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MEDICAL AND MENTAL HEALTH: The question of isotretinoin
The possibility of introducing prescription options for New Zealand is currently Psychologists study. Physicians were asked to comment on the appropriateness of this action and make suggestions on additional training needs. Without doubt, a thorough knowledge of possible side effects of medications can be prescribed would be necessary.
Indeed, an understanding of the potential short-and long-term side of drugs in general, and is an area that deserves much attention to all those working in mental health. The possible consequences of serious mental health from the ingestion of certain prescription drugs are now exposed in a series of platelet medication. In addition, organizations such as the U.S. Food and Drug Administration (FDA) has issued warnings involving warned against the use of certain prescription drugs, suggesting that may cause serious psychiatric disorders. There are currently proposals in Great Britain to give each new drug license for a rating of "suicide".
This reform, based on a system recently adopted in the U.S. has been driven by a growing body of evidence that drugs affect the brain in large amounts can affect behavior through seemingly innocuous changes in body chemistry. Medicines to treat acne, bloating, heartburn, pain, obesity, high blood pressure and cholesterol, bacterial infections, smoking and insomnia have been associated recently with problems psychiatric. (Mostrous, 2008).
One such drug is isotretinoin (Accutane or Roaccutane also known), indicated for the treatment acne. This vitamin is a derivative, manufactured by Hoffman-La Roche is one of the drugs most popular and controversial of the company. In its most recent warnings from the FDA (FDA, 2005), said:
FDA ALERT [7 / 2005]: suicidal thoughts or actions: In addition to risk management program strengthened the FDA continues to assess reports of suicide or suicide attempts associated with the use of isotretinoin. All patients treated with isotretinoin should be observed closely for symptoms of depression or suicidal thoughts, such as sad mood, irritability, acting on dangerous impulses, anger, loss of pleasure or interest Social Performance or sports activities, too much or too little sleep, changes in weight or appetite, school or work that is down, or difficulty concentrating or for mood disturbance, psychosis, or aggression. Patients should stop isotretinoin and they or their caregiver should contact their health care provider immediately if the patient has any symptoms listed above. Discontinuation of treatment may be insufficient and further evaluation may be necessary.
The "road of patient information" This medicine can also be read:
Serious mental health problems: Isotretinoin may cause:
- Depression
- Psychosis (seeing or hearing things that are not real)
- Thoughts suicidal actions
- The aggressive and violent behavior
Although approved for the treatment of "the most severe acne (nodular acne, acne) that can not be clarified by further treatment of acne (FDA, 2005), isotretinoin has been used increasingly for the treatment of moderate and milder forms of acne. "In 1995, doctors estimate that only sixteen percent of the prescriptions were for a serious illness "(Girling, 2002). Therefore, is now estimated that several million have been treated with isotretinoin in all the world. Unfortunately, the number of people who reported a serious adverse health Mental has also been growing. A literature search is expected in November 2006, cited more than 6,000 reported cases of psychiatric consequences of the use isotretinoin, to "estimate U.S. Health Authorities" It was about one percent of those actually affected (Tinar, 2006). According to this statement Carleton Smith, Gelin and Heathcote (2007) identified ADR (adverse effects) are a major cause of morbidity and mortality, and said that until 95% of ADRs are not reported. In a survey of New New Zealand students of high school (Purvis, Robinson, and Watson, 2004), 14.1% reported having acne. It has been estimated that 5,000 young New Zealanders taking isotretinoin (Lawrence, 2006). For 2006, the Centre for Adverse Reaction Monitoring (CARM) had received 93 reports of adverse drug reactions (ADR, 2006). If the United States Health Authority estimates are correct (Tinar and Haner, 2006), after about 930 New Zealanders have been significantly affected.
Isotretinoin was introduced on the market as a treatment for acne 1982. In 1983, Hazen, Carney and Walker had already published details of 24 cases of depression associated with their use. These results reinforced Myskens previously reported (1982), who had been using isotretinoin as a treatment for patients with advanced cancer. Approximately 25 percent of patients had suffered "psychological changes." These include 18 cases of depression. Four patients had attempted suicide. The years following have seen a major debate on the strength of the causal link between isotretinoin and mental health problems. The media have feasted on this debate and medicine, "said the type of security usually reserved for mass murderers or airline disasters" (Girling, 2002). In 2007, Carleton et al. conducted a retrospective analysis of 1193 suspected ADRs in Canadian children (including adolescents 58.6%). The drug most often cited was the descriptor of isotretinoin and reaction are the most common psychiatric disorders. In his summary of existing research linking isotretinoin to depression, psychosis and suicide, O'Donnell (2003), after examining birth defects known caused by ingestion of isotretinoin during pregnancy has also concluded that:
Less known is the risk that this fat-soluble chemicals that affect the central nervous system. Reports of intracranial hypertension, depression and suicidal ideation in the use of Accutane led to a review of its serious potential threat to life … the public must be adequately informed of the indication for limited use, because depression and suicide can follow in patients without a history of psychiatric symptoms or suicide attempts.
