Tranylcypromine (TCP) is an effective antidepressant with a complex pharmacological profile and a relevant risk of abuse and dependence. Withdrawal phenomena (WP, in the case of TCP-abuse/dependence) or discontinuation phenomena (DP, in the case of absent TCP-abuse/dependence) subsequent to abrupt termination of TCP are a potentially severe clinical syndrome. We conducted a systematic review of all previously published WP/DP cases following abrupt termination of TCP in order to identify typical clinical presentations and risk factors of WP/DP and frequency of TCP abuse or dependence within these patients. By searching the Medline and Scopus databases we identified n=25 cases (cohort WP: n=18, cohort DP: n=7). Delirium was found in n=13 patients (cohort WP: 10/55.6%; cohort DP: 3/42.9%), n=6 demonstrated WP/DP without delirium (WP: 6/33.3%; DP: 0/0%) and n=5 rapid relapse in depression (WP: 1/5.6%; DP: 4/57.1%). Mean time until development of WP/DP was 1.9 (WP) and 2.2 (DP) days. Mean duration of WP/DP was 5.7 (WP) and 11.3 (DP) days. All patients of cohort WP were described to feature TCP-abuse/dependence. Patients with delirium were on average older (41.8 years vs. 37.8 years) and featured higher mean prescribed (71.0 mg vs. 38.3 mg) and actually taken daily TCP dosages (285.8 mg vs. 187.7 mg). In conclusion, even termination of lower daily dosages of TCP may result in delirium. Thrombocytopenia features diagnostic value in patients with deliria of unknown etiology. TCP should be administered with great care, especially in dependence-prone patients.·

There is considerable evidence for an increase of methylphenidate (MPH) abuse; thus, physicians might be confronted more frequently with MPH intoxications. Possible symptoms of intoxications with MPH are orofacial, stereotypic movements and tics as well as tachycardia, cardiac arrhythmias, arterial hypertension, hyperthermia, hallucinations and epileptic seizures. Here we report a patient who demonstrated somnolence as an uncommon clinical feature of MPH intoxication. The patient exhibited subnormal MPH serum levels (3 μg/l), however markedly increased serum levels of ritalinic acid (821 μg/l; inactive metabolite of MPH), that finally confirmed the initially suspected MPH intoxication. Due to the short half-life of orally administered MPH (t1/2~3 h) the sole measurement of MPH serum levels might be misleading concerning the proof of MPH overdosing in some cases. Parallel measurement of MPH and ritalinic acid is recommended in cases with suspected MPH intoxication and insufficient anamnestic data.

We present the case of a 39-year-old female patient with disorganized schizophrenia showing no psychotic exacerbation under serial treatment with cabergoline and bromocriptine for ablactation. Pharmacological ablactation with dopamine agonists (DA), like cabergoline or bromocriptine, after delivery can be a necessity also in patients with schizophrenia. The dopamine hypothesis of schizophrenia justifi es a treatment dilemma with possible psychotic exacerbation as plausible [1] . The clinician ' s dilemma is to trade the risk of inducing psychosis with the DA off against the possible risks for not stopping lactation. Although the coincidence of schizophrenia, pregnancy and the need for ablactation must be common, there is a striking absence of any data according to a selective literature review. We only know that DA administered for suppression of antipsychotics-induced hyperprolactinemia [2, 3] or for ablactation in non-schizophrenic women [4, 5] may cause psychotic exacerbation. Here were present a fi rst case of serial ablactation with 2 diff erent DAs in schizophrenia without occurrence of psychotic exacerbation. A 39-year-old Caucasian woman with a fi fteen year history of disorganized schizophrenia was admitted to our psychiatric department after delivering a baby (gestation time 36 weeks) via Caesarean section the day before. She presented with incoherence, inappropriate and blunted aff ect, no overt psychotic phenomena, intermittent agitation and disturbed sleep, after having discontinued her antipsychotic treatment 1.5 years ago. Grossly disorganized behaviour and decline in social function had dominated over transient psychotic symptoms in the past. This had required the adoption of her fi rst child 8 years ago (and also caused intrauterine child death due to tobacco and alcohol abuse the year before). After losing custody of the second child, ablactation was obligatory to prevent mastitis. As a single shot strategy 1 mg of cabergoline was administered on day one. Lactation subsided within days and no changes in psychopathologicy occurred. After a week, olanzapine 5 mg per day was started to treat disorganization. However, lactation recommenced and therefore olanzapine was discontinued due to its risk of causing hyperprolactinemia. In order to achieve immediate ablactation we also administered bromocriptine as the second DA for 5 days (3.75 mg per day) now achieving continued ablactation, again without psychotic exacerbation. Due to its low tendency to induce hyperprolactinemia, quetiapinefumarate 300 mg per day was then used to treat disorganization and agitation without reoccurence of milk secretion. The patient was discharged 3 weeks later. It follows from the above that the DAs cabergoline and bromocriptine could be used eff ectively and safely for ablactation in disorganized schizophrenia without concomitant application of antipsychotics. Even so, schizophrenic mothers should be monitored closely after DA use, unless prospective studies have determined the risk of psychotic exacerbation with DA in ...