[Antibiomania: a case of a manic episode induced by clarithromycin]

Antibiomania, or mania induced by antibiotics, is a rare, but important side effect of clarithromycin and others antibiotics. Although underestimated due to low clinical incidence, this phenomenon is being reported in a growing number of cases of mania associated with administration of antibiotics, in patients without a previous diagnosis of Bipolar Affective Disorder. The importance of Antibiomania in current clinical practice is associated with the increasing introduction and prescription of new antibiotics, and to the need for awareness of the phenomenon as a possible differential diagnosis of secondary mania. There are several theories that may explain Antibiomania, one of the most studied is related to the interaction of antibiotics with neurotransmitters, including the gamma butyric acid (GABA). However, the mechanism is still unknown. The authors present a case of a manic episode triggered by clarithromycin in a patient with no clinical history of disturbance of mood, followed by a brief literature review of the subject, including treatment strategies.

Severe mania complicating treatment of narcolepsy with cataplexy

We report the case of a 22-year-old male who exhibited severe manic behavior shortly after beginning treatment with modafinil and venlafaxine for narcolepsy with cataplexy. The manic episode persisted several weeks after medication cessation and required management with a mood stabilizer. Reinstitution of modafinil and an alternate antidepressant for recurrent sleepiness and cataplexy was well tolerated and very effective. Sleep physicians should be aware that psychostimulants, including modafinil, and antidepressant medications commonly prescribed for treatment of narcolepsy may precipitate mania in patients with underlying bipolar disorder.

Is unrecognized bipolar disorder a frequent contributor to apparent treatment resistant depression?

BACKGROUND

There is widespread clinical belief that unrecognized bipolar disorder (BD) is a frequent contributor to apparent treatment resistant depression (TRD). This review attempts to assess the degree to which prevailing empirical data supports that view.

METHODS

All English-language articles published between January 1998 and January 2008 that focused on adults with major depressive disorder (MDD) and BD bearing on the question "Is unrecognized BD a frequent contributor to apparent TRD in patients initially diagnosed with MDD?" were reviewed.

RESULTS

196 articles were reviewed; the preponderance of the data suggested: 1) TRD populations demonstrate high rates of hidden bipolar disorder, 2) there is not sufficient evidence to unequivocally support or reject the hypothesis that patients who relapse despite continued antidepressant treatment are likely to have bipolar spectrum disorder, 3) patients initially diagnosed with MDD do not demonstrate high rates of switching to mania or hypomania when treated with antidepressants and 4) in patients diagnosed with BD, antidepressants are not robustly effective and are poorly tolerated.

LIMITATIONS

The main limitation of this review is that none of the individual studies were designed to test our primary hypothesis.

CONCLUSIONS

This review provides at least moderate support to the hypothesis that BD is a contributor to apparent TRD. Thus, clinicians treating MDD are urged to search for "soft" signs of bipolarity and to be prepared to alter diagnosis and treatment strategies accordingly.

Should mood during intravenous alcohol administration be studied as a bi- or unipolar phenomenon? a pilot study

In this study, alcohol was administered intravenously to study whether its effects on mood should preferably be studied as a bi- or unipolar phenomenon. This was studied in a double-blind, placebo-balanced, design on six healthy male volunteers. Of the three bipolar aspects of mood (calmness, activity, and pleasantness), only calmness was significantly affected by intravenous alcohol. In contrast, there were significant differences between alcohol and placebo for five of the six unipolar indexes. This support the hypothesis that subjective effects of alcohol on mood are preferably studied with self-ratings that allows positive and negative aspects to be analyzed separately. Further, our data suggest that the effects of alcohol are primarily on negative aspects of mood rather than on positive.

Drug induced mania in a boy with high functioning autism

Drug induced mania is sometimes associated with drug that are primarily not used for central nervous system effects. Here we report a manic episode during the treatment of leukemia with various agents in an adolescent with diagnosis of high functioning autism. In this case, most likely candidates to induce a manic episode were dexamethazone, a corticosteroid used in the treatment of T-ALL, cyclophosphamide and cotrimoxazole. Although literature on mood disorders associated with corticosteroids exceeds that of cyclophosphamide and cotrimoxazole, an absolute causal drug cannot be stated.

alpha/beta-Arteether-induced mania in a predisposed adolescent

Artemisinin, by the name of Qinghaosu, has been used in China for the treatment of fever over the years. Recently, a number of artemisinin derivatives such as artesunate, artemether, dihydroartemisinin, and arteether have been developed and have found widespread clinical use because of their efficacy against resistant forms of all plasmodial species and a favorable side-effect profile. However, concerns have been expressed about the neurotoxic effects of artemisinin derivatives based on some animal and human studies. We present a case of alpha/beta-arteether-induced mania in an adolescent having a family history of chloroquine-induced psychosis to discuss the hereditary predispositions, possible mechanisms, management, and clinical implications of this rare adverse event.

