CPCP: Carcinoid Tumors and SSRIs; Mood Disorders and Traumatic Brain Injury

So here’s a quick run-through of the rest of the Clinical Problems in Consultation Psychiatry (CPCP) presentations that were done last Friday but which I didn’t have room for in one post because the third one that day was the huge Catatonia Super Review. I have to hand it to these guys, they were simply the best.

Dr. Anisha Boetel gave an excellent summary of the review on mood disorders after traumatic brain injury (TBI) co-authored by a former department faculty member, Dr. Ricardo Jorge, MD, who drew on the work of the former department chair, Dr. Robert G. Robinson, MD [1]. I was interested especially in the use of lithium in this population, which was summarized as below:

Given that lithium carbonate is used often as a first-line treatment among persons with idiopathic bipolar disorder, it merits special comment as a treatment of mixed states among persons with TBI. Intolerance of doses necessary to effect mood stabilization appears to be more common among persons with TBI than with primary mania or mixed mood episodes. This intolerance is often attributable to the adverse cognitive and motor effects of lithium carbonate, which appears more likely to produce nausea, tremor, ataxia, and lethargy in persons with neurological disorders than in the general psychiatric population. Additionally, lithium carbonate lowers seizure threshold; in light of the risk for posttraumatic epilepsy as well as the potential comorbidity between posttraumatic epilepsy and mania, this effect is concerning with respect to lithium’s use in this population. As such, partial response, relapse of symptoms, or need for a second mood-stabilizing medication are common limitations of the use of this agent among TBI patients [1].

I pointed out to the group that I had just read an article from an author who had a different opinion about the usefulness of lithium for patients with mood instability after brain injury [2]. This opinion was based on a case report and while the limitations of the older literature on this subject were acknowledged, still the authors said:

Notwithstanding some very old and poorly substantiated concerns, there is little evidence that patients with TBI, dementia, or other neurologic deficits tolerate lithium any less well than patients with mood or other primary psychiatric disorders do. Such patients are of course subject to typical lithium adverse effects, but there is no evidence suggesting increased sensitivity. There is some controversy about the effect of lithium on seizure disorders, but overall, the effect of lithium on seizures seems at most minor [2].

This argues for viewing the literature with some degree of skepticism and exercising clinical judgement in individual cases.

Reference from Dr. Boetel’s CPCP:

  1. Jorge, R. E. and D. B. Arciniegas (2014). “Mood disorders after TBI.” Psychiatr Clin North Am 37(1): 13-29.
    In this article, we examine the epidemiology and risk factors for the development of the most common mood disorders observed in the aftermath of TBI: depressive disorders and bipolar spectrum disorders. We describe the classification approach and diagnostic criteria proposed in the fifth edition of the Diagnostic and Statistical Manual for Mental Disorders. We also examine the differential diagnosis of post-TBI mood disorders and describe the mainstay of the evaluation process. Finally, we place a special emphasis on the analysis of the different therapeutic options and provide guidelines for the appropriate management of these conditions.
  2. Cruz, C., et al. (2015). “Lithium Treatment for Post-Head Injury Volatility.” Psychosomatics 56(5): 576-579.

The presentation by the senior medical students, Daniel Fox and Robert Welborn, on carcinoid tumor and selective serotonin reuptake inhibitors (SSRIs) was very well done. The literature still tends to argue for caution in using SSRIs in the population of patients with carcinoid tumors although it’s clear that in my experience, they still tend to be prescribed in this setting and they’re not always poorly tolerated.

In order to see the picture galleries of photos or powerpoint slides, click on one of the slides, which will open up the presentation to fill the screen. Use the arrow buttons to scroll left and right through the slides or up and down to view any annotations.

 

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Comments

  1. When you talked about carcinoid tumors, did you talk about serum markers? Is there any role for follow-up serum markers once the carcinoid has been removed?

    Thanks,

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    • We didn’t focus on biomarkers because the talk was about serotonin syndrome and depression treatment rather than specifics of carcinoid treatment.

      Thanks.

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      • Did you come across if there is a role for checking biomarkers in someone who had carcinoid removed before/while being treated with an SSRI…I should have clarified my question.

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      • That’s an excellent question…except the medical students didn’t focus on it. So there might be literature on it, but we didn’t cover it on that particular day.

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