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Quetiapine Induced Hypomania: a Case Report and a Review of the Literature R

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Quetiapine Induced Hypomania: a Case Report and a Review of the Literature R Send Orders of Reprints at [email protected] 250 Current Drug Safety, 2012, 7, 250-253 Quetiapine Induced Hypomania: A Case Report and a Review of the Literature R. Bou Khalil* and C. Baddoura Psychiatric Hospital of the Cross, Jalledib, Lebanon Saint Joseph University, Beirut, Lebanon Abstract: Objectives: The 5-HT2 antagonistic action of quetiapine may disinhibit the dopaminergic system enhancing dopaminergic activity in the forebrain and influencing the mood state. Our objective is to investigate the possible induction of manic symptoms by quetiapine through a case report and a review of the literature. Method: We report the case of a 54 year old woman suffering from bipolar depression who developed hypomania seven weeks after the initiation of 300 mg/d of quetiapine. A literature review concerning the induction of hypomania or mania by quetiapine have retrieved the presence of seven similar case reports or series. Results: Available literature points toward an early induction of hypomania or mania with low dosage of quetiapine treatment (between 100 and 400 mg/day never exceeding 600 mg/day). Hypomania or mania are possible short term complications that can be present few days to few weeks of treatment initiation. The discontinuation of the drug or the increase of its dose seems to reverse the hypomanic or manic symptoms. Patients described in the literature suffer mostly from schizophrenia. Conclusion: The atypical antipsychotic drug quetiapine, which have antidepressant properties at low doses via its indirect dopamine enhancing activity due its serotoninergic antagonism, appears to be involved in the induction of rare hypomanic or manic state in patients suffering from bipolar disorders and to have mood stabilizing properties at higher doses when its dopamine antagonist activity becomes more prominent. Its manic/hypomanic induction properties should not prevent its administration to patients suffering from bipolar disorder. Keywords: Quetiapine, mood disorder, induced mania, induced hypomania, adverse drug reaction. 1. INTRODUCTION mania by quetiapine in patients suffering from mental disorders was made via MedLine, PsychINFO and Embase. The atypical antipsychotic, quetiapine, is characterized by a Terms used in the search were: “quetiapine”, “induced”, greater affinity to 5-HT2 receptors, compared to D2 receptors “mania” or “hypomania”. Only publications in English or in [1]. It is a dibenzothiazepine derivative with considerable French were included. No restrictions regarding the histamine receptor and 2-adrenoreceptor blockade [2]. At low publication date were considered. The search has retrieved doses (up to 300mg/day) it shows a consistently higher degree the presence of seven case reports or series describing ten of occupancy of 5-HT2A receptors than D2 receptors; the different patients. Every case report or series reporting a degree of occupancy of both receptors is dose-dependent [3]. patient(s) suffering from a severe mental disorder who has The 5-HT2 antagonistic action of quetiapine may disinhibit the (ve) developed a manic/hypomanic episode that has been dopaminergic system and enhance dopaminergic activity at the considered to be induced by quetiapine, was included in the level of forebrain and influences the mood state [4]. There are a review. limited number of cases which have suggested that quetiapine may induce hypomanic or manic symptoms in psychotic disorders [5]. We will report the first case of hypomania 3. RESULTS induced by quetiapine in a patient suffering from a mood 3.1. Case Report disorder and then expose available data from the literature. A 54 year old patient was admitted to our hospital suffering from depressive symptoms with suicidal ideation. 2. METHODS She was diagnosed, twenty five years ago, as having bipolar We report the case of a 54 year old woman suffering disorder type I. She has been receiving lithium treatment for from bipolar depression who developed hypomania seven many years. As she developed lithium induced weeks after the initiation of 300 mg/d of quetiapine. In the hypothyroidism and became resistant to the antimanic effect aim of performing a comprehensive literature review, a of lithium, her mood stabilizer was changed to valproic acid literature search concerning the induction of hypomania or (1000 mg/day) during the last 5 years. She did not manifest any manic or hypomanic episode while taking valproic acid as a mood stabilizer. She received thyroid hormone *Address correspondence to this author at the psychiatric hospital of the Cross, supplements and was euthyroid at admission. Additionally, Jalledib, Lebanon; P.O box: 60096; Tel: 