Correlates of treatment-emergent mania associated with antidepressant treatment in bipolar depression

OBJECTIVE

Treatment-emergent mania can have substantial negative impact on overall mood and psychosocial stability in patients receiving treatment for bipolar depression. This study examined the correlates associated with treatment-emergent mania in patients receiving adjunctive antidepressant treatment for bipolar depression.

METHOD

A total of 176 adult outpatients with bipolar disorder in a 10-week trial of adjunctive antidepressant treatment for depression were categorized into three groups based on the Clinical Global Impression Scale for Bipolar Disorder: those who responded to antidepressant treatment (N=85), those who did not respond to antidepressant treatment (N=45), and those who had treatment-emergent mania or hypomania (N=46). Symptom severity was measured with the Inventory of Depressive Symptomatology and the Young Mania Rating Scale (YMRS) at baseline and bimonthly intervals. Factor analysis was used to examine correlates of treatment-emergent mania.

RESULTS

Baseline YMRS scores were significantly different between groups. Otherwise, there were no significant between-group differences in demographic or clinical characteristics. Factor analysis showed that a subset of the YMRS items predicted treatment-emergent mania in this sample: increased motor activity, speech, and language-thought disorder.

CONCLUSIONS

These data suggest that minimal manic symptoms at baseline coexisting with otherwise full syndromal bipolar depression are associated with antidepressant treatment-emergent mania or hypomania. A careful examination of motor activation, pressured speech, and racing thoughts is warranted before starting antidepressant treatment in bipolar depression.

The role of 5-HTTLPR polymorphism in antidepressant-associated mania in bipolar disorder

BACKGROUND

The occurrence of mania during antidepressant treatment is a key issue in the clinical management of bipolar disorder (BD). The serotonin transporter gene is a candidate to be associated with antidepressant-associated mania (AAM) in some patients. This gene has a polymorphism within the promoter region (5-HTTLPR) with two allelic forms, the long (L) and the short (S) variants.

METHODS

We performed a case-control study to compare 5-HTTLPR genotype and allelic frequencies between 43 patients with a DSM-IV diagnosis of BD, with at least one manic/hypomanic episode associated with treatment with proserotonergic antidepressants (AAM+) and 69 unrelated, matched bipolar patients, who had been exposed to proserotonergic antidepressants without development of manic symptoms (AAM-(*)). Furthermore, we performed this comparison between a subgroup of 23 AAM+ patients that, when they presented AAM, were not using mood stabilizer (AAM+(*)) and 25 AAM- patients who used antidepressant without the concomitant use of a mood stabilizer (AAM-(*)). 5-HTTLPR genotyping was performed using PCR.

RESULTS

No significant differences were found between AAM+ and AAM-. Within the subgroups, our results show that S-carriers (LS+SS Genotypes) are more prone to make a manic/hypomanic episode associated with antidepressant (P=0.017).

LIMITATIONS

Our study is retrospective.

CONCLUSIONS

The 5-HTTLPR polymorphism may be considered a predictor of abnormal response to antidepressant in patients with BP, but this action is influenced by the presence of a mood stabilizer. Such observations reinforce that a correct diagnosis of bipolarity before the beginning of the treatment is essential, mainly for S-carriers patients.

[When an antidepressant helps too much]

Initiation of an antidepressant may result in hypomania or mania. The risk is lower with selective serotonin reuptake inhibitors and bupropione than with venlafaxine and tricyclic antidepressants. With a mood-stabilizing medication, the risk of hypomania or mania will remain very low, along with its correspondingly lower efficacy. The therapy involves discontinuation of the antidepressant, initiation or dose elevation of a maintenance drug preventing hypomania and mania, and when needed, short-course use of a second generation antipsychotic.

