Cases That Test Your Skills Manic after taking a vacation Emjay Tan, MD Mr. K, age 36, develops racing thoughts and euphoric mood after How would you returning from a cruise. Mr. K and his wife think his symptoms are handle this case? caused by a motion-sickness patch. How would you proceed? Answer the challenge questions throughout this article CASE From soft-spoken to manic active substances—other than scopolamine Mr. K, age 36, an Asian male with no psychiatric —that could trigger a manic episode. His family history, arrives at the outpatient psychiatry clinic history is significant for a younger brother who accompanied by his wife, after being referred had a single manic episode at age 12 and a sui- from the emergency room the night before. cide attempt as a young adult. He reports racing thoughts, euphoric mood, Mr. K works full-time on rotating shifts— increased speech, hypergraphia, elevated self- including some overnight shifts—as a man- esteem, decreased need for sleep, distractibility, ufacturing supervisor at a biotechnology and increased goal-directed activity. Notably, company. He has been unable to work since Mr. K states that he likes how he is feeling. returning from the cruise because of his psy- Mr. K’s wife says that his condition is a clear chiatric symptoms. change from his baseline demeanor: soft- Mr. K is started on sustained-release (SR) spoken and mild-mannered. lithium, 900 mg/d. In addition, the psychia- Mr. K reports that his symptoms started trist advises Mr. K to continue taking clon- approximately 10 days earlier, after he returned azepam, 0.5 to 1 mg as needed, which the from a cruise with his wife. During the cruise, he emergency medicine physician prescribed, used a scopolamine patch to prevent motion sick- for insomnia. Mr. K is referred to a psychiatric ness. Mr. K and his wife say that they believe that intensive outpatient program (IOP), 3 days the scopolamine patch caused his symptoms. a week for 2 weeks, and is advised to stay home from work until symptoms stabilize. Can scopolamine cause mania? Mr. K follows up closely with the psychia- a) No trist in the clinic, every 1 to 2 weeks for the b) Yes; this is well-documented in the first month, as well as by several telephone literature and e-mail contacts. Lithium SR is titrated to c) It is theoretically possible because of 1,200 mg/d, to a therapeutic serum level of scopolamine’s antidepressant and central 1.1 mEq/L. Clonazepam is switched to que- anticholinergic effects tiapine, 25 to 50 mg as needed, to address Dr. Tan is a psychiatrist at Kaiser Permanente, San Bruno, California. TREATMENT Lithium, close follow up Disclosure Mr. K has no history of psychiatric illness or Dr. Tan reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of Current Psychiatry substance use and no recent use of psycho- competing products. Vol. 15, No. 4 45 Cases That Test Your Skills Table 1 carinic cholinergic receptors, which reduces Theoretical antidepressant production of glutamate receptors and mechanisms of scopolamine leads to reduced glutamate transmission and neurotoxicity.3,4 Scopolamine—similar Downregulation of glutamate receptor to ketamine—could enhance synaptogene- production ➝ decreased glutamate transmission ➝ decreased excitotoxicity3,4 sis and synaptic signaling.5,6 Also, by block- Enhancement of synaptogenesis, similar ing muscarinic autoreceptors, scopolamine to ketamine5,6 results in an acute upregulation of acetyl- Upregulation of acetylcholine production choline release, which, in turn, influences ➝ modulation of nicotinic, serotonergic, the nicotinic, dopamine, serotonin, and and dopaminergic systems, and an anti- inflammatory effect7-9 neuropeptide Y systems. This action could contribute to anti-inflammatory effects, all Clinical Point of which can benefit mood.7-9 These anti- ongoing insomnia and to reduce the risk of depressant mechanisms also could explain The antidepressant dependency on clonazepam. why, theoretically, scopolamine could pre- mechanisms of Mr. K’s mania gradually abates. He finishes cipitate mania in a person predisposed to scopolamine the IOP and returns to work 3 weeks after his mental illness. could explain why, initial presentation. At an office visit, Mr. K’s Proposed by Janowsky et al10 in 1972, the theoretically, it could wife gives the psychiatrist 2 scientific articles cholinergic−adrenergic balance hypothesis documenting the antidepressant effect of of affective disorders suggests that depres- precipitate mania scopolamine.1,2 Mr. K and his wife both con- sion represents an excess of central choliner- tinue to believe that Mr. K’s manic episode gic tone over adrenergic tone, and that mania was triggered by the scopolamine patch he represents the opposite imbalance. Several used while on the cruise. They think this is lines of evidence in the literature support important because Mr. K believes he would this theory. For example, depressed patients not have developed mania otherwise, and he have been found to have hypersensitive cen- does not