009614710224; she was chronically receiving chlorpromazine at 300mg/d, E-mail: [email protected] 2212-3911/12 $58.00+.00 © 2012 Bentham Science Publishers Quetiapine Induced Hypomania Current Drug Safety, 2012, Vol. 7, No. 3 251 zolpidem at 10mg/d and bromazepam at 3mg/d. Two weeks week. The diagnosis of hypomania was established. The before her admission, she started developing a depressed management of this hypomanic episode relied on what was mood, along with anhedonia, insomnia, decreased appetite described in the literature regarding the management of and suicidal ideation. Because of her bipolar disorder, she quetiapine induced hypomania. Because six out of nine cases did not receive any antidepressant drug but she was switched (see Table 1) have been successfully treated with quetiapine from chlorpromazine to a rapidly escalated dose of 300 mg/d discontinuation the drug was stopped and replaced with the of quetiapine in order to improve her sleep and to control her same dose of chlorpromazine the patient used to take. One mood symptoms. All her biological parameters were within week after the discontinuation of quetiapine the patient the normal ranges including her thyroid function and her became normothymic. The episode was considered to be blood valproic acid dosage (65 mg/dl). She was discharged probably induced by quetiapine. one week after her admission after noticing an important improvement in her depressive symptoms especially concerning her suicidal ideation and sleep. Seven weeks 3.2. Comprehensive Literature Review after, while she was adherent to her psychotropic medication, Seven published case reports or case series between 2001 she consulted for suffering from pressured speech, insomnia, and 2010 were considered to be directly linked to the search inflated mood, and grandiosity that appeared during the last Table 1. Summary of Case Reports in the Literature Describing Quetiapine Induced Hypomanic/Manic Symptoms Personal or Highest Dose of Onset of Hypomanic/ Family Quetiapine Reached Authors and Age Sex of Axis I DSM-IV Manic Symptoms Management of History of Before Onset of Reference of Patients Patients Diagnosis After Quetiapine Hypomanic/Manic Symptoms Bipolar Hypomanic/Manic Treatment Disorder Symptoms Reinitiation of 100 mg/d of chlorpromazine and Benazzi 2001 Not Schizoaffective 43 yr woman 300 mg/d 4 weeks discontinuation of quetiapine: [6] determined disorder disappearance of hypomanic symptoms after week. Reduction of quetiapine dose to Atmaca et al. Paranoid 33 yr woman No 400mg/d 2 weeks 100 mg/d: remission of 2002 [7] schizophrenia symptoms after five days. Discontinuation of quetiapine and Biancosino Schizophrenia administration of zuclopenthixol 23 yr woman No 400 mg/d 4 weeks et al. [8] form disorder and lorazepam. Resolution of symptoms in 10 days. Discontinuation of quetiapine. Pacchiarotti Paranoid Association to haloperidol and et al. 2003 21 yr man No 300 mg/d 2 weeks schizophrenia chlorpromazine, clozapine and [9] Valproic acid. quetiapine’s dose escalation to Lykouras 600 mg/d worsened the clinical Paranoid et al. 2003 26 yr man No 100 mg/d One day picture. quetiapine schizophrenia [10] discontinuation led to symptom’s resolution the next day. Discontinuation of quetiapine. Mishra et al. Initiation of lithium then valproic 40 yr man No Schizophrenia 500 mg/d Few months 2004 [11] acid treatment. Resolution of manic symptoms after 4 weeks. Efficient increase in quetiapine Mishra et al. Not Paranoid Not determined man No 400mg/d dose to 6oomg/d, then to 800 2004 [11] determined schizophrenia (probably six weeks) mg/d Monosymptomati Discontinuation of quetiapine. Mishra et al. Not c delusion v/s 1000 mg/d of valproic acid and 27 yr man 600 mg/d Not determined 2004 [11] determined schizophreniform clozapine were efficiently disorder introduced. Discontinuation of quetiapine and Erberk-Ozen Paranoid introduction of chlorpromazine et al. 2008 29 yr man No 100 mg/d 4 days schizophrenia and clonazepam resolved manic [12] symptoms after ten days. Discontinuation of quetiapine and Erberk-Ozen Not Paranoid introduction of chlorpromazine et al. 2008 44 yr man 100 mg/d 5 days determined schizophrenia and clonazepam resolved manic [12] symptoms 252 Current Drug Safety, 2012, Vol. 7, No. 3 Bou Khalil and Baddoura subject (see Table 1). Patients described in the literature are stabilizing properties, they won’t benefit from its effect aged between 21 and 44 years old. They are predominantly unless higher doses than usual were attained [13]. of male gender (7 out of 10). The majority of these patients However, we do not deny the presence of other factors were diagnosed as suffering from paranoid schizophrenia that could have played a role in the induction of the according to DSM-IV (6 out of 10). The majority of these hypomanic state in our patient. For example, the occurrence patients
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