-grade students in special education was conducted to ( I ) screen for ADHD, employing s t a n d a r d d parent and teacher questionnaires, and determine health services use (n = 499) and (2) perform diagnostic assessments of A D H D (n = 3 18). Rmrftr:Almost half of the children qualified for a diagnosis of ADHD, yet only half of those were reportedly receiving care for the condition. mainly in the general health care sector. Girls were more than 3 times as likely as boys to have unmet service needs;minority status, low income, and health maintenance organization coverage also emerged as possible risk factors for unmet service needs. Conclusions: ADHD is a common yet often untreated condition among children in special education. Mental health services for children with this disorder should be integrated with general health care and special education programs. Am J Public Health 1998;88:88&886. Copyright 1998 by the American Public Health Association.
Abstracts srlcrrrd
Micbad J. Malonq, M .D., Assistant Editor.
J. A M . A C A D . C H I L D A D O L E S C . P S Y C H I A T R Y , 3 9 : l , J A N U A R Y ZOO0
17
Office of Technology Assessment (1990), Health Care in RuralAmerica (Publication OTA-H-434). Washington, DC: US Government Printing Office Preston J (1992), Using telemedicine to improve health care in distant areas. Hop Community Psychiatry 43:25-32
PRIAPISM ASSOCIATED WITH VENLAFAXINE USE
Ti the Editor: This letter is to alert clinicians to one possible side effect of venlafaxine (and possibly of selective serotonin reuptake inhibitors too) that has not been reported yet, to my knowledge. (A literature search did not reveal any reports). Venlafaxine was prescribed for a 16-year 8-month-old white male for a recurrence of depressive symptoms associated with alcohol abuse and intermittent cannabis abuse. He also had a history of attentiondeficidhyperactivity disorder. He had been off all psychotropic medications for more than a year, but before that had been in treatment for many years and had received a number of psychotropic medications, including clonidine, dextroamphetamine, Adderall@,imipramine, carbamazepine, and guanfacine; he had finally been stabilized on a combination of guanfacine, carbamazepine, and imiprarnine. With the recurrence of depressive symptoms, the patient was unwilling to go back to his previous combination, because he felt “drugged on them and had discontinuation reactions when he discontinued them independently. He did agree to the trial of venlafaxine (Effexor-XR@),which was titrated from 37.5 mglday to 150 mg/day with salutary results. Two and a half months later, at a follow-up visit, the patient reported the presence of prolonged erections on 4 separate occasions of sexual intercourse. He had not experienced this before talung venlafixine. He denied any drug or alcohol abuse and was not talung any other medication, apart from over-the-counter use of ibuprofen and guaifenesin (Robitussin@).At the time of the follow-up, his mood was euthymic and he was behaving better in his family, doing well academically, and holding a parttime job. The patient reported no problems with libido, erection, or ejaculation. However, even after ejaculating, he maintained an erection for at least 3 hours and on one occasion for about 8 hours (full erection for about 3 hours and partial erection for about 5 hours). He denied any pain associated with the erection. He reported loss of the erection upon micturition. He was advised to reduce the venlafixine to 112.5 mg/day, to obtain a urine drug screen, and to follow up to monitor the priapism. Unfortunately, the patient did not follow up as recommended and only returned to treatment 3 months later. At that point, he indicated that he had stopped takmg the venlafaxine 6 weeks previously. He reported having no prolonged erections after discontinuing the venlafaxine, except for one that lasted overnight 3 weeks after discontinuing the drug. He again denied drug or
16
alcohol abuse; although he reported he had obtained a urine drug screen as ordered, there was no record that he had ever done so at the hospital where he claimed to have had the test. I wonder whether other clinicians have noticed complaints of prolonged erections in individuals taking the serotonergic antidepressants. Any other thoughts on the possible etiology of this phenomenon would be helpful.
