LETTERS sant medications are preferred to could not resume her work and 6. Lenze EJ, Pollock BG, Shear MK, et al: benzodiazepines as a first-line of preferred to stay home to avoid sit- Treatment considerations for anxiety in the elderly. CNS Spectr 2003; 8(S3):6–13 treatment for anxiety disorders in uations that might provoke her the elderly.6 Psychotherapy, par- anxiety. She was prescribed sertra- ticularly cognitive behavior ther- line and was maintained on 150 apy, is often effective in these disor- mg/day. She reported lower anxi- Aripiprazole Diminishes 6 ders as well. ety level, became comfortable in Cannabis Use in We reviewed symptoms of three public, and decided to look for a cases in which onset of anxiety part-time job. Schizophrenia symptoms developed after age 60 The third case was a 75-year-old as a result of having a medical pro- male. He was a retired photogra- cedure. They were highly function- pher and developed minor neuro- To the Editor: Aripiprazole is the ing individuals and anxiety symp- logical deficits. Computed tomogra- first partial agonist dopaminergic toms led to impairment of their phy scan (CT) of the head was D2 with clear antipsychotic effect. social and occupational life. They conducted. After the image study, Many schizophrenic patients will were all successfully treated with he started to have periods of in- develop comorbid substance abuse. selective serotonin reuptake inhibi- tense fear and excessive worry cued Cannabis consumption may worsen tor medications without any side ef- by his presence in places from psychotic symptoms of schizo- fects and achieved the overall level which escape might be difficult. He phrenic patients.1 We describe the of functioning. isolated himself at home, stopped case of a schizophrenic patient The first case was a 61-year-old going to church services and the se- whose use of cannabis and related male who worked in graphic art. nior citizen center, and suffered de- problems disappeared after treat- He developed severe neck pains pression. He showed significant ment with aripiprazole. and a magnetic resonance imaging symptom response on paroxetine, Mr. A, a 33-year-old Caucasian scan (MRI) of cervical spines was 40 mg/day. patient with schizophrenia, has recommended. After having the Nahla A. Mahgoub, M.D. since his mid-20s been treated with MRI, he developed recurrent unex- Psychiatry, Weill Medical Col- olanzapine, 20 mg/day, and escital- pected panic attacks and anxiety lege of Cornell University, opram, 10 mg/day. He did reason- about being in a closed place. Com- New York ably well with this regimen but was muting to work caused marked dis- Jahandar Saifollahi, M.D. apragmatic. He frequently used tress and he subsequently avoided Melinda Lantz, M.D. cannabis every day (urine screen traveling in a bus, train, or car, and Geriatric Psychiatry, Beth Israel for tetrahydrocannabinol [THC] his daily activities were restricted. Medical Center, New York was positive). He was moderately He initially refused to consider any obese (BMI: 28) but had no other medications that might limit his medical problems. He lived in a creativity. He agreed to a trial of References community house, in which nurses sertraline, 50 mg/day, which was 1. Sadock BJ, Sadock VA: Geriatric psychi- ensured that he was compliant with increased gradually to 100 mg. He atry, in Kaplan and Sadock’s Synopsis treatment. His Brief Psychiatric Rat- noted significant improvement in of Psychiatry: Behavioral Sciences/ ing Scale (BPRS) score was 52. Be- intensity and frequency of his panic Clinical Psychiatry, 9th ed. Philadelphia, fore his mid-20s, the patient was Lippincott, Williams & Wilkins, 2002, pp attacks and regained the ability to 1318–1337 treated successively for different use the public transportation with- 2. Flint AJ: Management of anxiety in late classic antipsychotic conditions (i.e., out any fear. life. J Geriatr Psychiatr Neurol 1998; haloperidol, bromperidol, and pi- The second case involved a 61- 11:194–200 mozide) and he reported increased year-old female who was a medical 3. Rangaraj J, Pelissolo A: Anxiety disor- cannabis abuse concomitant with ders in the elderly: clinical and thera- technician. peutic aspects. Psychol Neuropsychiatr these regimens. She suffered gastrointestinal re- Vieil 2006; 4:179–187 Aripiprazole, 15 mg/day, was flux disease and underwent diag- 4. Flint AJ, Gagnon N: Diagnosis and man- added to his treatment regimen. Af- nostic upper endoscopy. Since then, agement of panic disorder in older pa- ter 1 week, the olanzapine dose was she had been feeling anxious, and tients. Drugs Aging 2003; 20:881–891 decreased to 10 mg. One week later, 5. Flint AJ: Epidemiology and comorbidity had poor concentration, frequent of anxiety disorders in later life: implica- olanzapine was discontinued. After unpredicted panic attacks, and tions for treatment. Clin Neurosci 1997; 5 weeks, escitalopram treatment anxiety about being in a crowd. She 4:31–36 was discontinued because the pa-

