Selective Serotonin withdrawal effect

With respect to a specific and common clinical problem, advice to withdraw hypnotic medication should follow a careful evaluation of self-reported sleep patterns, psychological factors and psychosocial status. Ambulant monitoring can be helpful in patients who have encountered severe problems in effecting withdrawal. A careful psychiatric assessment should be made to ascertain whether the patient has clinically significant anxiety and/or depression. Both should be treated with a selective serotonin receptor inhibitor (SSRI) before withdrawal from the hypnotic is attempted. An optimal tapering schedule should be discussed with the patient some will attempt a rapid withdrawal over less than 8 weeks and others will require much longer. This is particularly so if previous attempts to withdraw have been unsuccessful. Carers, family and friends should be mobilized to help in withdrawal, should the patient wish this. Substitution of zolpidem may facilitate withdrawal but should be kept as a reserve strategy. 

Bipolar depression affects 1% of the general population, and treatment resistance is a significant problem. The addition of pindolol can lead to significant improvement in depressed patients who are resistant to antidepressant drugs, such as selective serotonin reuptake inhibitors or phenelzine. Of 17 patients with refractory bipolar depression, in whom pindolol was added to augment the effect of antidepressant drugs, eight responded favorably (95). However, two developed transient hypo-mania, and one of these became psychotic after the resolution of hypomanic symptoms. In both cases transient hypomanic symptoms resolved without any other intervention, while psychosis required pindolol withdrawal. 

Other clinical uses Tricyclic drugs are also used in the treatment of bipolar affective disorders, acute panic attacks, phobic disorders (compare with alprazolam Chapter 22), enuresis, and chronic pain states. Clomipramine and the selective serotonin reuptake inhibitors, including fiuvoxamine, are effective in obsessive-compulsive disorders. SSRls are also effective in patients who suffer from panic attacks, social phobias, bulimia, and premenstrual syndrome (PMS) and may also be useful in the treatment of alcohol dependence. Bupropion is used for management of patients attempting to withdraw from nicotine dependence. 

Tricyclics modify peripheral sympathetic effects in two ways through blockade of norepinephrine reuptake at neuroeffector junctions and through alpha adrenoceptor blockade. Sedation and atropine-like side effects are common with tricyclics, especially amitriptyline. In contrast to sedative-hypnotics, tricyclics lower the threshold to seizures. The answer is (B). Selective serotonin reuptake inhibitors cause sexual dysfunction in some patients, with changes in libido, erectile dysfunction, and anorgasmia. Tricyclic antidepressants may also decrease libido or prevent ejaculation. Of the heterocyclic antidepressants bupropion is the least likely to affect sexual performance. The drug is also used in withdrawal from nicotine dependence. The answer is (B). 

Tryptophan is the most extensively studied amino acid in relation to alcohol and alcoholism. This is probably because it is the precursor of serotonin. Serotonin levels as altered by ethanol could have a role in disturbances in mood, clinical features of alcohol dependence, and alcohol withdrawal states. The control of alcohol consumption itself by serotonin has been considered.96 Accounts of the effects of ethanol on tryptophan and serotonin metabolism have been reviewed.9798 This section limits itself to selected aspects of ethanol and tryptophan metabolism in experimental animals and in humans. How these changes may secondarily affect serotonin metabolism is mentioned. 

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