Sir: Mirtazapine is classed as a noradrenergic and specific serotonergic antidepressant (NaSSA). It acts by blocking α 2 receptors on noradrenergic neurons and enhancing norepinephrine release. 1 Increased levels of norepinephrine act on α 1adrenoceptors on serotonergic cell bodies, increasing serotonergic firing. 1 Nightmares occur only in rapid eye movement (REM) sleep. Most antidepressants suppress REM sleep; hence, nightmares are not a commonly reported side effect of therapy with antidepressants. We report the first ever case, to our knowledge, of a patient who developed severe nightmares on initiation of therapy with mirtazapine, which necessitated stopping the drug.Case report. Mr. A, a 52-year-old white man, presented in 2006 with depressive symptoms including low mood, poor sleep and appetite, loss of weight, hopelessness, and fatigue. Because of his symptom profile, he was started on mirtazapine, 15 mg at night. One day later, he reported vivid nightmares of being murdered and his body being cut up. These nightmares woke him from sleep and left him feeling very scared and upset. He recalled that he had been treated with mirtazapine 2 years ago and it had to be discontinued because of similar distressing nightmares. After 4 days of therapy and experiencing nightmares every night, he requested that the medication be stopped.

support the hypothesis that compulsive hoarding is a discrete syndrome (5, 6). Drs. van Grootheest and Cath correctly state that genetic linkage results must be replicated "before we can conclude that there is a [specific] susceptibility locus for hoarding." However, as with most other psychiatric disorders, there are probably several genes that confer risk for compulsive hoarding. The OCD Collaborative Genetics Study is the third study to find genetic markers specifically associated with compulsive hoarding, indicating that it is a distinct and heritable phenotype. Other studies have confirmed that compulsive hoarding is strongly familial (7) and appears to breed true (8). Future genetic studies should be conducted on populations with the more homogeneous and well-defined categorical phenotype of compulsive hoarding syndrome in order to identify the specific genes involved in its etiology.

No abstract

Exercise for Mental Health Sir: In this era of exponential growth of the "metabolic syndrome" and obesity, lifestyle modifications could be a cost-effective way to improve health and quality of life. Lifestyle modifications can assume especially great importance in individuals with serious mental illness. Many of these individuals are at a high risk of chronic diseases associated with sedentary behavior and medication side effects, including diabetes, hyperlipidemia, and cardiovascular disease. 1 An essential component of lifestyle modification is exercise. The importance of exercise is not adequately understood or appreciated by patients and mental health professionals alike. Evidence has suggested that exercise may be an oftenneglected intervention in mental health care. 2 Aerobic exercises, including jogging, swimming, cycling, walking, gardening, and dancing, have been proved to reduce anxiety and depression. 3 These improvements in mood are proposed to be caused by exercise-induced increase in blood circulation to the brain and by an influence on the hypothalamic-pituitaryadrenal (HPA) axis and, thus, on the physiologic reactivity to stress. 3 This physiologic influence is probably mediated by the communication of the HPA axis with several regions of the brain, including the limbic system, which controls motivation and mood; the amygdala, which generates fear in response to stress; and the hippocampus, which plays an important part in memory formation as well as in mood and motivation. Other hypotheses that have been proposed to explain the beneficial effects of physical activity on mental health include distraction, self-efficacy, and social interaction. 4 While structured group programs can be effective for individuals with serious mental illness, lifestyle changes that focus on the accumulation and increase of moderate-intensity activity throughout the day may be the most appropriate for most patients. 1 Interestingly, adherence to physical activity interventions in psychiatric patients appears to be comparable to that in the general population. Exercise improves mental health by reducing anxiety, depression, and negative mood and by improving selfesteem and cognitive function. 2 Exercise has also been found to alleviate symptoms such as low self-esteem and social withdrawal. 3 Exercise is especially important in patients with schizophrenia since these patients are already vulnerable to obesity and also because of the additional risk of weight gain associated with antipsychotic treatment, especially with the atypical antipsychotics. Patients suffering from schizophrenia who participated in a 3-month physical conditioning program showed improvements in weight control and reported increased fitness levels, exercise tolerance, reduced blood pressure levels, increased perceived energy levels, and increased upper body and hand grip strength levels. 5 Thirty minutes of exercise of moderate intensity, such as brisk walking for 3 days a week, is sufficient for these health benefits. Moreover, these 30 minutes nee...

Sir: Bupropion hydrochloride (HCl) is an aminoketone antidepressant currently approved by the U.S. Food and Drug Administration (FDA) for depression and smoking cessation. Off-label uses include treatment of attentiondeficit/hyperactivity disorder, chronic fatigue, and cocaine dependence and adjunctive treatment for Parkinson's disease. Bupropion is available in 3 formulations: immediaterelease (IR), sustained-release (SR), and extended-release (XL).Bupropion-induced seizures have been described in safety surveillance studies and case reports. As with other antidepressants and psychotropic medications, bupropion appears to lower the seizure threshold in a dose-dependent fashion. The seizure incidence in patients taking ≤ 450 mg per day of bupropion IR is 0.4%, while the incidence in those taking 600 to 900 mg per day is 2.8%. 1,2 This elevated risk of seizure led to a lowering of the maximum dose and the development of sustained-and extended-release products. The seizure rate for the sustained-release formulation decreased to 0.1% at doses of up to 300 mg per day. 2 An emergency medicine study revealed that bupropion was the third leading cause of new-onset seizures at 1.4%, behind cocaine and benzodiazepine withdrawal. 3 Overdose literature indicates that 68% to 77% of bupropion-induced seizures occur within 4 hours of ingestion. 1,4 While bupropion-induced seizures are well described, data reflecting the consequences of bupropion nasal insufflation are limited. A MEDLINE search using the keywords bupropion and insufflation only revealed 2 letters reporting bupropion nasal insufflation in 2 adolescents, with 1 case resulting in seizure. 5,6 Neither of the 2 letters hypothesized about the mechanism for seizure production. This is the second reported case describing bupropion nasal insufflation-induced seizure.Case report. Mr. A, a 50-year-old homeless white man with a history of multiple emergency department (ED) admissions was brought into the ED in March 2005 by paramedics secondary to seizures from a standing position witnessed by 2 bystanders. Each seizure lasted 30 to 60 seconds with a brief postictal period and no incontinence. Bystander descriptions of the seizures were unavailable. During the intake history, Mr. A admitted to the nasal insufflation of bupropion SR tablets, but was unable to quantify the amount. The patient admitted to a history of bupropion nasal insufflation occasionally resulting in seizures over the past 3 years. He denied a long-standing seizure disorder or treatment with anticonvulsants. He claimed that this route of administration gives him a chemical euphoria, which he described as a "cocaine high." He did not complain of any auditory or visual hallucinations and exhibited no signs of intoxication.Mr. A's medical history was significant for substance abuse, questionable schizoaffective disorder, and prior seizures secondary to bupropion nasal insufflation. He denied a family history of seizure disorder or substance abuse. The patient admitted to smoking, but denied any current al...