CASE REPORT

GIOVANNI CARACCI, M.D.

PAOLO MIGONE, M.D.

SUKDEB MUKHERJEE, M.D.

Phencyclidine abuseand depressionThe epidemiology and clinical picture of phencyclidine(PCP) intoxication and the consequences of its chronicuse have been described by several authors.1.2 While thestriking similarity between schizophreniform symp­toms and those of PCP-related psychoses has beenemphasized,3 less attention has been paid to PCP-relat­ed depression. Smith and Wesson" in their proposedclassification of PCP-related disturbances, list PCP-in­duced depression as a Type 4 adverse reaction, follow­ing Type I or acute toxicity, Type 2 or PCP toxicpsychosis, and Type 3 or a PCP-precipitated psychoticepisode. These two authors found PCP-induced de­pression to be most frequent among chronic users, andoften accompanied by prolonged cerebral dysfunctionexperienced by the patient as "memory impairment" or"brain damage." In addition, they stressed the severityof the depression and the high suicide risk in thesepatients. The depression can last from a few days toseveral months and can follow any of the other stages.

In our experience with various studies of PCP users,we observed the clinical picture of PCP-induced de­pression in 15% to 20% of the patients. This conditionwas not as common as PCP-related psychosis. Wedescribe three cases of depression secondary to PCPuse. All three had a negative family history of depres-

Drs. Caracci and Migone are residents in psychiatry, and Dr.Mukherjee is assistant professor ofpsychiatry and chief, psy­chopharmacology program, all in the department ofpsychiatryat New York Medical College. Reprint requests to Dr. Caracci,Room 4M14, Metropolitan Hospital Center, 1900 SecondAvenue, New York, NY 10029.

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sion and had not suffered from depressive episodesprior to PCP use. They all experienced a craving for thedrug during the period of heavy use preceding thedepressive episode, or during the episode itself.

C... 1A 21-year-old woman with a two-year history of daily PCPuse had been hospitalized twice for acute PCP intoxicationcharacterized by agitation, bizarre behavior, and auditoryhallucinations. After her last hospitalization she resumedusing PCP. One month later she became increasingly de­pressed with insomnia, early morning awakening, loss ofappetite, lack of energy, and poor concentration. She alsoheard voices telling her to kill herself. Since discharge shehad been taking haloperidol 5 mg and benztropine mesylate1 mg/d. She eventually attempted suicide by taking anoverdose of these medications and was hospitalized. Sheshowed excellent response to imipramine 100 mg/d withcomplete recovery from both psychosis and depression.Three months later she remained on maintenance imipra­mine and off PCP.

Ca.. 2A 19-year-old woman with a history of daily PCP use for thelast seven years was seen as an outpatient for complaints ofaddiction to the drug. Three months prior to this visit she hadstarted to feel very depressed. The depression becameprogressively worse and she could not function in any wayunless she took PCP. She complained of chronic insomniaand poor appetite with weight loss. She was admitted fortreatment and placed on imipramine 100 mg/d. Her cravingfor the drug disappeared within two days and she showedcomplete recovery from depression. She was discharged toa drug-free program and has remained drug-free for the lastthree months.

PSYCHOSOMATICS

C.se3A 29-year-old man with a history of daily PCP use for sixyears had been admi"ed to the psychiatric unit on fouroccasions for threatening and violent behavior, persecutoryideation, and incoherence after smoking PCP. Each time hehad responded well to major tranquilizers. After his mostrecent discharge. in full remission. he did not resume PCPuse. In about a week he began to feel overwhelmed bydepressive feelings, with severe insomnia. anergy. anhe­donia. and poor appetite. He responded well to imipramine100 mg/d with total remission in about ten days.

DiscussionWe have not observed episodes of severe depressionfollowing occasional or irregular use of PCP. As sug­gested from previous studies! depressive episodes werenoted only among chronic users. Many of them hadexperienced "bad trips" before, or had emergencyhospitalizations for PCP toxic psychosis from whichthey had recovered on major tranquilizers. In thechronic user, statements such as "I feel I need the drug"or "I get depressed when I don't take it" should alert thephysician to the possibility of coexisting depression. Asystematic interview will often show the presence ofsymptomatology meeting DSM-III criteria for a majordepressive episode. We did not observe, as did others,4the concomitant occurrence oforganic impairment witha subjective feeling of"brain damage" in the depressedpatients. Rather, we observed a similar picture, report­ed by some as "My memory is not working well," inpatients coming out of a PCP-related psychosis, re­gardless of the presence or absence of depression.