want to take a mood stabilizer for tral cholinergic receptors.11,12 Also, central the rest of his life. cholinesterase inhibition has been shown to affect pituitary hormone and epinephrine levels via central muscarinic receptors.13 In The author’s observations addition, scopolamine has been shown to There are several proposed mechanisms attenuate these effects via the central anti- for scopolamine’s antidepressant effect muscarinic mechanism.14 (Table 1).3-9 Scopolamine blocks central mus- Rapid antidepressant therapy. Scopolamine NEXT MONTH IN is being studied as a rapid antidepressant treatment, although it usually is administered CASES THAT TEST YOUR SKILLS via IV infusion, rather than patch form, in tri- Ms. K, age 38, is confused, agitated, and als.15-17 IV ketamine is another therapy being endorsing suicidal ideations, symptoms investigated for rapid treatment of depres- that have worsened over several weeks. Her Discuss this article at sion, which might have downstream mecha- www.facebook.com/ presentation could indicate a psychiatric nisms of action related to scopolamine.5,18 CurrentPsychiatry condition, but her history is not consistent with Electroconvulsive therapy is a well-known a typical course of known psychiatric illness. for its quick antidepressant effect, which How would you evaluate her? could involve synaptogenesis or effects on Follow this case the neuroendocrine system.19 Sleep depriva- in the May 2016 tion also can produce a rapid antidepressant Current Psychiatry issue of 46 April 2016 effect20 (Table 21,2,5,6,15,16,18-20). Cases That Test Your Skills Table 2 Rapid antidepressant therapies Therapy Status Scopolamine1,2,6,15,16 Research only Sleep deprivation20 Somewhat established; not widely used Ketamine5,18 Established; early stages of use Electroconvulsive therapy19 Established; widely utilized OUTCOME Prone to motion sickness the past without triggering manic episodes, Approximately 3.5 months after his initial and he did not anticipate needing to take it presentation, Mr. K continues to do well very often. Clinical Point with treatment. He is euthymic and functioning well at work. He and his wife What would you tell Mr. K about Mr. K’s case are preparing for the birth of their first dimenhydrinate for motion sickness during underscores the role child. car rides? of the muscarinic Mr. K is prone to motion sickness, and asks a) Mr. K should not take dimenhydrinate cholinergic system if he can take over-the-counter dimenhydri- to prevent motion sickness because he in regulating mood nate tablets for long car rides. He reports that experienced a manic episode triggered by dimenhydrinate has worked well for him in a scopolamine patch Cases That Test Your Skills a robust antidepressant-level dosage, even Related Resources taking into account possible lower bioavailabil- • Furey ML, Zarate CA Jr. Pulsed intravenous administration of scopolamine produces rapid antidepressant effects and ity with transdermal administration compared modest side effects. J Clin Psychiatry. 2013;74(8):850-851. with IV infusion.) • Khajavi D, Farokhnia M, Modabbernia A, et al. Oral scopolamine The psychiatrist concludes that sporadic augmentation in moderate to severe major depressive disorder: a randomized, double-blind, placebo-controlled study. J Clin use of dimenhydrinate tablets for motion sick- Psychiatry. 2012;73(11):1428-1433. ness during occasional long car rides poses Drug Brand Names less of a risk for Mr. K of triggering mania than Clonazepam • Klonopin Lithium • Eskalith, Lithobid repeat use of a scopolamine patch. Dimenhydrinate • Dramamine Quetiapine • Seroquel Ketamine • Ketalar Scopolamine • Transderm Scop The author’s observations Clinical Point Mr. K’s case is notable for several reasons: b) Mr. K can use dimenhydrinate as much • Novelty. This might be the first report Sensible clinical as he wants to prevent motion sickness of scopolamine-induced mania in the litera- decision-making was because it poses no risk of mania ture. In clinical trials by Furey and Drevets,15 needed when Mr. K c) Mr. K can use dimenhydrinate with caution Drevets and Furey,16 and Ellis et al,17 no study asked about using and sparingly on a trial basis, as long as he participants who received scopolamine dimenhydrinate is taking his mood stabilizer infusion developed mania or hypomania. Although it is possible that Mr. K’s manic for motion sickness episode could have occurred spontaneously during car rides FOLLOW UP Cautious use and was coincidental to his scopolamine use, The psychiatrist advised Mr. K to take dimen- there are valid reasons why scopolamine hydrinate cautiously when needed for long car could trigger mania in a vulnerable person. rides. The psychiatrist feels this is safe because • Biochemical insight. The case under- Mr. K is taking a mood stabilizer (lithium). Also, scores the role of the muscarinic cholinergic although dimenhydrinate has anticholinergic system in regulating mood.10 properties, occasional use is thought to pose • Rational medical care.