Abstract
This article presents two cases of adolescent males who were admitted to our inpatient psychiatric unit with a psychotic, disorganized presentation. Both males had a genetic vulnerability to mental illness and reported significant substance use. Their symptoms were refractory to treatment and required the use of clozapine. Both patients experienced significant side effects, which limited the maximum daily dose of clozapine. However, they responded to a dose that was much lower than that typically used in adults. There is significant evidence in the literature about cannabis use triggering psychotic breaks in vulnerable individuals. We speculate that substance use (including synthetic cannabinoids) triggers treatment-resistant psychosis that requires the use of clozapine. Further, lower doses of clozapine may be sufficient to treat the substance-induced psychotic symptoms than those typically used in adult schizophrenia.
References
1. Dulcan MK. Dulcan’s textbook of child and adolescent psychiatry. Arlington, VA: American Psychiatric Publishing, Inc., 2010.10.1176/appi.books.9781585623921Search in Google Scholar
2. American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 4th ed., text rev. Washington, DC: American Psychiatric Association, 2000.Search in Google Scholar
3. Minzenberg MJ, Yoon JH, Carter CS. Schizophrenia. In: Hales RE, Yudofsky SC, Gabbard GO, editors. The American psychiatric publishing textbook of psychiatry, 5th ed. Arlington, VA: American Psychiatric Publishing Inc., 2008.Search in Google Scholar
4. Loranger AW. Sex difference in age at onset of schizophrenia. Archives of general psychiatry 1984;41:157–61.10.1001/archpsyc.1984.01790130053007Search in Google Scholar
5. Anderson KK, Fuhrer R, Abrahamowicz M, Malla AK. The incidence of first-episode schizophrenia-spectrum psychosis in adolescents and young adults in Montreal: an estimate from an administrative claims database. Can J Psychiatry 2012;57: 626–33.10.1177/070674371205701007Search in Google Scholar
6. Cantor-Graae E, Nordström LG, McNeil TF. Substance abuse in schizophrenia: a review of the literature and a study of correlates in Sweden. Schizophr Res 2001;48:69–82.10.1016/S0920-9964(00)00114-6Search in Google Scholar
7. Gershman JA, Fass AD. Synthetic cathinones (“bath salts”): legal and health care challenges. P & T: A Peer Reviewed Journal for Formulary Management 2012;37:571–95.Search in Google Scholar
8. Joksovic P, Mellos N, van Wattum PJ, Chiles C. Bath salts-induced psychosis and serotonin toxicity. J Clin Psychiatry 2012;73:1125.10.4088/JCP.12cr07819Search in Google Scholar
9. Jerry J, Collins G, Streem D. Synthetic legal intoxicating drugs: the emerging “incense” and “bath salt” phenomenon. Clev Clin J Med 2012;79:258–64.10.3949/ccjm.79a.11147Search in Google Scholar
10. Striebel JM, Pierre JM. Acute psychotic sequelae of “bath salts”. Schizophr Res 2011;133:259–60.10.1016/j.schres.2011.09.001Search in Google Scholar
11. Andréasson S, Allebeck P, Engström A, Rydberg U. Cannabis and schizophrenia. A longitudinal study of Swedish conscripts. Lancet 1987;ii:1483–6.10.1016/S0140-6736(87)92620-1Search in Google Scholar
12. Bugra H, Rapp C, Studerus E, Aston J, Borgwardt S, et al. Can cannabis use increase the risk for schizophrenic psychoses? Fortschr Neurol Psyc 2012;80:635–43.10.1055/s-0032-1325415Search in Google Scholar PubMed
13. Every-Palmer S. Synthetic cannabinoid JWH-018 and psychosis: an explorative study. Drug Alcohol Depen 2011;117:152–7.10.1016/j.drugalcdep.2011.01.012Search in Google Scholar PubMed
14. Moore TH, Zammit S, Lingford-Hughes A, Barnes TR, Jones PB, et al. Cannabis use and risk of psychotic or affective mental health outcomes: a systematic review. Lancet 2007;370: 319–28.10.1016/S0140-6736(07)61162-3Search in Google Scholar
15. Zammit S, Allebeck P, Andreasson S, Lundberg I, Lewis G. Self reported cannabis use as a risk factor for schizophrenia in Swedish conscripts of 1969: historical cohort study. Brit Med J 2002;325:1199.10.1136/bmj.325.7374.1199Search in Google Scholar PubMed PubMed Central