Against this conclusion, however, were the results of Cohen, Adams, and Patten (2007), who used scales to assess depression signs of disturbance of mental health at baseline and after two months of treatment isotreinoin. They found no correlation between isotretinoin use and development of depression in their actions. This study was later criticized as "the most complaints about depression (isotretinoin below) are about four months after starting treatment ('study', 2005). However, the researcher (Siegfried who had this opinion) and his colleagues (Chia, Lane, Chibnall, Allen, and Siegfried, 2005) to assess levels of depression four months under treatment with isotretinoin, also found that signs of this disorder are not more frequent in these patients than in the conservative treatment group. Both studies measured depression using the Center for epidemiological studies depression (CES-D) or self-rated Zung Depression Scale. Finally, in line with these results, Bremner et al. (2005) found that among their sample, there was no significant increase in depression scores (Hamilton Depression Rating Scale) after four months of treatment with isotretinoin. But no study of Bremner is much better known by other discoveries made during this investigation. In a world first, the function of brain Bremner extent its purpose by [18F] positron emission tomography fluorodeoxyglucose before and after four months of isotretinoin or antibiotic is. The results showed that treatment with isotretinoin, but not treatment with antibiotics been associated with decreased brain metabolism in the orbitofrontal cortex (-21% change relative to change of 2% of antibiotics). It is a brain region known to mediate symptoms of depression. It seems that these changes in brain function can produce observable symptoms (for example, anger, aggressiveness, paranoia) is not well measured when the tools are used to detect depression in isolation. depression scales "can not take the place of a full clinical interview to confirm a diagnosis of depression (WHO, 2008).
In recent research conducted at the University of Bath and Texas, researchers have observed the effect of isotretinoin in chemistry of cells that produce serotonin. They found that cells grown significantly increase the production of proteins and cell metabolites which are known to reduce the availability of serotonin (O'Reilly, Trent Bailey, and Lane, 2007). Researcher Sarah Bailey said: "Serotonin is an important chemical that transmits signals from nerve cells to other cells in the body …. In the brain thought to play a role important in regulating a number of behaviors such as aggression, anger and sleep. Low levels of serotonin have been associated with depression and bipolar disorder and anxiety "(GM, 2007). Previous research by some scientists themselves (O'Reilly, Shumaker, Gonzalez-Lima, Lane and Bailey, 2006) arrived concluded that isotretinoin caused depressive behavior mice. These findings were supported by those of Crandall et al. (2004) which showed a dose "Clinical 13-cis-RA (isotretinoin active ingredient) in mice significantly reduced the proliferation of cells in the hippocampus and the sub-ventricular zone, suppressed neurogenesis hippocampal and seriously affected the ability to learn a maze task …. "In a recent review, Strahan and Raimar (2006) taking into account these results, concluded: "It is clear that isotretinoin may stunt development and hormone receptors on the influence of neurotransmitters, including known systems involved in psychopathology. "This finding is similar to that of Bremner and McCaffery (2008) in its review report very lately, which describes several systems that may be targets of retinoic acid (isotretinoin component) and contribute to the pathophysiology depression.