J Neuropsychiatry Clin Neurosci 20:1, Winter 2008 117 LETTERS tient was euthymic. Three months patients may actually contribute to zole for alcohol dependence treatment. later, the patient signaled he felt greater substance use in an effort to Drugs Future 2003; 28:1227–1235 8,9 7. Warsi M, et al: Aripiprazole reduces al- very good and did not need canna- self-medicate the side effects. cohol use. Can J Psychiatry 2005; 50:244 bis anymore. After 12 months of Finally, there could be at least 8. McEvoy JP, et al: Haloperidol increases treatment with aripiprazole the pa- two explanations for the weight smoking in patients with schizophrenia. tient had not relapsed and did not loss. The reduction of cannabis use Psychopharmacology (Berl) 1995; use cannabis at all (urine screen did may have contributed to a reduc- 119:124–126 10 9. Siris SG: Pharmacological treatment of not reveal any THC). Moreover, his tion in eating, and the switch in substance-abusing schizophrenic pa- BMI was 24 and BPRS score de- the antipsychotic to aripiprazole tients. Schizophr Bull 1990; 16:111–122 creased to 40. may have been instrumental in 10. Kirkham TC: Endocannabinoids in the This case report highlights differ- such a significant weight reduction, regulation of appetite and body weight. ent proposals about mechanism of since aripiprazole is weight neutral Behav Pharmacol 2005; 16:297–313 action and side effects. and olanzapine is known to facili- First, the concurrence of the dimi- tate weight gain in patients. nution of cannabis consumption To our knowledge, this is the first Clinical Correlates of with the patient’s treatment with reported case of aripirpazole’s effect Personality Changes aripiprazole suggests that aripipra- on cannabis use. More research is zole contributed to the occurrence needed to establish the benefits of Associated With Traumatic of this diminution. Different mecha- aripiprazole in regard to cannabis. Brain Injury nisms may have played a part, such Some dual diagnosis patients may as aripirazole’s partial agonism at benefit from aripiprazole, which 2 dopamine D2 receptors. A similar may reduce craving for and use of To the Editor: Traumatic brain injury observation was made with cocaine cannabis. (TBI) is frequently complicated by dependence.3 Dopamine stimula- Martin Desseilles, M.D. alterations in temperament and tion in the nucleus accumbens has Department of Psychiatry, Uni- character that have adverse conse- been suggested to cause addictive versity of Lie`ge, Belgium quences for day-to-day living, man- behavior and aripiprazole’s partial Fernand Mathot, Pharm.D. ifesting as poor decision-making, dopamine agonist effect in this area Michel Desseilles, M.D. interpersonal problems, communi- may reduce this behavior.4 In addi- Psychiatric Hospital Centre cation problems, and often overall tion, aripiprazole has a number of “Le Petit-Bourgogne,” Lie`ge, poor quality of life.1 Max et al.2 serotonergic actions that are not re- Belgium have reported extensively on the lated to dopamine potentially mod- correlates and predictors of person- 5,6 ality changes after traumatic brain ulating the response to THC. References Other mechanisms may be involved injury in children, but there is scant and Mr. A’s rapid cessation of can- 1. Ujike H, Morita Y: New perspectives in mention in the literature on adults. the studies on endocannabinoid and In this report, we describe the re- nabis use after starting aripiprazole cannabis: cannabinoid receptors and suggests the need to verify these schizophrenia. J Pharmacol Sci 2004; sults of a preliminary study of the mechanisms systematically and to 96:376–381 clinical correlates of personality plan controlled trials. 2. Travis MJ, Burns T, Dursun S, et al: Ari- change following traumatic brain Second, several factors have to be piprazole in schizophrenia: consensus injury in adults. guidelines. Int J Clin Pract 2005; 59:485– considered when regarding why 495 there may be a concomitant in- 3. Beresford TP, et al: Aripiprazole in Analysis crease in substance abuse with the schizophrenia with cocaine dependence: Data are from a retrospective chart older antipsychotics. It was sug- a pilot study. J Clin Psychopharmacol review of 54 subjects with closed gested that a strong antagonist ef- 2005; 25:363–366 head injury enrolled in an outpa- 4. Pilla M, et al: Selective inhibition of co- fect at the dopamine D2 receptors in caine-seeking behaviour by a partial do- tient neuropsychiatry brain injury the nucleus accumbens was in- pamine D3 receptor agonist. Nature clinic. Patients with depressed skull volved in concomitant increase in 1999; 400:371–375 fractures were excluded. substance abuse with old antipsy- 5. Kenna GA, McGeary JE, Swift RM: Every patient was evaluated and chotics.7 Moreover, unrelated to do- Pharmacotherapy, pharmacogenomics, followed by a clinic psychiatrist. and the future of alcohol dependence paminergic mechanisms, the use of treatment, part 2. Am J Health Syst The assignment of personality certain antipsychotics with substan- Pharm 2004; 61:2380–2388 change due to a general medical tial side effects by schizophrenia 6. Kenna GA: Rationale for use of aripipra- condition (TBI) diagnosis was based

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