16. Arseneault L, Cannon M, Poulton R, Murray R, Caspi A, et al. Cannabis use in adolescence and risk for adult psychosis: longitudinal prospective study. Brit Med J 2002;325:1212–3.10.1136/bmj.325.7374.1212Search in Google Scholar PubMed PubMed Central
17. Power BD, Dragovic M, Jablensky A, Stefanis NC. Does accumulating exposure to illicit drugs bring forward the age at onset in schizophrenia? Aust NZ J Psychiatry 2013;47:51–8.10.1177/0004867412461957Search in Google Scholar PubMed
18. Galvez-Buccollini JA, Proal AC, Tomaselli V, Trachtenberg M, Coconcea C, et al. Association between age at onset of psychosis and age at onset of cannabis use in non-affective psychosis. Schizophr Res 2012;139:157–60.10.1016/j.schres.2012.06.007Search in Google Scholar PubMed PubMed Central
19. FDA. FDA approves risperdal for two psychiatric conditions in children and adolescents. FDA news release, (2007). http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/2007/ucm108969.htmSearch in Google Scholar
20. Fischer-Cornelssen KA, Ferner UJ. An example of European multicenter trials: multispectral analysis of clozapine. Psychopharmacol Bull 1976;12:34–9.Search in Google Scholar
21. Honigfeld G, Patin J, Singer J. Clozapine: antipsychotic activity in treatment-resistant schizophrenics. Adv Ther 1984;1:77–97.Search in Google Scholar
22. Shopsin B, Klein H, Aaronsom M, Collora M. Clozapine, chlorpromazine, and placebo in newly hospitalized, acutely schizophrenic patients: a controlled, double-blind comparison. Arch Gen Psychiatry 1979;36:657–64.10.1001/archpsyc.1979.01780060047005Search in Google Scholar PubMed
23. Kane J, Honigfeld G, Singer J, Meltzer H. Clozapine for the treatment-resistant schizophrenic. A double-blind comparison with chlorpromazine. Arch Gen Psychiatry 1988;45:789–96.10.1001/archpsyc.1988.01800330013001Search in Google Scholar PubMed
24. Cianchetti C, Ledda MG. Effectiveness and safety of antipsychotics in early onset psychoses: a long-term comparison. Psychiatry Res 2011;189:349–56.10.1016/j.psychres.2011.03.020Search in Google Scholar PubMed
25. Cohen D, Bonnot O, Bodeau N, Consoli A, Laurent C. Adverse effects of second-generation antipsychotics in children and adolescents: a Bayesian meta-analysis. J Clin Psychopharm 2012;32:309–16.10.1097/JCP.0b013e3182549259Search in Google Scholar PubMed
26. Bachmann CJ, Gebhardt S, Lehr D, Haberhausen M, Kaiser C, et al. Subjective and biological weight-related parameters in adolescents and young adults with schizophrenia spectrum disorder under clozapine or olanzapine treatment. Z Kinder Jug-Psych 2012;40:151–9.10.1024/1422-4917/a000165Search in Google Scholar PubMed
27. Maayan L, Correll CU. Weight gain and metabolic risks associated with antipsychotic medications in children and adolescents. J Child Adol Psychop 2011;21:517–35.10.1089/cap.2011.0015Search in Google Scholar PubMed
28. Wehmeier PM, Heiser P, Remschmidt H. Pancreatitis followed by pericardial effusion in an adolescent treated with clozapine. J Clin Psychopharm 2003;23:102–3.10.1097/00004714-200302000-00017Search in Google Scholar PubMed
29. Markovic J, Momcilov-Popin T, Mitrovic D, Ivanovic-Kovacevic S, Sekuli S, et al. Clozapine-induced pericarditis. Afr J Psychiatry (Johannesbg) 2011;14:236–8.10.4314/ajpsy.v14i3.7Search in Google Scholar PubMed
30. Layland JJ, Liew D, Prior DL. Clozapine-induced cardiotoxicity: a clinical update. Med J Australia 2009;190:190–2.10.5694/j.1326-5377.2009.tb02345.xSearch in Google Scholar PubMed
31. Raju P, Rao GK, Davis G. Pericardial effusion in patients with schizophrenia: are they on clozapine? Emerg Med J 2008;25:383–4.10.1136/emj.2007.056879Search in Google Scholar PubMed
32. Marder SR, Wirshing DA. Chapter 28. Clozapine. In: Schattzberg AF, Nemeroff CB, editors. Textbook of Psychopharmacology, 4th ed. Arlington, VA: American Psychiatric Publishing, 2009.Search in Google Scholar
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