Finally, many published case studies have documented the development of psychiatric symptoms after use isotretinoin. Barak et al. (2005) describes a "series of cases of manic psychosis that developed in a period of one year in association with isotretinoin treatment and resulted in trends of suicide and progression of long-standing psychosis. The cases were drawn from 500 soldiers who had been evaluated in a military specialists dermatology clinic "For severe acne." Hence, Friedman et al. (2006) conducted an analysis of five years and reported a significantly increased use of mental health services in 1419 Forces soldiers IDF, which had a history of use of isotretinoin, which, for the control group. There are many Single presentations of case studies reporting symptoms similar to those described by Barak et al. (2005). Bachmann, Grabarkiewicz, Remschmidt and Theisen (2007), for example, the case of a 16-year-old, who has experienced two episodes of depression "strongly associated" with isotretinoin and requires "attention dependent." They concluded: "The report presents case clearly demonstrates that isotretinoin may lead to depression patients idiosyncratic. Therefore, prescribers of isotretinoin should be aware of adverse drug reactions and if necessary, refer patients in psychiatric institutions. "
Pursuant to this recommendation for referral to a "Mental institution" (FDA 2005), after evaluating all available research on isotretinoin, followed by a warning the recommendation that "orientation is a mental health professional may be necessary. "Presumably, then, that professionals Mental Health who receive these notifications have the knowledge and skills to manage a person with psychiatric side effects of exposure isotretinoin. Unfortunately, there was a serious failure to educate professionals in this regard. Many have little or no knowledge of the implications of isotretinoin research and how that translates into real customers and management of patients. Critics of the support offered to those who ascribe psychiatric symptoms of exposure to isotretinoin abound. Many media communication and forensic reports of suicides related to isotretinoin, visit the slow or inadequate responses to mental health professionals and lack of knowledge of isotretinoin – Relationship of disease mental. (Drug cons acne, 2004, Girling, 2002; Sims, 2005; Tinar and Haner, 2006). Without a thorough understanding of potential side effects of isotretinoin, physicians do not make a precise assessment of causal factors problems, failing assist clients / patients in their understanding of these factors contribute to their illness, not to notifications of adverse drug reactions and failing to refer clients / patients to health more likely to provide professionals with a successful intervention.
It seems a lack of meaningful communication between those responsible for approving the distribution of drugs such as isotretinoin and professionals Health who are responsible for handling side effects. In 2006, the minutes of new adverse Zealand'sMedicines Committee stated:
The Committee noted that dermatologists were aware of the possible association between isotretinoin and depression or other mood changes, and were aware of the need to counsel patients about a possible effect on mood and time of the stop treatment. The Committee considered whether the doctors who prescribed these products must be reminded of the possible association between isotretinoin and the effect on mood. (Mark, 2006)
It seems that, although dermatologists and (possibly) doctors header has been made aware of potential psychiatric side effects of isotretinoin, these warnings have not reached those who are responsible for Isotretinoin treatment permits disorders. To date, there is no specific treatment or studies published describing the success of strategies treatment. Do not recognize symptoms of clients and isotretinoin is caused by a subsequent failure to share information on successes and failures of treatment.
Although psychologists in New Zealand see the benefits and disadvantages of adding the limitation of rights of their professional responsibilities, it should consider improving our knowledge base and assessment strategies on the use of its former clients of other drugs that may cause or influence their immediate problems, and should affect treatment options. Good clinical practice should include:
- Specific questions on the current use and historical of all drugs;
- specific questions about the use of isotretinoin by those who work with acne exposed populations (eg adolescents);
- Monitoring of known side effects of all drugs mentioned by customers.
- Report any side effects of drugs at the Centre for Adverse Reaction Monitoring (CARM)
- Educating clients on contributions Possible side effects of drugs to their problems;
- Given recent research findings into account when considering treatment options (user example, depletion of serotonin in the isotretinoin);
- Documentation official discussion of these cases with their colleagues. A fruitful exchange of information to facilitate growth in knowledge of treatment strategies more effective.
References
cons acne medication may have contributed to depression among adolescents (2004, October 28). South Wales New ABC. (Online). Retrieved February 8, 2008, from http://www.accutaneaction.com/press/28.10.04htm
Bachmann, C., Grabarkiewicz, J., Theisen, FM, and Remschmidt, H. (2007). Isotretinoin, depression and suicidal ideation among adolescents in a child. Pharmacopsychiatry, 40, 128-131.
Barak, Y. Wohl, Y., Greenberg, Y., Dayan, YB, Friedman, T., Shoval. G., and Knoble, HY (2005). affective psychosis following Accutane (isotretinoin) treatment. International Clinical Psychpharmacology, 20, 39-41.
Bremner JD, Fani N, Ashraf, A., Votaw JR, Brummer ME, Cummins T, Vaccarino, V., Goodman, MM, Reed, L., Siddiq, S., and Nemeroff, CB (2005). The functional brain imaging changes in patients with acne treated with isotretinoin. American Journal of Psychiatry, 162, 983-991.
Bremner, JD, and McCaffery, P. (2008). The neurobiology of retinoic acid in affective disorders. Advances in Biological Psychiatry Neoropsychopharmacology, 32, 315-331.
Carleton BC, Smith MA, Gelin, MN, and Heathcote, SC (2007). Pediatric reporting adverse drug reactions: understanding and future directions. Journal of Clinical Pharmacology, 14, 45-57.
