Dothiepin dependence syndrome.

Singh GP, Kaur P, Bhatia S. Dothiepin dependence syndrome. Indian J Med Sci [serial online] 2004 [cited 2009 Mar 9];58:253-4. Available from: http://www.indianjmedsci.org/text.asp?2004/58/6/253/8181


Sir,
Clinicians have depended on antidepressants for years in the management of depressive disorders Drug abuse involving antidepressants is not common, most of them involve agents with amphetamine like properties, including amineptine and tranylcypromine.[1] Amineptine dependence and tianeptine abuse has been well documented.[2] No case report related to dothiepin abuse has been documented till date. Herein we report on a case of dothiepin dependence.

A 56 year old female higher secondary school teacher was brought to medical emergency with the symptoms of nausea, abdominal distress, marked apprehension, bodyaches, weakness, tremulousness, cold feeling, vertigo, insomnia, restlessness, difficulty in controlling urination, left arm twitching and hand spreading, headache and paresthesias for one day. She was diagnosed to have dysthymia 5 years ago and was prescribed dotheipin 75 mg daily. During initial 2 months of the treatment, she had shown significant improvement in this disorder. The maximum dose prescribed was 150 mg per day. In the next 6 month she herself increased the dose to 300 mg. But craving for this drug continued. She had been taking a maximum dose of 450 mg for last 1 year without the knowledge of her clinician or family members.

At the time of examination in medical emergency her general physical and systemic examination as well as all investigations including haemogram, serum electrolytes, renal, liver and thyroid function tests, cerebrospinal fluid examination and magnetic resonance imaging (Brain) revealed no organicity, hence psychiatric consultation was sought. Her past and family history had no medical or psychiatric disorder. On detailed psychiatric evaluation it was found that she had been abstinent from dothiepin for last 24 hours. She fulfilled all the dependence syndrome criteria,[3] and with this diagnosis, was prescribed sertraline 100mg, clonazepam 3 mg, and psychological interventions including psychoeducation, Jacobson progressive muscle relaxation and motivation enhancement therapy sessions. On the adverse drug reaction probability scale, the score was 6.[4] She came for regular follow-up thrice a week. Within first week she reported improvement in her symptomatology. Her sleep improved and tremulousness as well as somatic problems were diminished. and craving for dothiepin was less. In the next three weeks her sadness of mood and other depressive phenomenology also improved and she again started going to her school.

In this case report patient had presented with variable symptoms and on detailed evaluation all systemic disorders were ruled out. There was a temporal association of these withdrawal symptoms with dothiepin use. Ours is the first observation of dothiepin dependence and its abuse. Though the patient fulfilled the WHO criteria for drug dependence,[3] however being an isolated case it needs further scrutinization in a large cohort of patients receiving dothiepin.

Dependence syndrome with Dothiepin is clinically relevant as it can be misdiagnosed with a medical disorder and may result in inappropriate treatment. Clinicians must judiciously use dothiepin in maintenance therapy as an antidepressant. Though it is reported that antidepressants are not substances of abuse and dependence,[5] our report highlights need for more research in this aspect.

¤ References

1. Guillem E, Lepine JP. Does addiction to antidepressants exist? About a case of one addiction to tianeptine. Encephale 2003;29:456-9. [PUBMED] [FULLTEXT]
2. Perera I, Lim L. Amineptine and midazolam dependence. Singapore Med J 1998;39:129-31. [PUBMED]
3. World Health Organization. The ICD-10 Classification of Mental and Behavioural Disorders; Clinical Descriptions and Diagnostic Guidelines. Geneva 1992.
4. Naranjo CA, Busto U, Sellers EM, Sandor P, Ruiz I, Roberts EA, et al. A method for estimating the probability of adverse drug reactions. Clin Pharmacol Ther 1981;30:239-45. [PUBMED]
5. Lichtigfeld FJ, Gillman MA Antidepressants are not drugs of abuse or dependence. Postgrad Med J 1998;74:529-32.



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