Hypomania induced by escitalopram: 2 case reports

Two cases, one of recurrent depression and another of major depressive disorder with hypertension switched to hypomania while on escitalopram. Both patients achieved remission with atypical antipsychotics and divalproex. The implications of diagnosis and treatment are discussed.

[Cannabis-induced mania? A case study and literature review]

A 22-year-old man with a long history of cannabis-use presented with a full blown mania. According to recent population-based studies, someone who starts using cannabis early in life runs the risk of developing not only psychosis but also manic symptoms and bipolar disorder. Further literature research showed that the use of cannabis influences both the onset and the course of bipolar disorder. When a patient presents with mania it might be advisable for the psychiatrist to take cannabis-use into account when making a diagnosis and prescribing treatment.

Long-term antidepressant treatment in bipolar disorder: meta-analyses of benefits and risks

OBJECTIVE

Long-term antidepressant (AD) treatment for depression in bipolar disorder (BPD) patients is highly prevalent, but its benefits and risks remain uncertain, encouraging this meta-analysis of available research.

METHOD

We reviewed randomized controlled trials for BPD involving >or=6 months of treatment with AD +/- mood stabilizer (MS) vs. placebo +/- MS, using meta-analyses to compare reported risks of new depression vs. mania.

RESULTS

In seven trials (350 BPD patients) involving 12 contrasts, long-term treatments that included ADs yielded 27% lower risk of new depression vs. MS-only or no treatment [pooled relative risk, RR = 0.73; 95% CI 0.55-0.97; number-needed-to-treat (NNT) = 11], but 72% greater risk for new mania [RR = 1.72; 95% CI 1.23-2.41; number-needed-to-harm (NNH) = 7]. Compared with giving an MS-alone, adding an AD yielded neither major protection from depression (RR = 0.84; 95% CI 0.56-1.27; NNT = 16) nor substantial increase in risk of mania (RR = 1.37; 95% CI 0.81-2.33; NNH = 16).

CONCLUSION

Long-term adjunctive AD treatment was not superior to MS-alone in BPD, further encouraging reliance on MSs as the cornerstone of prophylaxis.

Switching, induction of rapid cycling, and increased suicidality with antidepressants in bipolar patients: fact or overinterpretation?

Antidepressants constitute a central cornerstone in the treatment of depressive syndromes. In bipolar patients, however, there is an ongoing controversy about their usefulness for at least 3 decades. Early reports, mainly concerning tricyclic antidepressants, have repeatedly pointed toward unfavorable side effects on the course of the disorder, namely switching into (hypo)mania, induction of rapid cycling, and increased risk of suicide. Most evidence for both unfavorable and favorable effects has been deducted, thus far, from small studies with methodological flaws. More substantiated evidence only recently became available. From this it appears that, at least, the switch risk, and perhaps also the risk for rapid cycling and new-onset suicidality have been overinterpreted. At the same time, these new data raise doubt about the efficacy of antidepressants as a primary-treatment choice in bipolar depression.

Cannabis and psychiatric disorders: it is not only addiction

Since the discovery of the endocannabinoid system, a growing body of psychiatric research has emerged focusing on the role of this system in major psychiatric disorders like schizophrenia (SCZ), bipolar disorder (BD), major depression and anxiety disorder. Continuing in the line of earlier epidemiological studies, recent replication studies indicate that frequent cannabis use doubles the risk for psychotic symptoms and SCZ. Further points of clinical research interest are alterations of endocannabinoids and their relation to symptoms as well as postmortem analyses of cannabinoid CB(1) receptor densities in SCZ. A possible neurobiological mechanism for the deleterious influence of cannabis use in SCZ has been suggested, involving the disruption of endogenous cannabinoid signaling and functioning. Even though the number of studies is still limited for affective and anxiety disorders, previous results suggest these diseases to be exciting objectives of cannabinoid-associated research. Therefore, it became apparent that cannabis use is not only frequent in patients suffering from BD, but that it also induces manic symptoms in this group. In addition, prior antipsychotic treatment decreased the numerical density of CB(1) immunoreactive glial cells in bipolar patients. Although the data on the influence of cannabis use on the development of major depression is controversial, cannabinoid compounds could display a new class of medication, as suggested by the antidepressive effects of the fatty acid amino hydrolase inhibitor URB597 in animal models. With numerous open questions and controversial results, further research is required to specify and extend the findings in this area, which provides a promising target for novel pharmacotherapeutic interventions.