Letters to the Editor
Venlafaxine-Induced Mania
Dear Editor:
In bipolar disorders, the shift to mania as a result of using antidepressants constitutes a great trouble for clinicians. It has been known for a long time that tricyclic antidepressants, monoamine oxidase inhibitors, selective serotonin reuptake inhibitors, and even bupropion can cause mania or hypomania (1,2). In clinical studies, venlafaxine, which acts through the blockage of serotonergic or noradrenergic receptors, proved to be an efficient, reliable, and rapidly effective drug that could be used without any problem to treat bipolar depression (3). The literature reveals only a few cases of venlafaxine-induced mania and hypomania (5,7). However, in the case we report, the treatment dosage of venlafaxine resulted in mania.
Mr F, aged 38 years, had a diagnosis of bipolar disorder followed in different centres for 16 years. Within this period, he experienced 2 manic and 2 hypomanic attacks. Two years prior to this report, he was taking lithium 1200 mg daily for prophylaxis but gave up taking the drug because he felt healthy. Approximately 1 month before presenting, he began to feel valueless and bad, without any reason. He did not want to do anything, slept all day, and never spoke. He had frequent thoughts that suicide would solve all his troubles but felt it was something he could not do. His appetite decreased, and he lost 4 to 5 kg within this period. Owing to these problems, he was admitted to an outpatient clinic. A general practitioner prescribed venflaxine 75 mg daily. After 10 days, his sleep gradually began to decrease, and he started to speak excessively. He was feeling euphoric. He asserted that he was very handsome and enjoyed aggressive and angry behaviours. He was immediately taken to our emergency service and hospitalized with the diagnosis of bipolar disorder, manic episode. After his relatives provided a history, venlafaxine was stopped, and haloperidol and carbamazepine as a mood stabilizer were prescribed. His clinical picture improved rapidly within the first few days. He stayed in our clinic for a week and was then discharged from the hospital. Thereafter, he and his relatives were informed about the clinical presentation and prodromal symptoms of mania and depression.
The elimination of mania symptoms shortly after stopping antidepressant treatment suggests that venlafaxine could have caused the development of mania. Of course, it is also possible that the patient’s nonuse of a mood stabilizer while using an antidepressant may have led to the development of mania. It is not clear whether these shifts depend on the antidepressant dosage and on the length of use. The literature contains contradictory reports regarding this issue (5–7). In our case, the manic shift was experienced as a result of venlafaxine 75 mg daily taken for only 10 days.
It should be remembered that it is necessary to get detailed information about every patient applying for depression treatment. The risk of bipolar disorder is especially high in early-onset acute depression, chronic depression, and seasonal pattern depression, as well as in patients suffering from hyperthymic–cyclothymic temperament and in those having a family history of bipolar disorder. These patients should be followed closely during the first stage of treatment (8). What really constitutes a great trouble for us is the treatment of a bipolar depressive episode, as in our case. For these patients, mood stabilizers should be given; if the patient already uses mood stabilizers, their dosage should be increased. If the treatment fails, antidepressant treatment may be applied, but the patient should be followed regularly at short time intervals (9).
References
1. Peet M. Induction of mania with selective serotonin re-uptake inhibitors and tricyclic antidepressants. Br J Psychiatry 1994;164:549–50.
2. Wehr TA, Goodwin FK. Can antidepressants cause mania and worsen the course of affective illness? Am J Psychiatry 1987;144:1403–11.
3. Wilson R, Jenkins P. Suspected complications of treatment with venlafaxine. J Clin Psychopharmacol 1997;17:323.
4. Amsterdam J. Efficacy and safety of venlafaxine in the treatment of bipolar II major depressive episode. J Clin Psychopharmacol 1998;18:414–7.
5. Stoner SC, Williams RJ, Worrel J, Ramlatchman L. Possible venlafaxine-induced mania. J Clin Psychopharmacol 1999;19:184–5.
6. Gupta N. Venlafaxine-induced hypomanic switch in bipolar depression. Can J Psychiatry 2001;46:760–1.
7. Shulman RB, Scheftner WA, Nayudu S. Venlafaxine-Associated Mania. J Clin Psychopharmacol 2001;21:239–41.
8. Akiskal HS, Walker PW, Puzantian VR, King D, Rosenthal TL, Dranon M. Bipolar outcome in the course of depressive illness: phenomenologic, familial and pharmacologic predictors. J Affect Disord 1983;5:115–28.
9. American Psychiatric Association. Practice guideline for the treatment of patients with bipolar disorder. Am J Psychiatry 1994;151(Suppl 12):1–36.
Fatih Volkan Yuksel, MD
Ayse Devrim Basterzi, MD
Erol Goka, MD
Ankara, Turkey
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