Letters to the Editor
Mirtazapine-Induced Shopping Spree
Dear Editor:
Many antidepressants, either alone or in combination, can induce mania. Mirtazapine is a new noradrenergic and specific serotinergic antidepressant that has been associated with mania when used to augment fluoxetine (1) and with hypomania when combined with sertraline (2). Bhanji and others have recently proposed a “norepinephrine syndrome” of dysphoric mania that is based on mirtazapine’s mechanism of action and a constellation of symptoms it likely caused when prescribed at high dosages (3). We report the case of a young woman who went on a shopping spree after mirtazapine was added to paroxetine that was unsuccessful in treating her depression.
Case Report
The patient is a mother of 3, aged 35 years, with a positive family history of unipolar depression. Seven years earlier, she had been diagnosed with postpartum depression that was successfully treated with paroxetine. After stopping the paroxetine, she remained well until recently, when she presented to her family physician with complaints of fatigue, decreased libido, loss of interest, bouts of tearfulness, and panic attacks. Her doctor started her on paroxetine 10 mg daily and subsequently referred her to the local psychiatrist, who confirmed the diagnosis of a major depressive illness and increased her paroxetine gradually to 50 mg daily. Despite the above regimen, she continued to suffer from depression, except for rare good days when she was able to do some of her housework. To relieve the depression, bupropion, olanzapine, and L-tryptophan were separately added to the paroxetine, but with little success.
After stopping the above 3 agents because they failed to boost the antidepressant effect of paroxetine, her psychiatrist added mirtazapine to her treatment. The dosage was gradually increased to 45 mg daily, and she took the combination for 8 weeks. Around this time, the patient was referred to the Mood Disorder Service for consultation. She reported that she had become irritable and impulsive. She described herself as easily “snapping” at people. Her energy had increased and she had started binge eating for the first time. Most dramatically, she began to make large purchases; for example, she bought 10 T-shirts and 5 pairs of shorts for her children, 5 pairs of pants and 8 pairs of shorts for herself, and magnifying glasses for many of the neighbourhood children. Her husband had to return all these items.
Mirtazapine-induced hypomania was recognized, the mirtazapine was discontinued, and the shopping sprees ceased soon thereafter. The remaining hypomanic symptoms also subsided later. However, the patient experienced depression. Her mood has stabilized with the addition of lithium carbonate.
Conclusion
The sudden episode of excessive and inappropriate spending resolved promptly when the offending agent, mirtazapine, was discontinued. We believe this is the first case of a shopping spree that was precipitated by the addition of mirtazapine to paroxetine when the latter failed to treat depressive symptoms.
References
1. Ng B. Mania associated with mirtazapine augmentation of fluoxetine. Depress Anxiety 2002;15:46–7.
2. Soutullo CA, McElroy SL, Keck PE. Hypomania associated with mirtazapine augmentation of sertraline. J Clin Psychiatry 1998;59:320.
3. Bhanji NH, Margolese HC, Saint-Laurent M, Chouinard G. Dysphoric mania induced by high dose mirtazapine: a case for “norepinephrine syndrome.” Int Clin Psychopharmacol 2002;17:319–22.
Eric Prost, MD
Gaby Abraham, MD, FRCPC
Kingston, Ontario
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