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Objective: To report a case of apathy treated with methylphenidate in which improvement in apathy was independent of improvement of depression., Case Summary: A 47-year-old woman with a 20-year history of recurrent major depression was diagnosed as having significant apathy with lack of initiative and motivation. Over the course of a 4-week treatment regimen with methylphenidate, her apathy, as measured by the Apathy Evaluation Scale, improved, with her score decreasing from 57 to 31. During this period, her depression, as assessed by the 21-item Hamilton Rating Scale for Depression, remained unchanged., Discussion: Our report of improvement of apathy with methylphenidate is consistent with other reports in the literature, although previous studies have not specifically used the rating scales to assess apathy. Even though this patient had experienced apathy for a long time, it had not been detected due to lack of direct questioning. In this case, as noted, the improvement of apathy was independent of improvement in depression., Conclusions: A high degree of suspicion and specific inquiry is required for identification of apathy. Once detected, methylphenidate may be beneficial in its treatment, a strategy that may work independently of augmentation of antidepressants.

Background: Over 1000 medications contain pork- and/or beef-derived gelatin and stearic acid as inert ingredients. Use of these medications in patients with religious beliefs against consumption of these ingredients might constitute an ethical conflict., Objective: To assess patients' and physicians' attitudes about using medications with religiously prohibited ingredients derived from pork and/or beef., Methods: In this pilot study, 100 patients and 100 physicians completed a survey designed to assess their knowledge and opinion on using medications that might contain inert ingredients derived from animals whose consumption offends followers of certain religions., Results: Of the 100 patients surveyed, most (84%) reported that they were not aware that several medications contained ingredients derived from pork and/or beef. About 63% of the patients wanted their physicians, and 35% of the patients wanted their non-physician healthcare providers (pharmacists, nurses), to inform them when using such medications. Thirteen percent of the patients shared religious reasons for not consuming pork and/or beef products. Approximately 70% of physicians were unaware that several medications contain ingredients that might be against their patients' religion, and most (70%) thought that it was important to inform their patients if such drugs were prescribed., Conclusions: This pilot study suggests that both patients and physicians think that patients should be informed whenever medications that contain pork- and/or beef-derived products are prescribed. The use of medications with these ingredients is an ethical issue. Informing patients about this issue promotes respect for their religious beliefs and may promote therapeutic alliance; therefore, this might have public health implications and needs further research.

Objective: To report 4 cases of medication nonadherence due to presence of inert ingredients forbidden by the patients' religion., Case Summaries: We describe 4 cases in which religious concerns about prescribed medications' inert components led to discontinuation of these medications. These inert components are gelatin and stearic acid, which might be derived from pork or beef products. In these 4 cases, patients of Muslim, Orthodox Christian, and Seventh Day Adventist faiths, who consider it against their religion to consume pork products, stopped their medications on discovering this possibility. This led to relapse of their illnesses., Discussion: These cases demonstrate that, for some patients, inert medication components that are forbidden by their religion may lead to discontinuation of medications. This could lead to relapse of symptoms and might even lead to hospitalization. Therefore, it is important for prescribers to inform patients of this possibility when treating patients whose religious background might conflict with these inert medication components., Conclusions: Patients with religion prohibitions against consumption of pork and/or beef products might stop their medications when prescribed those with pork- and beef-derived gelatin and/or stearic acid. Prescribers should discuss this possibility with their patients, perhaps as part of informed consent.

Objective: To report 2 cases of bipolar disorder with recent depression in remission with prominent residual hypersomnia, responding well to the addition of the psychostimulant modafinil., Case Summaries: Two patients with bipolar disorder with recent depressive episodes in remission are presented. Despite the absence of prominent depressive symptoms, both patients had significant hypersomnia, with scores ranging from 15 to 20 (maximum 24) on the Epworth Sleepiness Scale. The addition of modafinil to their medication regimen resulted in a decrease in hypersomnia and improvement in their level of functioning., Discussion: This is the first report (MEDLINE search, October 7, 2003) demonstrating the use of modafinil in the treatment of hypersomnia in bipolar disorder while mood symptoms were in remission. Hypersomnia frequently occurs in depressive episodes and can be disabling when severe. The patients had optimal mood stabilization with mood stabilizers and antidepressants, but continued to experience excessive daytime sleepiness. Conventional stimulants were not considered because of the risk of triggering mania. The addition of the selective psychostimulant modafinil resulted in significant improvement in the hypersomnia, with improvement in functioning. No adverse effects or mood changes were noted., Conclusions: Modafinil may be a well-tolerated and effective alternative to conventional stimulants in the treatment of hypersomnia, especially in bipolar disorder, where there is considerable risk of switch to mania with stimulant medications. Modafinil may be useful even when depressive symptoms are not prominent.

Objective: To report a case of somnambulism due to a probable interaction between valproic acid and zolpidem in a patient with no prior personal or family history of somnambulism., Case Summary: A 47-year-old white man with a history of bipolar disorder was being maintained on citalopram 40 mg once daily and zolpidem 5 mg at bedtime. During treatment, he developed manic symptoms and was started on adjunctive valproic acid therapy. Soon after this, he developed episodes of somnambulism, which stopped when valproic acid was discontinued. On rechallenge with valproic acid, somnambulism returned., Discussion: To our knowledge, this is the first report in the literature describing a probable interaction between valproic acid and zolpidem leading to somnambulism. Even though valproic acid has been associated with sleep changes, there are no published reports of somnambulism with this agent. Zolpidem has been associated with somnambulism, but our patient did not experience this when he was on zolpidem monotherapy. However, within 2 days of starting adjunctive valproic acid, sleepwalking occurred. It stopped after valproic acid was withdrawn. On rechallenge with valproic acid, sleepwalking recurred. However, when zolpidem was discontinued and valproic acid was continued, somnambulism did not occur. An assessment on the Naranjo probability scale suggests probable pharmacokinetic or pharmacodynamic interactions between the 2 medications., Conclusions: Valproic acid and zolpidem are generally safe medications that are commonly prescribed and often used together. No interactions have been previously reported with combined use of valproic acid and zolpidem. This case suggests a probable interaction between these 2 agents that can have a serious consequence, somnambulism. This could be frightening to patients and put them in danger. Recognition of such interactions that place patients at risk for potentially serious adverse events is imperative for appropriate care.

Objective: To report a case of improvement in posttraumatic stress disorder (PTSD) after adjunctive therapy with quetiapine., Case Summary: A 49-year-old white man witnessed a traumatic event and experienced severe PTSD. He was started on paroxetine, with increases in dosage and no significant improvement. Quetiapine was added to his regimen, with increased doses resulting in improvement of PTSD symptoms, both clinically and as measured on the Hamilton-D rating scale for depression and the clinician-administered PTSD screen., Discussion: This is the first case published in the English language literature describing improvement in PTSD symptoms after treatment with quetiapine. There are several treatment options for PTSD, but some severe cases may require treatment with antipsychotic medications. Because of the lower risks of serious adverse effects, the newer atypical antipsychotics are much safer than the older antipsychotics. Although use of risperidone and olanzapine in the successful treatment of PTSD has been reported in the literature, there are no reports of quetiapine use in this clinical condition., Conclusions: Quetiapine appeared to improve clinical signs and symptoms of PTSD in this patient. It may be a treatment option in other severe cases of PTSD.