Fwd: SSRI Withdrawal Can Induce Psychosis, Mania

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Sertaline = Zoloft

 

http://www.cpa-

apc.org/publications/archives/cjp/2002/august/letterspsychoticmania.as

p

 

 

Psychotic Mania in Bipolar II Depression Related to Sertraline

Discontinuation

 

Canadian Journal of Psychiatry, August 2002

 

Letters to the Editor

 

Dear Editor:

Discontinuing selective serotonin reuptake inhibitors (SSRIs) may

induce a

syndrome wherein the main neuropsychiatric symptoms are dizziness,

shock-like sensations, anxiety, irritability, agitation, and

insomnia. These

symptoms usually develop 1 to 7 days after either abrupt or gradual

discontinuation (1-3). Antidepressant discontinuation may also induce

mania,

mainly reported with tricyclics and monoamine oxidase inhibitors

(MAOIs) but

also observed with SSRIs (4). Acute psychosis has been reported in

previously nonpsychotic patients following abrupt discontinuation of

the

MAOI phenelzine (5). Biological mechanisms may be cholinergic

overdrive

activating monoaminenergic systems (6) or a hyposerotonergic state

arising

from SSRI-induced postsynaptic serotonin receptor desensitization

coupled

with increased serotonin reuptake after discontinuation (7).

I report the case of a patient diagnosed with bipolar disorder II (BD

II,

depression and hypomania alternating) according to DSM-IV criteria.

This

patient had a first episode of psychotic mania soon after rapid

discontinuation of sertraline. A Medline search did not find similar

reports, although 2 similar cases were reported in a case series (4).

Case Report

A 32-year-old woman with long-term BD II had been treated during the

last 2

years with sertraline 50 mg daily for depression, which had partially

remitted. She was taking no other drugs, and her family doctor tried

discontinuing sertraline. The patient took 25 mg daily for 1 week and

then

discontinued sertraline altogether. After some days, she felt

anxiety,

irritability, agitation, insomnia, and " electrical shocks " all over

her

body. A few days later, she became manic, showing marked

irritability,

insomnia, talkativeness, racing thoughts, psychomotor agitation,

increased

goal-directed activities, and marked impairment of functioning.

Because she

could not understand the cause of the very distressing " electrical

shocks, "

she became convinced that family members were inducing the shocks to

kill

her. The clinical picture worsened in 2 weeks, when she ran away from

home

for fear of being killed. At this point, she was involuntarily

committed to

hospital. After 2 weeks of treatment with a neuroleptic, her

delusions and

mania disappeared, and she became mildly depressed. In the following

weeks,

after the neuroleptic dosage was gradually reduced, her mood became

normal.

My own long-term research on BD II supports her diagnosis. Because

she had

never had mania, a spontaneous cycling concurrent with sertraline

discontinuation seems unlikely. However, switching from BD II to BD I

during

long-term follow-up has been reported in a small percentage of

patients (8).

Mania-related confounding elements could be antidepressant-induced

mania,

agitated depression, and SSRI discontinuation syndrome (4).

Antidepressant-induced mania usually appears 3 to 6 weeks after

antidepressant institution (9) and seems unlikely in this case

because this

patient had been taking sertraline for 2 years. Agitated depression

also

seems unlikely: she was agitated and manic. The timing of the

symptoms

suggests a link with sertraline discontinuation. However, while she

showed

some typical symptoms of SSRI discontinuation syndrome, psychotic

mania is

not listed among them (1,2). It seems that the psychotic mania

presented by

this patient may be related to mania induced by antidepressant

discontinuation. This case presents a link between such mania and

SSRI

discontinuation syndrome. The link is the shock-like sensations,

which she

believed were induced by family members to kill her. The mechanism

underlying this psychotic mania after sertraline discontinuation may

be a

hyposerotonergic state (7). The serotonin system is closely linked

with the

dopamine system: increased serotonin reduces dopamine activity, and

reduced

serotonin increases dopamine activity (10). Because increased

dopamine has

historically been linked to psychosis and mania (11), discontinuing

sertraline may have increased dopamine activity too greatly. The

bipolar

vulnerability of this patient may have heightened her sensitivity to

this

effect. It seems likely that, owing to sertraline's weak dopamine

reuptake

blockade, these biochemical effects overcame sertraline's possible

downregulating effect on dopamine receptors (12).

References

1. Black K, Shea C, Dursun S, Kutcher S. Selective serotonin reuptake

inhibitor discontinuation syndrome: proposed diagnostic criteria. J

Psychiatry Neurosci 2000;25:255-61.

2. Michelson D, Fava M, Amsterdam J, Apter J, Londborg P, Tamura R,

and

others. Interruption of selective serotonin reuptake inhibitor

treatment.

Double-blind, placebo-controlled trial. Br J Psychiatry 2000;176:363-

8.

3. Benazzi F. Sertraline discontinuation syndrome presenting with

severe

depression and compulsions. Biol Psychiatry 1998;43:929-30.

4. Goldstein TR, Frye MA, Denicoff KD, Smith-Jackson E, Leverich GS,

Bryan

AL, and others. Antidepressant discontinuation-related mania:

critical

prospective observation and theoretical implications in bipolar

disorder. J

Clin Psychiatry 1999;60:563-7.

5. Liskin B, Roose SP, Walsh BT, Jackson WK. Acute psychosis

following

phenelzine discontinuation. J Clin Psychopharmacol 1985;5:46-7.

6. Dilsaver SC, Greden JF. Antidepressant withdrawal-induced

activation

(hypomania and mania): mechanism and theoretical significance. Brain

Res Rev

1984;7:29-48.

7. Zajecka J, Tracy KA, Mitchell S. Discontinuation symptoms after

treatment

with serotonin reuptake inhibitors: a literature review. J Clin

Psychiatry

1997;58:291-7.

8. Coryell W, Endicott J, Maser JD, Keller MB, Leon AC, Akiskal HS.

Long-

term stability of polarity distinctions in the affective disorders.

Am J

Psychiatry 1995;152:385-90.

9. Wehr T, Goodwin F. Can antidepressants cause mania and worsen the

course

of affective illness? Am J Psychiatry 1987;144:1403-11.

10. Kapur S, Remington G. Serotonin-dopamine interaction and its

relevance

to schizophrenia. Am J Psychiatry 1996;153:466-76.

11. Goodwin FK, Jamison KR. Manic-depressive illness. New York:

Oxford

University Press; 1990.

12. Richelson E. Synaptic effects of antidepressants. J Clin

Psychopharmacol

1996;16 (Suppl 2):1S-9S.

Franco Benazzi

Forlí, Italy

 

 

 

 

 

 

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