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MJP Online Early MJP-01-09-10

CASE REPORT

Antidepressant induced and Steroid in a Patient with Bell’s Palsy

Tan CL, Anne Yee HA, Majid SM, Koh OH, Ng CG

Department of Psychological Medicine, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur Malaysia

Abstract

Steroid is commonly used for various connective tissue diseases and immunological related disorders. Psychiatric side effects are common in patient with systematic treatment of steroid. The reported prevalence ranges from 6% to 28%. Antidepressant-induced mania occurs when the mood of a patient switches to manic or hypomanic from after the use of antidepressant. We reported a case of a 55 year old lady, who presented with agitation and grandiosity after the treatment with antidepressant. She was initially diagnosed as having Bell’s palsy with unilateral facial muscle weakness. Oral prednisolone was prescribed for seven days where she became depressed, having auditory and of guilt. She was then started on antidepressant where she became irritable, agitated and developed grandiose delusion. The antidepressant was withheld and she was started on atypical . Her condition improved and discharged well after three days of stay in the ward.

Keywords: Steroid, psychosis, antidepressant-induced mania

Introduction sclerosis), cerebello-pontine angle lesions (Acoustic neuroma) and systemic disease Bell’s palsy is an idiopathic palsy of the (Diabetes Mellitus, Sarcoid, Guillain- facial nerve (VII) resulting in a usually Barre)2. Within a few days of onset of unilateral facial weakness or paralysis. The Bell’s palsy, high doses of prednisolone incidence rate of this disorder is about 23 (0.5mg/kg/12h PO for 5 days) should be per 100,000 annually, or about 1 in 60 or 70 given to reduce nerve edema, hence persons in a lifetime1. The pathogenesis of preventing the progression of weakness to the paralysis is unclear and the diagnosis is total paralysis3. made by excluding other causes which may cause facial palsy such as infection (Ramsay Corticosteroid is a class of steroid hormone Hunt Syndrome, Lyme disease, HIV, that is produced in the adrenal cortex. It Meningitis, Polio, TB), brainstem lesions involves in a wide range of physiological (Brainstem tumour, Stroke, Multiple processes such as stress response, immune response and regulation, carbohydrate MJP Online Early MJP-01-09-10 metabolism, protein catabolism and 28% depends on severity5. Most often, the electrolyte homeostasis. There were two patient who received short term major groups of corticosteroid which is the corticosteroids will have and glucocorticoids group that control euphoria. In contrast, a long term carbohydrate, fat and protein metabolism corticosteroids therapy is related to and anti-inflammatory; and mineralcorticoid depressive symptoms. A serious paranoid group that control electrolyte and water state or depression with risk of suicide can homeostasis in the body1. be induced, particularly in patients with a history of mental disorder, however, is not a Synthetic pharmaceutical drugs with definite predictor for occurrence5. Female corticosteroid-like effect are used in a has an increase risk of develop the variety of conditions, ranging from brain psychiatric disturbance with the unknown tumors to skin disease. Dexamethasone and reason. Most of the neuopsychiatric its derivatives are almost pure disturbances occur during the early glucocorticoids, while prednisolone and its corticosteroid therapy. However, these derivatives have some mineralcorticoid disturbances can happen any time, even after action in addition to the glucocorticoid stopping the corticosteroid therapy. effect. Synthetic corticosteroid such as prednisolone is used in the treatment of Case report arthritis, temporal arteritis, dermatitis, allergic reactions, asthma, hepatitis, Mrs T is a 55 years old, Chinese lady, who systemic lupus erythematosus, inflammatory works as a primary school teacher. She was bowel disease, sarcoidosis and Bell’s palsy1. admitted to University Malaya Medical Centre (UMMC) with a presenting Corticosteroids have been used in complaint of irritability, talking irrelevantly, ophthalmology for almost 50 years. Hench, having and grandiose in 1949, was the first to report on the delusion. beneficial effects of ACTH and cortisone on rheumatoid arthritis4. Now, prednisolone is Mrs T was diagnosed to have Right Bell’s widely prescribed for various medical Palsy ten days prior to admission. MRI conditions. However, there are a number of showed no significant abnormality except well-known side effects with corticosteroid. small old influx in the right temporal lobe. They include increase blood glucose, She was then treated with oral prednisolone Cushing’s syndrome, weight gain and 40mg daily for seven days. She complained osteoporosis5. of poor sleep and depressed mood associated with irritability after she was started on In addition to physical side effects, prednisolone. She also developed delusion corticosteroids often induce psychiatric of guilt whereby she felt excessive burden to syndromes. Glaser divided the steroid her family for no reasons. Later, Mrs T induced psychiatric side effects in to two started to have auditory hallucination where categories: (a) a primary affective disorder she heard “evil” talking to her and of either elation or depression, and (b) a threatening to harm her. She was seen by a more complex reaction with organic reaction psychiatrist in a private hospital and and psychosis6. These symptoms are diagnosed to have depression with collectively known as “steroid psychosis”. psychotic features. She was treated with The reported incidence range from 6% to antidepressant ( 20mg daily). MJP Online Early MJP-01-09-10

