Fluvoxamine-associated manic behavior: a case series

Did My Brain Implant Make Me Do It? Questions Raised by DBS Regarding Psychological Continuity, Responsibility for Action and Mental Competence

Deep brain stimulation (DBS) is a well-accepted treatment for movement disorders and is currently explored as a treatment option for various neurological and psychiatric disorders. Several case studies suggest that DBS may, in some patients, influence mental states critical to personality to such an extent that it affects an individual's personal identity, i.e. the experience of psychological continuity, of persisting through time as the same person. Without questioning the usefulness of DBS as a treatment option for various serious and treatment refractory conditions, the potential of disruptions of psychological continuity raises a number of ethical and legal questions. An important question is that of legal responsibility if DBS induced changes in a patient's personality result in damage caused by undesirable or even deviant behavior. Disruptions in psychological continuity can in some cases also have an effect on an individual's mental competence. This capacity is necessary in order to obtain informed consent to start, continue or stop treatment, and it is therefore not only important from an ethical point of view but also has legal consequences. Taking the existing literature and the Dutch legal system as a starting point, the present paper discusses the implications of DBS induced disruptions in psychological continuity for a patient's responsibility for action and competence of decision and raises a number of questions that need further research.

A display of hypomania in a depressed male in response to fluvoxamine

The present report describes the behavioural and psychological changes in a 55-year-old depressed male who displayed hypomania after the use of fluvoxamine in addition to other antidepressant medications. The patient experienced his first major depressive episode after the bankruptcy of his company. When fluvoxamine was prescribed at a dose of 50 mg/day in addition to sulpiride at 150 mg/day and a 50 mg dose of trazodone before sleep seven months after admission, grinning and a violation of ward rules occurred repeatedly. The patient became verbally aggressive to the staff and addicted to gambling and alcohol. Six days after the cessation of fluvoxamine, his condition remitted. None of the neuromuscular abnormalities indicative of serotonin syndrome appeared during the episode. Upon review of previous reports on manic switches induced by SSRIs and other antidepressants, we speculate that the fluvoxamine accounted for his hypomania.

Retrospective analysis of serum valproate levels and need for an antidepressant drug

We sought to determine whether patients receiving valproate plus an antidepressant had significantly lower serum valproate levels before initiation of the antidepressant than those patients receiving valproate without an antidepressant. We further sought to identify the prevalence of antidepressant-induced mania and to determine if valproate provided a protective effect against antidepressant-induced mania. A computer database search from January 1, 1990-June 30, 1998, identified patients with bipolar or schizoaffective disorder treated with valproate. Patients receiving an antidepressant during valproate therapy were identified as the treatment group (9 patients), and the remaining patients served as the control group (17 patients). Serum valproate levels were recorded just before starting the antidepressant for the treatment group and monthly during a comparable period for the control group. The mean time to antidepressant initiation was 15 +/- 8 weeks. The mean serum valproate level just before antidepressant initiation was significantly lower for the treatment group compared with the mean serum valproate level averaged over 16 +/- 6 weeks for the control group (54 +/- 24 vs 73 +/- 13 microg/ml, p<0.05). Four patients (44%) developed antidepressant-induced mania. Three required discontinuation of the antidepressant; their serum valproate levels were 54, 60, and 71 microg/ml. Patients requiring the addition of an antidepressant had significantly lower valproate serum levels than those who did not require an antidepressant. Further study is necessary to determine whether higher serum valproate levels are needed for prevention of depressive symptoms in bipolar and schizoaffective disorders.

Guanfacine and secondary mania in children

INTRODUCTION

Guanfacine hydrochloride is an alpha-2 adrenergic agonist, which has gained recent attention in the field of child and adolescent psychiatry. This medication has been described as effective in the management of attention-deficit hyperactivity and tic disorders, with minimal side effects.

METHODS

Presented here are five cases of behavioral activation in children treated with guanfacine.

RESULTS

In each instance the clinical presentation resembled an acute hypomanic or manic episode. The dose of guanfacine was 0.5 mg/day. Later investigation revealed that all of the youngsters had clear risk factors (clinical and/or familial) for bipolar disorder.

CONCLUSIONS

It appears as though guanfacine may be capable of precipitating secondary mania in vulnerable children.

Assessment and treatment of bipolar disorder in the elderly

The aetiology of late-onset bipolar disorder is heterogeneous because the disease is more likely to have a secondary (i.e. a medical disorder or medication-induced) cause in older than in younger patients. Elderly patients with bipolar disorder typically require lithium dosages that are 25 to 50% lower than those used in younger individuals. Information on the use of valproic acid (sodium valproate) in elderly patients with bipolar disorder is limited but encouraging. In contrast, there is virtually no information regarding the use of carbamazepine or other drugs in this patient group. Electroconvulsive therapy is well tolerated by older people and can be useful for these patients.

Pharmacology of the selective serotonin reuptake inhibitors in children and adolescents

OBJECTIVE

To review the pharmacology of a new class of medications, the potent selective serotonin reuptake inhibitors (SSRIs), what is known about their metabolism in children and adolescents, and the practical clinical implications of such.

METHOD

Articles were retrieved through index Medicus searches for articles published during the past 10 years on the SSRIs and on pediatric pharmacology.

RESULTS

More than 300 articles were reviewed. Pharmacological data, derived from relevant adult literature, were summarized and extrapolated to children and from the limited pediatric literature. The SSRIs represent a new class of antidepressants with distinct advantages in their side effect profile and their broad therapeutic index over that seen with the tricyclic antidepressants. Their advantage of few anticholinergic side effects and limited cardiovascular toxicities are particularly relevant for the pediatric population. The SSRIs are metabolized via the hepatic cytochrome isoenzyme P450 system, and potential drug-drug interactions are reviewed.

CONCLUSIONS

The SSRIs appear to offer advantages over the tricyclic antidepressants. Unfortunately, pharmacokinetic data are lacking, and systematic studies of safety and efficacy in the pediatric age group are limited. Preliminary reports are encouraging, but further study is required.