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Editorial
Canadian Journal of Psychiatry: New Editor and New Policies
Joel Paris, MD
(PDF)

Guest Editorial
Risk Assessment in Psychiatric Practice
Kenneth Hashman, MD, FRCPC, DABPN
(PDF)

In Review
The Canadian Contribution to Violence Risk Assessment: History and Implications for Current Psychiatric Practice
Hy Bloom, LLB, MD, Christopher Webster, PhD, Stephen Hucker, MB, Karen De Freitas, MD
(PDF)

The Clinical Use of Risk Assessment
Graham D Glancy, MB, ChB, FRCPsych, FRCPC, Gary Chaimowitz, MB, ChB, FRCPC
(PDF)

The State of Contemporary Risk Assessment Research
Michael A Norko, MD, Madelon V Baranoski, PhD
(PDF)

Review Paper
Community Treatment Orders: Profile of a Canadian Experience
Ann-Marie A O’Brien, MSW, RSW, Susan J Farrell, PhD, CPsych*
(PDF)

International Dosage Differences in Fluoxetine Clinical Trials
Scott Patten, MD, Andrea Cipriani, MD, Paolo Brambilla, MD3, Michela Nosè, MD, Corrado Barbui, MD
(PDF)

Original Research
Panic-Agoraphobic Spectrum and Light Sensitivity in a General Population Sample in Italy
Letizia Bossini, MD, Mirko Martinucci, MD, Katia Paolini, MD, Paolo Castrogiovanni, MD
(PDF)

Psychotic Disorders Clinic and First-Episode Psychosis: A Program Evaluation
Suzanne Archie, MD, FRCPC, Jane Hamilton Wilson, RN, Kevin Woodward, BSc, Heather Hobbs, RN, Shelley Osborne, RN, Jean McNiven, RN
(PDF)

Screening for Mild Cognitive Impairment: Comparing the SMMSE and the ABCS
D William Molloy, MB, MRCPI, FRCPC, Timothy IM Standish, David L Lewis, PhD
(PDF)

Attention-Deficit Hyperactivity Disorder With and Without Obsessive–Compulsive Behaviours: Clinical Characteristics, Cognitive Assessment, and Risk Factors
Paul Daniel Arnold, MD, FRCPC, Abel Ickowicz, MD, FRCPC, Shirley Chen, MD, MPH, Russell Schachar, MD, FRCPC
(PDF)

Brief Communication
Validation de la version française de l’inventaire de détresse péritraumatique
Louis Jehel, MD, PhD, Alain Brunet, PhD, Sabrina Paterniti, MD, PhD, Julien D Guelfi, MD, Pr
(PDF)

Book Reviews
(PDF)

The Confinement of the Insane: International Perspectives, 1800–1965
Review by
Laurence Jerome, MD

Suicide in Children and Adolescents
Review by
Paul S Links, MD, FRCPC

Letters to the Editor
(PDF)

A Novel Form of Treatment Resistance in Anorexia Nervosa

Capgras Syndrome in the Modern Era: Self Misidentification on an ID Picture

Effectiveness of Risperidone in Delirium

Family-Oriented Rehabilitation for Unexplained Chronic Pain

Hypokalemia from Risperidone and Quetiapine Overdose

A Renewed Interest in Day Treatment

Quetiapine Therapy for Corticosteroid-Induced Mania

Letters to the Editor

Quetiapine Therapy for Corticosteroid-Induced Mania

Dear Editor: Corticosteroids are routinely used for immunosuppression in patients who have received liver transplants (1). Mood symptoms and psychosis have long been documented as potential adverse effects of corticosteroid treatment (2). We report a case of corticosteroid-induced mania that followed a liver transplant and that resolved with quetiapine therapy.

