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Mania and hypomania with olanzapine use
European Psychiatry 19 (2004) 175–176 www.elsevier.com/locate/eurpsy
Case report
Mania and hypomania with olanzapine use Asena Akdemir *, Hakan Türkçapar, Sibel Örsel SSK Ankara Residency Training Hospital, Adakale Sok 22/16, Kızılay Ankara, Turkey Available online 20 April 2004
1. Introduction It is known that many drugs used in psychiatry, mainly the antidepressants, may cause manic symptoms [5]. Publications on similar effects of atypical antipsychotics recently used in the treatment of schizophrenia and bipolar disorders have also increased [2]. Olanzapine, after getting an approval from FDA in the treatment of schizophrenia in 1996, got an approval for use in bipolar manic attacks, [4]. Together with the publications about the anti-depressant effect, publications on mania-like symptoms occurring during the atypical antipsychotic use have also been issued [3–6]. In this case report, in addition to the individual cases published up to date, cases in our own clinic treated by olanzapine and who had mania or hypomania-like symptoms will be reviewed. 2. Case 1 SD. Female, 33 years old, married, one child, housewife, graduate of high school. Diagnosed as paranoid schizophrenia and having no manic episode before or familial psychiatric disorder. Olanzapine dose was started 10 mg per day when she wanted to quit the drug because its side effects after using of classical antipsychotics for 10 years. During her visits in the second week, a manic picture was considered, with her and her family’s consent, she was convinced to stop the drug and a different drug was started. She is still on antipsychotic treatment (Risperidon 6 mg/day, Biperiden 4 mg/day). Manic symptoms improved, paranoid symptoms alleviated; however, complete recovery could not be achieved. 3. Case 2 AÜ. Male, 36 years old, married, two children, graduate of primary school, retired due to disability. Diagnosed as para* Corresponding author. E-mail address: [email protected] (A. Akdemir). © 2004 Elsevier SAS. All rights reserved. doi:10.1016/j.eurpsy.2003.12.003
noid schizophrenia, having no manic episode and had a familial history of schizophrenia. He has been treated with antipsychotics and anticholinergic drugs (biperiden) and hospitalized three times since he was 17. He has been hospitalized because of hallucinations, aggression and olanzapine started 10 mg per day. As of the third day, his actions in the clinic increased, by increasing the dose of olanzapine to 15 mg/day, there was no improvement in his excessive actions, excessive talking and sleep disorder. Due to the compliance problems in drug monitoring, zuklopentixol was given intramuscularly. Still, the same drug is being given bimonthly with partial remission. 4. Case 3 IZ. Male, 18 years old, graduate of primary school, single, worker, having no psychiatric disease history in the family. He has been treated for schizophrenia since he was 13. Upon worsening of his complaints, he was hospitalized for the first time and 10 mg/day olanzapine was started. Since there was no response, the dose was increased to 20 mg/day. After that, the patient became more active and talkative and dysphoria developed, impulse control and sleep duration decreased. His recalls were disjointed and had bizarre behavior. Olanzapine was reduced to 15 mg and 5 mg haloperidol was added. At this dose, the increase in his actions and talking and his dysphoria decreased much. He is still being monitored. 5. Case 4 AC, 24 years old, male, single, worker however he is not working for 1 year. No psychiatric disease history in the family. He has been treated for disorganized schizophrenia using haloperidol 15 mg/day, biperiden 6 mg/day since he was 15. Olanzapine was added because of an acute psychotic attack. However, in 3 weeks, there was an excessive increase in self-respect, he was more talkative, cheerful than ever. However he is able to work, his family mentions that his current situation is much bearable than before. He is not
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A. Akdemir et al. / European Psychiatry 19 (2004) 175–176
being treated for his hypomania, he is coming for regular checks.
6. Case 5 ZD. Male, 33 years old, has been studying Business Administration in Open University. He has been under pharmacological treatment with the diagnosis of paranoid schizophrenia since he was 23 and having a familial history of schizophrenia. Since he did not like giving blood regularly for clozapine treatment, Olanzapin was started 10 mg/day. In regular visits, it was noticed that he was more cheerful, he said that he could study and did not feel sick. Though he was dismissed from school for two times, he was saying that he would get a master’s degree, that he would be very successful in business administration. By the way his mother did not complain saying that “my son is strange but he is very happy, I cannot do anything, this is the first in his life”. He is still being monitored. The drug has not been changed.
