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Letters

Dr Mittal and Colleagues Reply

See original letter by Zamani.

Dr Mittal and Colleagues Reply

To the Editor: We thank Dr Zamani for taking the time and interest to pose these important questions about our article.1 First, we would like to clarify that the article is based on a case report and is not a formal study. We will address the questions and concerns in the same order as received.

“They have interestingly attributed the patient’s signs and symptoms to the contents of the detoxification kit.” Response: We merely established a temporal association between the consumption of the detoxification compound and the development of psychotic symptoms. We did not establish any causative associations.

“They treated the patient with haloperidol and lorazepam.” Response: The patient was given haloperidol and lorazepam only in the emergency room once for agitation. The medications were not repeated during the patient’s stay on the inpatient unit. Also, 1 dose of haloperidol and lorazepam is unlikely to treat a patient with psychotic illness secondary to cannabis abuse. As we mentioned in the case report, the psychotic symptoms resolved after discontinuation of the detoxification compound without any treatment.

“No side effects have been reported for proprietary blend.” Dr Zamani provides a reference for an acai berry product with a proprietary blend. Response: The proprietary blend is the undisclosed ingredients in any product. So, it would be unjustified to compare 2 different compounds with proprietary blends, which can very well be different. Our response is that we do not know what ingredients are included in the proprietary blend, so any comment on its effects or side effects could not be justified.

Dr Zamani provides a statement about the side effects of creatine. Response: We provided references for isolated case reports of psychosis with consumption of large amounts of creatine. Dr Zamani has presented a review of the side effects of the ingredients of the detoxification compound. As mentioned in our article, we completed an extensive review of the ingredients using not only the information Web sites such as www.webmd.com and information sites for the respective compounds, but also case reports and any ongoing research about these compounds, with special focus on psychotic symptoms.

“How do the authors know that his symptoms were not due to acute cannabis intoxication? Response: As we mentioned in the original article, cannabis intoxication has been shown to be only a component cause of psychosis.3 In our patient, the cannabis intoxication was chronic with no history of psychotic symptoms in the past. There was no family history of psychotic illness, and psychotic symptoms resolved within 2 to 3 days without using antipsychotics, except for the single dose of haloperidol. The patient denied any psychotic symptoms at a follow-up appointment 6 months after his hospitalization. On the basis of these facts, it is unlikely that his psychosis was a direct effect of acute cannabis intoxication.

References

1. Mittal MS, Kalia R, Khan AY. A case of psychosis after use of a detoxification kit and a review of techniques, risks, and regulations associated with the subversion of urine drug tests. Prim Care Companion CNS Disord. 2011;13(5):doi:10.4088/PCC.11r01178. PubMed

2. Boos CJ, White SH, Bland SA, et al. Dietary supplements and military operations: caution is advised. J R Army Med Corps. 2010;156(1):41-43. PubMed

3. Arseneault L, Cannon M, Witton J, et al. Causal association between cannabis and psychosis: examination of the evidence. Br J Psychiatry. 2004;184(2):110-117. PubMed doi:10.1192/bjp.184.2.110

Moneeshindra Singh Mittal, MD

mittal.fdk@gmail.com

Rachna Kalia, MD

Ahsan Y. Khan, MD

Author affiliations: Department of Psychiatry and Behavioral Sciences, University of Kansas School of Medicine, Wichita.

Potential conflicts of interest: Dr Khan has served on the speakers or advisory boards of Merck and Schering Plough. Drs Mittal and Kalia report no conflicts of interest related to the subject of this letter.

Funding/support: None reported.

Published online: December 27, 2012.

Volume: 14

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