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Ask Dr Ivan

In the fourth of his regular column, Dr Ivan Goldberg,MD, Director, N.Y. Psychopharmacologic Institute, New York, NY, answers a few of the many questions that arrive in our mailbox. We are sorry, but Dr Goldberg cannot enter into individual correspondence.

This month:


I would like to find any current research on the medical uses of cannabis. I wonder if there might be good physiological reasons that cannabis would help some people who suffer from migraine. My understanding is that migraine is associated with vasoconstriction and decreased blood flow in the brain. Cannabis has a vasodilation effect that could be useful in increasing blood flow in migraine patients. Has any research been done to see if migraine pain is reduced by cannabis?

Although the medical use of cannabis has been the subject of some recent research I have been unable to find any studies of the use of cannabis for the treatment of migraine head- aches. The two indications for which cannabis, or its active ingredient, tetrahydrocannabinol, is occasionally used are glaucoma and the nausea and vomiting that is secondary to cancer chemotherapy.


What are the advantages of so-called SNRIs over SSRIs and even old tricyclic antidepressants?

The newly developed antidepressants such as the SNRI, venlafaxine, and the SSRIs, fluoxetine, sertraline, fluvoxamine, etc is that they generally have fewer and milder side effects than the older tricyclic antidepres- sants. While this advantage is real, there is some evidence that when dealing with people who are severely depressed, the tricyclic drugs are more effective than the newly developed agents.


What discontinuation symptoms might I expect from suddenly stopping an SSRI?

SSRIs differ in terms of how rapidly they disappear from the blood after the medication is stopped. Fluoxetine takes up to a month to disappear, while paroxetine (and the SNRI, venlafaxine) take just a day or two. If an antidepressant that rapidly leaves the body is suddenly stopped, a discontinuation syndrome may be experienced. The symptoms of the syndrome my include:

The discontinuation syndrome does not occur if one goes from one SSRI to another, and can be prevented by not abruptly discontinuing paroxetine sertraline or vanlafaxine.


What drugs might help with spasmodic torticollis?

Spasmodic torticollis is a neurological disorder that is usually treated by injections of small doses of botulinus toxin. Psychopharmacologic agents do not play a significant role in its treatment.


Are there any antipsychotics that are more effective (and safer) for refractive schizophrenia than clozapine?

There are no atypical antipsychotic agents that are more effective than clozapine. Risperidone is a recently introduced atypical antipsychotic that is considerable safer than clozapine. After a year or so of its having been available, it is clear that is is not nearly as effective for the treatment of individuals with refractory schizophrenia as clozapine.

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