After taken the medication, she became very induced (with manic or irritable and agitated. She developed mixed features)9. grandiose delusion where she claimed that she is the Jesus Christ and the ruler of the The rate of antidepressant-associated mania world. She commanded people to bow and in unipolar depression (1% - 6%) is much pray to her in order to save the world. lower than in (20% -40%)10. The mechanisms of “switching” from Due to her condition, she was then referred depression to mania are not completely to UMMC psychiatry department. Due to understood. However, there are evidence her unmanageable behavior, she was given revealing the involvement of central parenteral diazepam 10mg and haloperidol catecholamine especially dopamine and 5mg in the emergency department and serotonin. Studies have shown that the admitted to the psychiatric ward. She was assumption of cocaine and sleep deprivation started on (Quetiapine therapy can induce manic or hypomanic XR 100mg ON). Her condition settled episodes through dopaminergic pathway11. down on the second day of admission and Serotonin can mediate she was discharged well after three days in Methylenedioxymethamphetamine the ward. For family history, Mrs T’s elder (MDMA) which produce exciting and brother is a known case of depression and euphorizing effects12. was on treatment. Some authors argued that antidepressant- Disscussion induced mania occurs solely among individuals with a pre-existing susceptibility In the nineteenth century, to bipolar, hence, environmental factors coined the term “manic-depressive insanity” (such as sleep deprivation in our case) will which initially referred to all kinds of mood evoke the switch process from depression to disorder, including episodic depression, mania or hypomania, this is termed bipolar mania, hypomania, cyclothymic disorders diathesis model. In contrast, some authors and many other mood variations. In 1957, viewed this type of mania more as adverse Karl Leonhard, a German psychiatrist, events of antidepressant because it typically further split the manic depressive insanity resolves with antidepressant cessation into major depressive disorder (unipolar although time-limited symptomatic depression) and bipolar disorder7. This management may still be needed. This conceptualization was later adopted by the concept is adopted by DSM-IV-TR, in DSM first edition. Young and Klerman which antidepressant-induced are further sub-classified Bipolar disorder into 6 classified as substance-induced mood subtypes, namely Bipolar I: Mania and disorders rather than as a subtype of bipolar depression, Bipolar II: Hypomania and illness9. Back to our case, Mrs. T was fully depression, Bipolar III: Cyclothymic recovered from the manic episode after the disorder, Bipolar IV: Hypomania or mania withdrawal of the antidepressant. Therefore, precipitated by antidepressant drugs, Bipolar her manic episode could be an iatrogenic V: Depressed patients with a family history side effect of antidepressant. of bipolar illness, Bipolar VI: Unipolar Mania8. In DSM-IV-TR, the occurrence of Many family-pedigree studies suggest that manic symptoms during treatment with bipolar and unipolar probands may represent antidepressants was termed as substance- the same underlying disorder, the only MJP Online Early MJP-01-09-10 differences are the severity in between them. discontinuation of the steroid drugs15. Davis Blacker et al found that depressed relatives et al found that neuroleptics in low doses led of bipolar patients had a higher threshold of to rapid symptom resolution in 83% of the having bipolar features13. Mrs. T has a patients who had steroid–induced brother who also has depression and has psychiatric disturbances16. Now newer been on antidepressant for many years. atypical agents such as olanzapine which are rarely associated with dystonic reactions or Therefore, Mrs. T may already have some extrapyramidal side effects, are proven genetic loading which made her vulnerable useful in treating psychiatric symptoms to antidepressant-induced mania. during steroid therapy and are recommended as first-line-treatment15. In this case, Mrs. T Although antidepressant-induced mania was had completed her seven days’ course of first described in connection with the use of prednisolone and her fluoxetine were tricyclic antidepressants, the safety of the withheld. She then recovered fully from the newer antidepressants such as selective illness after she was treated with an serotonin reuptake inhibitor (SSRI) eg antipsychotic medication. fluoxetine, paroxetine and SNRI eg venlafaxine, duloxetine still remains In summary, systemic corticosteroids should unknown. There are evidences that tricyclic be prescribed with care in those who are antidepressant will exacerbate the acute predisposed to psychiatric reactions, symptoms of agitation and psychosis on including those who have previously patients who have steroid-induced suffered from corticosteroid-induced psychiatric disturbances but little psychosis, or who have a personal or family information is available for newer history of psychiatric disorders. antidepressants14. Some even recommend if Antidepressants should probably be avoided an antidepressant is needed for the treatment as first-line treatment in persons with mood of steroid-induced psychiatric disturbance, symptoms likely secondary to steroid. SSRI such as fluoxetine, 20mg/day is the Atypical generally are safe drug of choice14. However, Mrs. Teh and effective in treating steroid-induced developed manic symptoms while she was psychiatric disturbances. given flouxetine for her steroid-induced psychiatric disturbances. References

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Corresponding Author Dr Ng Chong Guan Department of Psychological Medicine, Faculty of Medicine, University of Malaya

Email: [email protected]