Depression with cocaine

The coca leaf is commonly chewed by the natives of South America. The natives claim that the cocaine depresses their hunger and increases their strength. The leaves are very bitter when chewed and are often flavored with another substance such as lime. It has been estimated that over 90% of the Indians chew the coca leaf. The native chews, on an average, about two ounces of coca leaf daily and is often characterized by blackish red deposits on his teeth. 

Meanwhile, some medical researchers, including Sigmund Freud, began for a time to tout the advantages of medicinal cocaine as a stimulant for depressed or lethargic patients and even as a cure for morphine addiction. In 1884, Freud, treating his own bout of depression with cocaine, reported feeling... 

Sigmund Freud treats his own depression with cocaine and reports that it produces exhilaration and lasting euphoria. He says he cannot detect any deleterious effects. 

For years, scientists have known that cocaine interferes with the brain s dopamine system. Dopamine is a neurotransmitter—a chemical that passes nerve impulses from one nerve cell to another, and dopamine is associated with movement, emotional response, and the ability to experience pleasure. Research indicates that serotonin transporters are also inactivated with cocaine use. Serotonin is another neurotransmitter, and adequate levels are associated with well-being. Low levels of serotonin in the brain have been linked to depression. Inactivation of dopamine and serotonin transporters leads to receptor over-stimulation and the high. Continued use of cocaine can result in long-term changes in the brain chemistry as receptors decrease in number. These changes can be persistent and even irreversible, and may be responsible for the feeling of depression that lasts long after withdrawal. 

A 34-year-old woman with a history of polysubstance dependence (alcohol, cannabis, and cocaine), depressive episodes associated with multiple suicide attempts, and borderline personality disorder, who had been incarcerated after conviction on charges of physical assault and possession of controlled substances, complained of difficulty in sleeping, poor impulse control, irritability, and depressed mood. She was given oral quetiapine 600 mg/day. On one occasion, she crushed two 300-mg tablets, dissolved them in water, boiled them, drew the solution through a cotton swab, and injected the solution intravenously. Apart from having the best sleep I ever had she described no dysphoric, euphoric, or other effects. She admitted to previous intranasal abuse of crushed quetiapine tablets. 

Besides its effects on the higher centers, cocaine depresses the respiratory center when it is applied in a mixture with gelatin on the floor of the fourth ventricle (137). Aducco (138) observed a respiratory depression when cocaine was mixed with vaseline and put in direct contact with the respiratory center. Mosso (139) stated that cocaine, administered to the animal in small doses, stimulates the respiration. 

Cocaine. This lias a bitter taste, is mydriatic, produces local anaesthesia and is toxic. After absorption, or when taken internally, it acts chiefly by stimulation of the central nervous system, succeeded by depression. Since the two phases may be present in different areas simultaneously, a mixed result may ensue. With large doses the chief symptoms are those of medullary depression. Death is due to paralysis of the respiratory centre. The main use of cocaine in medicine is as a local anaesthetic. 

Antipsychotic medications are indicated in the treatment of acute and chronic psychotic disorders. These include schizophrenia, schizoaffective disorder, and manic states occurring as part of a bipolar disorder or schizoaffective disorder. The co-adminstration of antipsychotic medication with antidepressants has also been shown to increase the remission rate of severe depressive episodes that are accompanied by psychotic symptoms. Antipsychotic medications are frequently used in the management of agitation associated with delirium, dementia, and toxic effects of both prescribed medications (e.g. L-dopa used in Parkinson s disease) and illicit dtugs (e.g. cocaine, amphetamines, andPCP). They are also indicated in the management of tics that result from Gilles de la Tourette s syndrome, and widely used to control the motor and behavioural manifestations of Huntington s disease. 

Dependence and withdrawal can occur with all of the stimulants. Cocaine is one of the most strongly reinforcing drugs in self-administration paradigms in animals and also has a psychological withdrawal syndrome. A typical pattern of withdrawal includes a ravenous appetite, exhaustion, and mental depression, which may last for several days after the drug is withdrawn. Because tolerance develops quickly, abusers may take large doses, compared with those used medically, for example, as anorexiants. 

A meta-analysis of placebo-controlled studies by Levin and Lehman (1991) showed that desipramine produced greater cocaine abstinence than placebo. Although a more recent review did not concur (Lima et al. 2001), secondary analyses of studies with imipramine, desipramine, and bupropion suggested that depressed cocaine abusers are more likely to show significant reductions in cocaine abuse than nondepressed cocaine abusers (Margolin et al. 1995 Nunes et al. 1991 Ziedonis and Kosten 1991). Furthermore, recent work with desipramine supported its efficacy in opioid-dependent patients, particularly in combination with contingency management therapies (Kosten et al. 2004 Oliveto et al. 1999). 

Schmitz JM, Averill P, Stotts AL, et al Fluoxetine treatment of cocaine-dependent patients with major depressive disorder. Drug Alcohol Depend 63 207-214,2001 Schottenfeld RS, Pakes JR, Oliveto A, et al Buprenorphine vs methadone maintenance treatment for concurrent opioid dependence and cocaine abuse. Arch Gen Psychiatry 54 713-720, 1997... 

Uslaner J, Kalechstein A, Richter T, et al Association of depressive symptoms during abstinence with the subjective high produced by cocaine. Am J Psychiatry 156 1444-1446, 1999... 

Kl, a 27-year-old woman, was admitted to the cardiology unit from the emergency department after she called 911 claiming that she had severe chest pain. Upon arrival in the ED it was noted that her blood pressure was slightly elevated at 143/92 mm Hg, and that she was diaphoretic. She was in otherwise good physical condition, with no previous cardiac history. After a urine toxicology screen was positive for cocaine she admitted that she had smoked several rocks of crack an hour prior to having the chest pain. She said she almost never uses crack, but she s currently really depressed because she has lost her job. 

Modified and reprinted with permission from American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed.r text revision. Washington, DC American Psychiatric Association, 2000 Sofuoglu M, Dudish-Poulsen S, Poling J, et al. The effect of individual cocaine withdrawal symptoms on outcomes in cocaine users. Addict Behav 2005,30 1 125-1134 and Patten SB, Barbui C. Drug-induced depression a systematic review to inform clinical practice. Psychoth Psychosom 2004 73 207-215. 

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