Song, A, N, Cardinault, N., Rock, E., Martin, JF, Souteyrand, P., D'Inca, M., & Brachet P. (2008). Decrease plasma folate concentrations in elderly and young healthy after a short-term supplementation with isotretinoin. Journal of the European Academy of Dermatology and Venereology, 22, 94-100.
Chia CY, Lane W, Chibnall, J., Allen, A., Siegfried & E. (2005). Isotretinoin therapy and mood changes in adolescents with moderate to severe acne: a cohort study. Archives of Dermatology, 141. 557-560.
Cohen, J. Adams, S. and Patten, S. (2007). Association Not Found between patients receiving isotretinoin for acne and the development of depression in a prospective cohort of Canada. Canadian Journal of Clinical Pharmacology, 14, 227-233.
Crandall, J., Sakai, Y. Zhang, J., Koul O., Mineur, Y., Crusie, we, and McCaffery, P. (2004). 13-cis-retinoic acid suppresses hippocampal-dependent learning in mice. (Online).
Friedman, T., Wohl, Y., Knoble, HY, Lubin, G., Brenner, S., Levi, Y., and Barak, Y. (2006). The increased use of mental health services related to isotretinoin therapy: an analysis of five years. European Neuropsychopharmacology, 16, 413-416.
Girling, R. (2002). Marked for Life: acne treatment drugs have devastating side effects? (2002, June 30). Sunday Times (online).
Hazen PG, Carney, JF, and Walker, AE (1983). Depression – a side effect of retinoic acid treatment from 13-cis. Journal of the American Academy of Dermatology, 9, 278-279.
Jofre, J. (2008, February 7). Accutane, depression, suicide and degenerative diseases. Legal News (online). Accessed February 24, 2008, of http://www.lawyersandsettlements.com/articles/accutane-depression-lawsuit.html
Lawrence J. (20 September 2006) The treatment of acne may be a precipitating factor for suicide, researchers say. New Zealand Herald (In line). Accessed February 10, 2008, of http://www.nzherald.co.nz/section/1/story.cfm?c_id=1&objectid=10402011
Drug Reactions Committee reactions (ADR, 2006, December 14). and suicide. The side effects isotretinoin reports and minutes AGI. (Online).
Acne Drug Facility link to depression suggests new research. (2007, November 12.) ScienceDaily. (Online) Retrieved February 13, 2008, from http://www.sciencedaily.com / Releases/2007/11/071112092800.htm
A., & Rose, D. (2008, February 09). "Suicide rating, Mostrous "could give every new drug licensed in the United Kingdom. TimesOnline. (Online). Accessed February 13, 2008, of http://www.timesonline.co.uk/tol/life_and_style/health/article3337966.ece
Meyskens, FL (1982). Brief clinical reports. Journal of the American Academy of Dermatology, 6, 732.
O'Donnell J. (2003). Overview of existing research and information between isotretinoin (Accutane), depression, psychosis and suicide. American Journal of therapy, 10, 148-159.
O'Reilly, KC, Shumaker, J., Gonzalez-Lima, F., Lane, MA and Bailey SJ (2006). Administration Chronic depression increases cis-retinoic-acid 13-same behavior in mice. Neuropsychopharmacology, 31, 1919-1927.
O'Reilly KC Trent, S. Bailey, SJ, Lane, MA (2007). Acid 13-cis-retinoic acid alters intracellular serotonin, increases 5-HT 1A receptors and reuptake transporter serotonin in vitro. Experimental Biology and Medicine, 232, 1195-1203.
Purvis, D., Robinson, E. and Watson, P. (2004). prevalence acne among students in secondary education and the perception of difficulty in accessing acne treatment. New Zealand Medical Journal, 117. –
Sims, S. (2005, April) miracle drug or a deadly weapon? Real world. (Online).
Strahan, JE, and Rafe, S. (2006). Isotretinoin and the controversy over psychiatric side effects. International Journal of Dermatology, 45, 789-799.
Study: No Link Between Accutane and Teen Depression (2005, May 17) News of health. (Online). Accessed February 10, 2008, http://health.dailynewscentral.com/content/view/780/63
Tinar, S., and Haner, H. (2006, November) Dying for skin. Swiss national TV. (Online). Retrieved January 10, 2008, the U.S. Food and Drug Administration (FDA, 2005, May) Isotretinoin (Marketed as Accutane Capsule information. Food and Drug Administration (FDA) Home. Retrieved February 10, 2008, http://www.fda.gov/cder/drug/infopage/accutane/
The World Health Organization (WHO, 2008). Zung Depression Scale self-assessment (online)
About the Author
Annette Fea, Clinical Psychologist, Queenstown, New Zealand
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