Mania associated with procainamide

Neuropsychiatric consequences of cardiovascular medications

The use of cardiovascular medications can have a variety of neuropsychiatric consequences. Many cardiovascular agents cause higher rates of fatigue and sedation than placebo, and case reports of medication-induced mood syndromes, psychosis, and cognitive disturbances exist for many cardiovascular drugs. Depression has been associated with β-blockers, methyldopa, and reserpine, but more recent syntheses of the data have suggested that these associations are much weaker than originally believed. Though low cholesterol levels have been associated with depression and suicide, lipid-lowering agents have not been associated with these adverse effects. Finally, cardiovascular medications may have beneficial neuropsychiatric consequences; for example, the use of clonidine in patients with attention deficit-hyperactivity disorder, the use of prazosin for patients with post-traumatic stress disorder, and the use of propranolol for performance anxiety and akathisia.

Neuropsychiatric effects of cardiovascular drug therapy

Various cardiovascular drugs have been shown to have neuropsychiatric effects that can be harmful or therapeutically beneficial to patients. As an example, both sedation and mental depression have been described in patients receiving centrally acting antihypertensive drugs and beta-adrenergic blockers, related to their antiadrenergic actions. In contrast, because of these antiadrenergic actions, agents like clonidine have been used to treat opiate, alcohol, and nicotine withdrawal, while beta blockers have been used to treat symptoms of performance anxiety, migraine, and psychocardiac disorders. Some antiarrhythmic drugs have been associated with delirium, and digitalis toxicity has been shown to cause hallucinations, mania, euphoria, and depression. The calcium-channel blocker verapamil has been used as an adjunctive treatment in patients with bipolar disorders. Since neuropsychiatric symptoms are seen in patients with cardiovascular disease, clinicians should be aware of the possible relationship between these symptoms and concurrent cardiovascular drug therapy.

Procainamide-induced psychosis: a case report and review of the literature

OBJECTIVE

To describe a case of procainamide-induced psychosis in an adult treated for atrial fibrillation.

CASE SUMMARY

A 45-year-old Native American woman developed acute psychosis within 72 hours of initiating procainamide for atrial fibrillation. Symptoms abated within 24 hours of discontinuing procainamide. Serum procainamide/N-acetylprocainamide concentrations were therapeutic throughout treatment. Sotalol was started without recurrence of symptoms.

DISCUSSION

Psychosis is a rare complication of treatment with procainamide, but the exact mechanism for this adverse event is not fully understood. Seven cases implicating procainamide as the cause of acute psychosis are reported in the literature. Cases of psychosis involving other antiarrhythmic agents have also been reported.

CONCLUSIONS

Healthcare personnel should be aware of this adverse event related to procainamide and other antiarrhythmic agents.

Drug-induced mania--causative agents, clinical characteristics and management. A retrospective analysis of the literature

128 case reports of drug-induced mania were reviewed. Steroids, levodopa and other dopaminergic agents, iproniazid, sympathomimetic amines, triazolobenzodiazepines and hallucinogens were the agents that most commonly induced manic syndromes. The most common characteristics of drug-induced manic episodes were increased activity, rapid speech, elevated mood, and insomnia. Patients who developed mania often had a prior history, family history, or current symptoms of mood disturbance. The episodes were most commonly treated by discontinuing or reducing the dose of causative agent. Discontinuation of the inciting drug and treatment with neuroleptic agents were equally efficacious: lithium treatment was less effective. The majority of agents that induce mania have an effect on monoaminergic systems.

Organic causes of mania

Manic syndromes have many neurologic, toxic, and metabolic causes. It is important for clinicians to be able to distinguish these organic disorders from primary idiopathic mania (bipolar disorder). The cardinal symptom of organic mania is an abnormally and persistently elevated or irritable mood. Organic mania usually develops in patients who are older than 35 years of age, whereas bipolar disorder generally has its onset between late adolescence and age 25 years. In patients with the first episode of mania, the clinician should thoroughly elicit information about current symptoms, recent infections, use of drugs, and past or family history of psychiatric disorders. In addition, a complete medical examination, computed tomography of the head, electroencephalography, and screening for drugs and toxins should be done. Treatment of organic mania includes correcting the underlying disorder when possible.