Roger Z. Samuel, M.D. Boca Raton Psychiatric Group, PA. Boca Raton, FL
Comment by Drs. Horrigan and Barnbill, at the invitation of the Editor: Drug-induced priapism comprises about 30% of cases (although most are idiopathic; medical disorders such as sickle cell anemia account for a small minority of cases) (Banos et al., 1989).Obviously, the case at hand does not make the tightest of arguments that venlafaxine (EffexorB) causes priapism in adolescents. Nonetheless, this report mirrors a growing series of case reports that have indicted the various selective serotonin reuptake inhibitors (SSRIs) as culprits behind a rash of priapism in both genders (Berk and Acton, 1997). In the meantime, this case also counters the more apparent trend of sexual dysfunction as a consequence of exposure to SSRIs (these agents can ostensibly prevent the initiation of an erection).The net result is a bit confusing. SSRIs seem to have an unpredictable and idiosyncratic effect on sexual responsivity-witness the various reports that emerged over the past decade concerning spontaneous orgasms while yawning (in those who were taking SSRIs) (Modell, 1989). In terms of a possible mechanism, a antagonism is frequently the key behind situations of blocked detumescence (it is worth noting, at this point, that emergent treatment is often necessary, as damage to the corpora can occur within 3-4 hours). Here is where the finger is more often pointed at older psychotropic agents such as the phenothiazines, and similarly at trazodone (Thompson et al., 1990). Olanzapinehas been implicated as well. There have also been case reports of atypical dystonic reactions to neuroleptics, beginning in the more reactive regions of the groin, with relief noted only when anticholinergic agents have been delivered. The story is not as simple as one would hope, though. Proper cholinergic tone is required for detrusor muscle responsivity, while adrenergic input to the bladder plays a key role in sphincter relaxation. Accordingly, timely resolution of an erection requires harmonious interplay of these various transmitter systems or circuits. To return to the present case, the disappearance of the priapism with micturition suggests that an adrenergic mechanism may be of primary importance here, although this is hard to fathom given venlafaxine’s capacity as a noradrenergic reuptake inhibitor (and thus as an indirect agonist). The haziest parts of the history involve the possible substance abuse by this young
J. A M . ACAD. C H I L D A D O L E S C . PSYCHIATRY, 3 9 : 1 , JANUARY 2000
L E T T E R S TO T H E EDITOR
man, tempered by his apparent appetite for sexual encounters. Topical cocaine as well as “Spanish fly” (cantharidin) have been credited with an ability to induce an unremitting erection, and it is likely that there is underreporting of such phenomena in both the emergency room and the medical literature (Karras et a]., 1996).Of course,marijuana and ethanol have also been known to caw priapism. The net result is that it is difficult in this case to sort out the possible offending agent or agents, although this first observation concerning venlafaxine may be a harbinger of more substantial reports to follow. Joseph t? Horrigan, M.D.
L.Jarrett Barnhill, M.D. Developmental Neuropharmacology Clinic University of North Carolina at Chapel Hill Banos JE, Bosch F, Farre M (1989), Drug-induced priapism: its etiology, incidence and treatment. Mrd Toxic01Advrnr Dnrg Erp 4:46-58 Berk M, Acton M (1997),Citalopram-associated clitoral priapism: a w series. Int Clin Psychophannarol12:121-122
b r a s DJ, Farrcll SE, Harrigan RA. Henretig FM. Gealt L (1996),Poisoning
from ”Spanish fly“ (cantharidin). Am J Emng Mcd 14:478-483 Modell JC (1989), Repeated observationsof yawning, clitoral engorgement, and orgasm associated with fluoxetinc administration. J Clin Psychopha-ol9:63-65 Thompson JW. Ware MR. Blashficld RK (19901, Psychotropic medication and priapism: a comprehensive review. 1Clin Pychiatry 51:410-433
The Letters column is a corner of the Journal that encourages opinion, controversy. and preliminary ideas. We especially invite reader comments on the articles we publish as well as issues or interests of concern to child and adolcscent psychiatry. The Editor rcscrvcs the right to solicit responses and publish replies. All statements expressed in this column are those of the authors and do not reflect opinions of the Journal Letters should not cxcecd 750 words, including a maximum of 5 references. They must be signed, typed double-spaced, and sub mined in duplicate. All letters are subject to editing and shortening. They will be considered for publication but may not necessarily bc published nor will their receipt be acknowledged. Please direct your letters to Mina K. Dulcan, M.D., Editor, Journal of the AACAP Editorial Office, Children’s Memorial Hospital, 2300 Children’s Plaza #156, Chicago, IL 60614-3394.
Children in Special Education Programs:Attention Deficit Hyperactivity Disorder, Use of Services, and Unmet Needs. Regina Bussing, MD, MSHS, Bonnie T. Zima, MD. MPH, Amy R. Pcrwien, BA, Thomas R. Belin, PhD, Me1 Widawski, MA 06jrm’ws:Atrention deficit hyperactivity disorder (ADHD), a common psychiatric condition, may impair a childi ability to learn and to form social relationships, tasks critical to healthy development. This study describe the prevalence of the disorder among children
in special education programs and identifies the extent and predictors of unmet service nccds. Mnhodr: A 2-stage screening protocol of a countywide population of second- through fourth-grade students in special education was conducted to ( I ) screen for ADHD, employing s t a n d a r d d parent and teacher questionnaires, and determine health services use (n = 499) and (2) perform diagnostic assessments of A D H D (n = 3 18). Rmrftr:Almost half of the children qualified for a diagnosis of ADHD, yet only half of those were reportedly receiving care for the condition. mainly in the general health care sector. Girls were more than 3 times as likely as boys to have unmet service needs;minority status, low income, and health maintenance organization coverage also emerged as possible risk factors for unmet service needs. Conclusions: ADHD is a common yet often untreated condition among children in special education. Mental health services for children with this disorder should be integrated with general health care and special education programs. Am J Public Health 1998;88:88&886. Copyright 1998 by the American Public Health Association.
Abstracts srlcrrrd
Micbad J. Malonq, M .D., Assistant Editor.
J. A M . A C A D . C H I L D A D O L E S C . P S Y C H I A T R Y , 3 9 : l , J A N U A R Y ZOO0
17