have occurred in its natural course. A third possible explanation might be that the olanzapine itself might have formed the manic picture in patients. If these symptoms have a causal relationship with olanzapine use, two explanations related to each other may be discussed: (1) olanzapine has an antidepressant feature and creates a manic inclination like the other antidepressants or (2) olanzapine improves the mood of the patient by its anti-depressant effect and this improvement is in the form of hypomania or mania-like picture in some patients. This supports the possibility that while olanzapin removes the depressive symptoms in patients with its antidepressant effect, it might create a picture that mimics mania-hypomania. It has been suggested that the higher affinity of olanzapine to 5HT2 receptors, not only improves the negative symptoms of schizophrenia but it is also responsible for the antidepressant activity of the drug [3]. However, in order to answer such questions and to establish a causal relationship, controlled studies, in which depression and mania symptoms of patients are followed by related scales, are required. References
7. Discussion In recent years, it is found out that mania and hypomania cases induced by two new atypical antipsychotics in the literature, olanzapine and risperidone. Aubry et al. [1] have critically approached the case reports suggesting that these two antipsychotics have an effect on mood, however further studies are required to understand the underlying mechanism of this effect. The first possible explanation of this picture occurring in patients is that, this might be a coincidental case rather than due to the use of drugs. Another possibility is that, an affective disorder of the patient, which has not occurred until then, may be stimulated with the use of drugs or it might
[1]
[2]
[3]
[4] [5] [6]
Aubry JM, Smon AE, Brtschy G. Possible induction of mania and hypomania by olanzapine or risperidone: a critical review of reported cases. J Clin Psychiatry 2000;61(9):649–55. Dwight MM, Keck PE, Stanton SP. Antidepressant activity and mania associated with risperidone treatment of schizoaffective disorder. Lancet 1994;344:554–5. Ghaemi SN, Cherry EL, Katzow JA, Goodwin FK. Does olanzapine have antidepressant properties? A retrospective preliminary study. Bipolar Disord 2000;2(3 Pt 1):196–9. Goodnick PJ, Barrios CA. Use of olanzapine in non-psychotic psychiatric disorders. Expert Opin Pharmacother 2001;2:667–80. Krauthammer C, Klerman G. Secondary mania. Arch Gen Psychiatry 1978;35:1333–9. Narayan G, Puranik A. Olanzapin-induced mania. Int J Psychiatry Clin Practice 2000;4:333–4.
Case report
Mania and hypomania with olanzapine use Asena Akdemir *, Hakan Türkçapar, Sibel Örsel SSK Ankara Residency Training Hospital, Adakale Sok 22/16, Kızılay Ankara, Turkey Available online 20 April 2004
1. Introduction It is known that many drugs used in psychiatry, mainly the antidepressants, may cause manic symptoms [5]. Publications on similar effects of atypical antipsychotics recently used in the treatment of schizophrenia and bipolar disorders have also increased [2]. Olanzapine, after getting an approval from FDA in the treatment of schizophrenia in 1996, got an approval for use in bipolar manic attacks, [4]. Together with the publications about the anti-depressant effect, publications on mania-like symptoms occurring during the atypical antipsychotic use have also been issued [3–6]. In this case report, in addition to the individual cases published up to date, cases in our own clinic treated by olanzapine and who had mania or hypomania-like symptoms will be reviewed. 2. Case 1 SD. Female, 33 years old, married, one child, housewife, graduate of high school. Diagnosed as paranoid schizophrenia and having no manic episode before or familial psychiatric disorder. Olanzapine dose was started 10 mg per day when she wanted to quit the drug because its side effects after using of classical antipsychotics for 10 years. During her visits in the second week, a manic picture was considered, with her and her family’s consent, she was convinced to stop the drug and a different drug was started. She is still on antipsychotic treatment (Risperidon 6 mg/day, Biperiden 4 mg/day). Manic symptoms improved, paranoid symptoms alleviated; however, complete recovery could not be achieved. 3. Case 2 AÜ. Male, 36 years old, married, two children, graduate of primary school, retired due to disability. Diagnosed as para* Corresponding author. E-mail address: [email protected] (A. Akdemir). © 2004 Elsevier SAS. All rights reserved. doi:10.1016/j.eurpsy.2003.12.003
