Fiorinal contains butalbital, 50 mg, and caffeine, 40 mg, which presumably cancel each other out. Other compounds contain caffeine as an additional ingredient.
I EDITORLALSJ Should psychiatric patients drink coffee? K.Z. BEZCHLIBNYK,* B SC PHARM; J.J. JEFFRIES,t MB, FRCP[C]
dysphoria among coffee drinkers who omitted their morning coffee; these symptoms included irritability, inability to work effectively, nervousness, lethargy and restlessness. Headache is commonly associated with coffee withdrawal; it responds to caffeine or caffeinecontaining analgesics, and can lead to an endless cycle of "therapy" - that is, treatment with caffeine-containing analgesics. Although caffeine has a sedative effect in children, it is well known to cause insomnia in adults. Those less than 30 years old can tolerate the excitatory effects of caffeine and will feel energetic without agitation and many between the ages of 28 and 32 can describe a point at which a cup of coffee taken after 6 pm will delay the onset of sleep or break up the sleep pattern. As caffeine is a competitive inhibitor of diazepam, it has been suggested that caffeine's stimulant effects may result from its competition with an endogenous ligand for the benzodiazepine receptor.6 Among psychiatric inpatients, caffeine appears to be associated with more severe disturbances. Heavy drinkers of coffee score higher on tests for anxiety, are more likely to have a disorder diagnosed as psychotic7 and have higher depression scores.8 Case reports confirm that underlying schizophrenia is made worse by excessive caffeine consumption.8 Neil and colleagues9 believe that self-medication with large doses of caffeine is a likely response to the lack of energy and drowsiness (hypersomnia) experienced during certain types of depression. Patients suffering from bipolar depression with mixed affective states who were treated with sedating tricyclic compounds continued to drink large amounts of coffee after therapy started, but they complained that the drugs made them dizzy. When they were persuaded to reduce or eliminate their coffee consumption, they all returned to a retarded hypersomnic depressive state and their anxiety, irritability and psychomotor agitation diminished. Forrest and associates'0 found that when caffeine was taken with phenobarbital at bedtime the effects of the phenobarbital as a hypnotic equalled that of a placebo. DeFreitas and Schwartz11 evaluated the effects of in a double-blind study of 14 psychiatric pacaffeine Toronto * Director of pharmacy, Clarke Institute of Psychiatry, of whom were schizophrenic. Without most tients, University and pharmacy, tAssociate professor of psychiatry informing the staff or the patients, deFreitas and of Toronto Schwartz managed to get the patients to switch to Reprint requests to: Dr. K.Z. Bezchlibnyk, Director of decaffeinated coffee for 3 weeks. From psychologic pharmacy. Clarke Institute of Psychiatry, 250 College St., testing they found a substantial decrease in hostility, Toronto, Ont. M5T 1R8
Caffeine may be considered the most popular psychotropic drug (not excluding alcohol) in North America. Each day in Ontario 9 out of 10 adults drink a caffeine-containing beverage and 1 out of 4 drinks five or more cups of coffee or tea, or both.1 The caffeine content of beverages varies widely, but a cup of coffee may contain from 29 to 176 mg, depending on the size of the cup and the manner of preparation; the usual amount of caffeine in a cup of coffee is 60 to 80 mg. Cola beverages contain about 40 mg per serving, and a small chocolate bar contains 25 mg. Some over-the-counter analgesics, antihistamines and stimulants, as well as prescription analgesics and migraine therapy agents, also contain caffeine. An individual who in 1 day consumes three cups of coffee, two over-the-counter headache pills, one chocolate bar and one cola drink will ingest about 400 mg of caffeine. Approximately 20% to 30% of respondents to surveys on caffeine say they consume more than 500 to 600 mg of caffeine per day. Since 250 mg or more produces observable effects on the nervous system nervousness, irritability, headache, rapid breathing, tremulousness, reflex hyperexcitability, fasciculation, and, of course, insomnia - it is apparent that about one adult out of four risks experiencing these signs of "caffeinism".2 The actions of caffeine on the central nervous system are particularly significant in psychiatry. Caffeinism or caffeine withdrawal may be indistinguishable from anxiety neurosis, and each condition may potentiate the other.3 Diagnosis may be made unclear and management may become frustrating because of the interference of excess caffeine. Lutz4 believes that caffeine is the main factor causing the restless leg syndrome; he found that the elimination of caffeine and other xanthine derivatives from the diet, the temporary use of diazepam, and increased physical exercise gave complete relief to all 62 of his patients with this syndrome. Goldstein and Kaizer5 reported typical symptoms of
