Letters to the Editor
Topiramate-Induced Suicidality
Dear Editor:
Topiramate is a novel antiepileptic medication used as an adjunctive mood stabilizer in some patients with bipolar disorder (BD) (1). Its association with appetite suppression and weight loss makes it appealing both to patients and to clinicians. Even though topiramate has been reported to be safe, psychiatric side effects in neurology (2) and BD (3) patients warrant caution. I describe a case of severe suicidal symptoms associated with topiramate in a BD patient.
Case Report
Ms Y, aged 41 years, has a 7-year history of BD. For the first 5 years, she did well on lithium carbonate. However, lithium was discontinued owing to intolerable dermatological conditions. She was taking carbamazepine 400 mg twice daily and levothyroxine 0.15 mg daily (for hypothyroidism) when topiramate was added as an adjuvant mood stabilizer and because of weight gain. The topiramate dosage was gradually increased to 50 mg 3 times daily. A few weeks after she had begun the 150-mg daily dosage of topiramate, Ms Y noticed the onset of sudden and severe suicidal symptoms. She had made her will and started putting her life in order, when her husband suspected a serious problem and brought her to our attention. She was obviously suffering from depression and admitted to planning to take her life. Topiramate was the only medication recently increased, and we were aware of its association with psychiatric symptoms. It was therefore stopped immediately, and Ms Y was closely monitored. Within a week, her mood stabilized: she become euthymic, and her suicidal symptoms cleared completely.
Among obese subjects with BD, the weight loss potential of topiramate may be beneficial and significant (4,5). Side effects, such as sedation, nausea, headache, dizziness, and cognitive effects, have been reported in 82% of BD patients taking topiramate, with 36% discontinuing treatment because of side effects (5). Topiramate has also been associated with development of depressive and psychotic symptoms in patients with epilepsy and BD (2,6).
To my knowledge, this is the first report of severe suicidality associated with topiramate use in a patient with BD. Depression and suicidality are common features of mood disorder patients; however, the close temporal relation of new-onset suicidal symptoms and the addition of topiramate, together with the speedy resolution after its discontinuation, highlight a possible relation between topiramate and the suicidal behaviour.
Topiramate has some usefulness in the management of psychiatric illness, especially when there is associated obesity. Nevertheless, clinicians should be aware that topiramate may be associated with the development of serious psychiatric symptoms, including severe suicidality, through a poorly understood mechanism that may involve multiple neurotransmitters.
References
1. McElroy SL, Suppes T, Keck PE, Frye MA, Denicoff KD, Altshuler LL, and others. Open-label adjunctive topiramate in the treatment of bipolar disorders. Biol Psychiatry 2000;47:1025–33.
2. Khan A, Faught E, Gilliam F, Kuzniecky R. Acute psychotic symptoms induced by topiramate. Seizure 1999;8:235–7.
3. Klufas A, Thompson D. Topiramate-induced depression. J Clin Psychiatry 2001;62:653.
4. Chengappa KN, Rathore D, Levine J, Atzert R, Solai L, Parepally H, and others. Topiramate as add-on treatment for patients with bipolar mania. Bipolar Disord 1999;1:42–53.
5. Ghaemi SN, Manwani SG, Katzow JJ, Goodwin FK. Topiramate treatment of bipolar spectrum disorders: a retrospective chart review. Ann Clin Psychiatry 2001;13:185–9.
6. Andrade C. Confusion and dysphoria with low-dose topiramate in a patient with bipolar disorder. Bipolar Disord 2001;3:211–2.
G Abraham, MD, FRCPC
Kingston, Ontario
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