noid schizophrenia, having no manic episode and had a familial history of schizophrenia. He has been treated with antipsychotics and anticholinergic drugs (biperiden) and hospitalized three times since he was 17. He has been hospitalized because of hallucinations, aggression and olanzapine started 10 mg per day. As of the third day, his actions in the clinic increased, by increasing the dose of olanzapine to 15 mg/day, there was no improvement in his excessive actions, excessive talking and sleep disorder. Due to the compliance problems in drug monitoring, zuklopentixol was given intramuscularly. Still, the same drug is being given bimonthly with partial remission. 4. Case 3 IZ. Male, 18 years old, graduate of primary school, single, worker, having no psychiatric disease history in the family. He has been treated for schizophrenia since he was 13. Upon worsening of his complaints, he was hospitalized for the first time and 10 mg/day olanzapine was started. Since there was no response, the dose was increased to 20 mg/day. After that, the patient became more active and talkative and dysphoria developed, impulse control and sleep duration decreased. His recalls were disjointed and had bizarre behavior. Olanzapine was reduced to 15 mg and 5 mg haloperidol was added. At this dose, the increase in his actions and talking and his dysphoria decreased much. He is still being monitored. 5. Case 4 AC, 24 years old, male, single, worker however he is not working for 1 year. No psychiatric disease history in the family. He has been treated for disorganized schizophrenia using haloperidol 15 mg/day, biperiden 6 mg/day since he was 15. Olanzapine was added because of an acute psychotic attack. However, in 3 weeks, there was an excessive increase in self-respect, he was more talkative, cheerful than ever. However he is able to work, his family mentions that his current situation is much bearable than before. He is not
176
A. Akdemir et al. / European Psychiatry 19 (2004) 175–176
being treated for his hypomania, he is coming for regular checks.
6. Case 5 ZD. Male, 33 years old, has been studying Business Administration in Open University. He has been under pharmacological treatment with the diagnosis of paranoid schizophrenia since he was 23 and having a familial history of schizophrenia. Since he did not like giving blood regularly for clozapine treatment, Olanzapin was started 10 mg/day. In regular visits, it was noticed that he was more cheerful, he said that he could study and did not feel sick. Though he was dismissed from school for two times, he was saying that he would get a master’s degree, that he would be very successful in business administration. By the way his mother did not complain saying that “my son is strange but he is very happy, I cannot do anything, this is the first in his life”. He is still being monitored. The drug has not been changed.
have occurred in its natural course. A third possible explanation might be that the olanzapine itself might have formed the manic picture in patients. If these symptoms have a causal relationship with olanzapine use, two explanations related to each other may be discussed: (1) olanzapine has an antidepressant feature and creates a manic inclination like the other antidepressants or (2) olanzapine improves the mood of the patient by its anti-depressant effect and this improvement is in the form of hypomania or mania-like picture in some patients. This supports the possibility that while olanzapin removes the depressive symptoms in patients with its antidepressant effect, it might create a picture that mimics mania-hypomania. It has been suggested that the higher affinity of olanzapine to 5HT2 receptors, not only improves the negative symptoms of schizophrenia but it is also responsible for the antidepressant activity of the drug [3]. However, in order to answer such questions and to establish a causal relationship, controlled studies, in which depression and mania symptoms of patients are followed by related scales, are required. References
7. Discussion In recent years, it is found out that mania and hypomania cases induced by two new atypical antipsychotics in the literature, olanzapine and risperidone. Aubry et al. [1] have critically approached the case reports suggesting that these two antipsychotics have an effect on mood, however further studies are required to understand the underlying mechanism of this effect. The first possible explanation of this picture occurring in patients is that, this might be a coincidental case rather than due to the use of drugs. Another possibility is that, an affective disorder of the patient, which has not occurred until then, may be stimulated with the use of drugs or it might
[1]
[2]
[3]
[4] [5] [6]
Aubry JM, Smon AE, Brtschy G. Possible induction of mania and hypomania by olanzapine or risperidone: a critical review of reported cases. J Clin Psychiatry 2000;61(9):649–55. Dwight MM, Keck PE, Stanton SP. Antidepressant activity and mania associated with risperidone treatment of schizoaffective disorder. Lancet 1994;344:554–5. Ghaemi SN, Cherry EL, Katzow JA, Goodwin FK. Does olanzapine have antidepressant properties? A retrospective preliminary study. Bipolar Disord 2000;2(3 Pt 1):196–9. Goodnick PJ, Barrios CA. Use of olanzapine in non-psychotic psychiatric disorders. Expert Opin Pharmacother 2001;2:667–80. Krauthammer C, Klerman G. Secondary mania. Arch Gen Psychiatry 1978;35:1333–9. Narayan G, Puranik A. Olanzapin-induced mania. Int J Psychiatry Clin Practice 2000;4:333–4.