Chronic PCP users often tend to use larger quantitiesof the drug in an effort to overcome their depression.Apart from reports from patients, the mood-elevatingeffect of PCP is also suggested by the accounts ofPCP-induced mania,s.6 The chronic use of PCP maymask the depressive syndrome, leading to its beingmissed. Also, these patients are often admitted to thehospital for treatment of acute psychotic episodes sec­ondary to PCP use. With attention focused on thepsychosis, a history of depression is often not sought.The depression in these patients frequently is associat­ed with psychotic symptoms and can mislead the phy­sician into making a diagnosis of schizophrenia andtreating the patient with major tranquilizers. In ourexperience, after discharge from the hospital, the pa­tient often becomes severely depressed and drops out oftreatment, or is followed in the clinic with maintenanceon major tranquilizers. The latter could worsen a de-

OCTOBER 1983 • VOL 24 • NO 10

pressive state, with an increased probability that theperson will drop out to resume use of PCP.

In some cases the diagnosis ofdepression may indeedbe difficult because of its atypical presentation. Thepatient often presents with an irritable mood anddenies feeling depressed; the lack of energy may bemasked by the energizing effects of the drug; and thepatient may account for the insomnia with remarkssuch as "You can't sleep on dust" or "The dust keepsme up." It is often difficult to ascertain whether asymptom is related to depression or to PCP use. Carefulhistory taking and interviewing should, however, iden­tify most cases of depression in PCP users, atypicalpresentations notwithstanding.

The treatment of PCP-induced depression posesmany problems. Many of these patients comply poorlywith regular clinic attendance. It is generally verydifficult to engage them in a meaningful therapeuticalliance. Individual and group therapies appear to havea weak impact. Pharmacotherapy on an outpatientbasis is difficult as these persons tend to self-medicatewith PCP or other illicit drugs. A population seekingimmediate gratification, they are usually too impatientto wait out the period before antidepressant drugs showappreciable effect. Because of these problems and thehigh suicide risk, we recommend hospitalization fortreatment of PCP-induced depression.

In summary, PCP-induced depression appears re­sponsive to conventional antidepressants. Cliniciansshould be aware of the often atypical manifestationsand the possibility. of psychotic symptoms' occurringduring the depression. Proper diagnosis and treatmentmay prevent complications and repeated hospitaliza­tions from PCP use and, on occasion, end the drugabuse. 0

REFERENCES1. Lerner S. Burns R: PCP use among youth: History. epidemiology. and

acute and chronic intoxication. in: NIDA Research Monograph: pcpAbuse. An Appraisal. Rockville. Md. National Institute on Drug Abuse.t978. pp 66-tt9.

2. Fauman M. Fauman B: The psychiatric aspects 01 chronic phencyclidineuse: A study of chronic PCP users. in: NIDA ResearCh Monograph: pcpAbuse. An Appraisal. Rockville. Md. National Institute on DrugAbuse.1978. pp 183-201.

3. Luisada P: The phencyclidine psyChOSes: Phenomenology an.d treatment.in: NIDA Research Monograph: pcp Abuse. An Appraisal. Rockville. Md.National Institute on Drug Abuse. 1978. p 241 .

4. Smith D. Wesson 0: The diagnosis and treatment of PCP abuse syndrome.in: NIDA Research Monograph: pcp Abuse. An Appraisal. Rockville. Md.National Institute on Drug Abuse. 1978. pp 229-240.

5. Slavney p. Rich G. Pearlson G. et al: Phencyclidine abuse and symptomat­ic mania. BioI Psychiatry t2:697-7oo. t977.

6. Rosen A: Symptomatic mania and phencyclidine abuse. Am J Psychiatry136:118-119.1979.

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