1764 – Case report: antidepressant withdrawal mania

Abstract

Introduction Antidepressant withdrawal mania is a rare paradoxical event. It was initially reported in unipolar patients but it can also occur in bipolar patients, despite adequate mood-stabilizing treatment. It has been described with all antidepressant classes and may be self-limited or require medical hospitalization. Tapered withdrawal doesn’t seem to prevent the condition, though most reported cases developed after abrupt antidepressant discontinuation. Chronic antidepressant therapy enhances dopaminergic neurotransmission in the mesolimbic system. Noradrenergic hyperactivity and cholinergic overdrive secondary to antidepressant cessation are the most accepted theoretical mechanisms proposed. Objectives Case report, discussion and literature review. Aims We report a case of fluoxetine withdrawal mania and discuss its implications on clinical practice. Methods Case report and non systematic literature review. Results We present a case of a divorced 59-year-old woman who developed a manic episode shortly after antidepressant discontinuation. She was under antidepressant therapy since 2001, due to an unipolar chronic depressive disorder. She was put on fluoxetine 20 mg q.d. since 2005. On May 2012, she discontinued the antidepressant therapy upon misunderstanding medical advice. Few weeks later, she was involuntarily admitted to our inpatient unit presenting a manic episode with psychotic features. She started valproic acid 1000 mg q.d. and risperidone 4 mg q.d. and a complete remission was quickly obtained. Conclusions This case illustrates the potential for mania related to antidepressant discontinuation. Differential diagnosis includes spontaneous mania, antidepressant withdrawal syndrome and antidepressant induced mania. Finally, the authors discuss the adequacy of categorizing this entity in bipolar spectrum disorders.