A white man, aged 52 years, was admitted for a liver transplant. The donor was his biological brother. Approximately 5 years previously, he had been diagnosed with hepatitis B and hepatitis C. He had no psychiatric history; however, his daughter had been diagnosed with bipolar disorder. After the transplant, the patient was given methyl-prednisolone 50 mg intravenously every 6 hours (4 doses) and then 40 mg intravenously for an additional 4 doses. Cumulatively, he received more than 250 mg of steroids before the onset of behavioural symptoms.

On postoperative day 3, psychiatry was consulted because he was talking incessantly, preoccupied with hyperreligious themes, and making hypersexual comments. He claimed that he was a prophet and that he could speak different languages; his speech contained numerous neologisms. He was grandiose and claimed to posses spiritual powers that enabled him to “sense different pleasant odours.” He refused to divulge his name for “security reasons.” He had not slept for the last 2 days. He was not physically aggressive or agitated. The Young Mania Rating Scale (YMRS, 3) was used to assess symptom severity; his total score was 31, indicative of mania.

On a mental status examination, he was poorly groomed and disrobed repeatedly, but he was awake, alert, cooperative, and oriented as to place, person, and time. He displayed pressure of speech and rambling speech with incoherent narration, neologisms, and loose associations. His mood was significantly elevated and euphoric. His thought content revealed grandiose delusions, ideas of reference, and hyperreligious themes. His attention, concentration, insight, and judgment were poor.

The presumptive diagnosis was steroid-induced mania. A CT scan of the head on postoperative day 3 was unremarkable. He had a benign neurological examination; there was no evidence of infection; and laboratory values were within normal limits. The patient was started on quetiapine 25 mg at bedtime and 12.5 mg as needed twice daily. Within 10 hours of quetiapine therapy, his mental status gradually improved. His YMRS score was less than 5 at discharge. His thought process and concentration improved significantly. He recognized that he had experienced changes in his behaviour and apologized to the staff. His sleep normalized, and he was discharged on the fifth day after his transplant. His tacrolimus level ranged from 21 to 20 by the time of discharge. His medications at discharge included acylovir, prednisone 20 mg daily, and quetiapine 25 mg daily. The patient’s symptoms of mania did not recur, nor were there symptoms of depression during the subsequent 3 months. At the last follow-up visit, the results of his mental status examination were normal.

To our knowledge, this is the first case report of quetiapine use in treating steroid-induced mania in a transplant patient. This patient was given quetiapine for several reasons. It has antimanic and mood-stabilizing properties (4), as well as sedative properties. Its relatively short half-life and transient dopamine D2 receptor binding are also to be considered in treating transplant and other patients with complex medical problems. Additionally, quetiapine may be administered frequently as needed for agitation and aggression. Interestingly, while this patient did not have any psychiatric history, he might have been vulnerable for developing mania, owing to his positive family history; possibly, he had an undiagnosed or subsyndromal bipolar disorder that was unmasked or exacerbated by steroids.

We conclude that quetiapine is a useful medication to consider for patients with steroid-induced mania. Its prophylactic use might be considered for patients at risk of developing a manic syndrome with steroids.

References

1. Washburn K, Speeg KV, Esterl R, Cigarroa F, Pollack M, Tourtellot C, and others. Steroid elimination 24 hours after liver transplantation using daclizumab, tacrolimus, and mycophenolate mofetil. Transplantation 2001;72:1675–9.

2. Wada K, Yamada N, Suzuki H, Lee Y, Kuroda S. Recurrent cases of corticosteroid-induced mood disorder: clinical characteristics and treatment. J Clin Psychiatry 2000;61:261–7.

3. Young RC, Biggs JT, Ziegler VE, Meyer DA. A rating scale for mania: reliability, validity and sensitivity. Br J Psychiatry 1978;133:429–35.

4. Altamura AC, Salvadori D, Madaro D, Santini A, Mundo E. Efficacy and tolerability of quetiapine in the treatment of bipolar disorder: preliminary evidence from a 12-month open-label study. J Affect Disord 2003;76:267–71.

Zakaria Siddiqui, MD
Sriram Ramaswamy, MD
Frederick Petty, MD
Omaha, Nebraska