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suspiciousness, anxiety and irritability. However, 1 week after regular coffee was reinstituted, these gains were lost; there was also an increase in manifest psychosis and retardation, as well as a decrease in social competence. Coffee drinking is well known to be associated with the use of sedative-hypnotics, minor tranquillizers, cigarettes and alcohol.2 Although coffee is not necessarily a major cause of these problems, studies in rats have shown that caffeine substantially increases intake of alcohol, especially when the diet is initially deficient.12"3 The pervasive and almost unnoticed habit of drinking caffeine-containing beverages has a number of implications for the diagnosis and management of psychiatric problems, from the mildest to the most severe. No patient should be treated for insomnia without a thorough investigation of his or her caffeine consumption.14 (Caffeine may antagonize the therapeutic effects of sedative drugs.) Doctors working with alcoholics should be aware of the possibility that caffeine intake and poor diet may lead to increased alcohol intake. Doctors who prescribe neuroleptics, anxiolytics, hypnotics, tricyclic and quadracyclic antidepressants and monoamine oxidase inhibitors should warn their patients to avoid excess caffeine. The hospital too has a major responsibility in reducing the caffeine intake of psychiatric patients. Tea and coffee should not be served on psychiatric wards. Many hospitals now provide these stimulants six times a day - with all three meals, as well as mid-morning, mid-afternoon and with the evening snack. Counting refills, a psychiatric patient may thus drink 12 cups of coffee or more, provided free of charge by the hospital. Because the tea and coffee habit is so widespread in our society, hospitals should provide decaffeinated alternatives. (Decaffeinated tea is a recent addition to grocery stores and supermarkets and is more acceptable to tea drinkers than milk or juice.) Of course, many psychiatric patients do not spend all their time on the ward, and the staff then has the added responsibility of monitoring their intake of caffeine outside by checking with them from time to time, particularly on weekends. Pharmacists working in psychiatric hospitals should affix labels to all bottles containing neuroleptics, anxiolytics, hypnotics, tricyclic and tetracyclic antidepressants and monoamine oxidase inhibitors that warn about excess caffeine intake, just like the warnings on many of these bottles about alcohol intake. The pharmacist or pharmacy committee should review the hospital's formulary and remove all drugs containing therapeutically useless amounts of caffeine. For example, :To be classified into schedule C (nonprescription drugs) of the Food and Drugs Act and Regulations issued by the health protection branch of the Department of National Health and Welfare, Ottawa, a narcotic preparation containing codeine phosphate, not exceeding 8 mg per tablet, must include a minimum of two additional medicinal ingredients other than narcotics (Health Disciplines Act, 1974). For example, 222s contain codeine phosphate, 8 mg, plus acetylsalicylic acid, 375 mg, plus caffeine, 30 mg. 358 CMA JOURNAL/FEBRUARY 15, 1981/VOL. 124
Fiorinal contains butalbital, 50 mg, and caffeine, 40 mg, which presumably cancel each other out. Other compounds contain caffeine as an additional ingredient to permit over-the-counter sales of the drug* (e.g., 222s); however, the caffeine does nothing for the primary condition for which the compound is presumably prescribed. Many pharmacies provide instruction for patients, and, when indicated, these should contain appropriate warnings. Similarly, many hospital wards now have drug information groups for their patients; caffeine use should be one of the main topics for discussion. Many psychiatric patients are now provided with informative questionnaires about their illness and its management; these too should contain warnings about abuse of stimulants. The widespread adoption of such changes will not come easily. In our experience it is the medical and professional staffs who oppose changes in caffeine consumption habits, not the patients. Physicians who understand that "caffeinism" sanctioned in hospitals is a significant medical problem should put pressure on hospital administrators to reduce the availability of caffeine-containing drinks and drugs. In this way, neither patients nor staff will run the risk of caffeinism as a byproduct of their lifestyles. References 1. GILBLRT.RM, MARSHMAN JA, SCHWIEDER M, BERG R: Caffeine content of beverages as consumed. Can Med
Assoc J 1976; 114: 205-208 2. GREDEN JF, FONTAINE P, LUBETSKY M, CHAMBERLIN K: Anxiety and depression associated with caffeinism amone psychiatric inpatients. Am I Psychiatry 1978; 135: 963-
966 3. GREDEN JF: Anxiety or caffeinism: a diagnostic dilemma.
Am I Psychiatry 1974; 131: 1089-1092 4. LUTZ EG: Restless legs, anxiety and caffeinism. J C/ill
Psychiatry 1978; 39: 693-698 5. GOLDSTEIN A, KAIZER S: Psychotropic effects of caffeine in man. III. A questionnaire survey of coffee drinking and its effects in a group of housewives. C/ill Pharmacol Ther 1969; 10: 477-488 6. PAUL SM, MARANGOS PJ, GOODWIN FK, SKOLNICK P: Brain-specific benzodiazepine receptors and putative endogenous benzodiazepine-like compounds. Bid Psychiatry 1980; 15: 407-428 7. WINSTEAD DK: Coffee consumption among psychiatric
inpatients. Am I Psychiatry 1976; 133: 1447-1450 8. MIKKELSEN EJ: Caffeine and schizophrenia. I C/ill Psvchiatry 1978: 39: 732-736 9. NEIL JF, HIMMELHOCK JM, MALLINGER AG, MALLINGER J, HANIN I: Caffeinism complicating hypersomnic depres-
sive episodes. Compr Psychiatry 1978; 19: 377-385 10. FORREST WH JR. BELLvILLE JW, BROWN BW JR: The interaction of caffeine with pentobarbital as a nighttime hypnotic. Anesthesiology 1972; 36: 37-41 II. DEFREITAS B, SCHWARTZ G: Effects of caffeine in chronic psychiatric patients. Am I Psychiatry 1979; 136: 1337-
1338 12. GILBERT RM: Dietary caffeine and alcohol consumption
by rats. I Stud Alcohol 1976; 37: 11-18 13. REGISTER UD, MARSH SR, THURSTON CT, FIELDS BJ, HORNING MC, HARDINGE MG, SANCHEZ A: Influence of nutrients on intake of alcohol. I Am Diet Assoc 1972;
61: 159-162 14. GOODMAN LS, GILMAN A: The Pharmacological Basis of Therapeutics, 5th ed, Macmillan, New York, 1975
