Psychosomatics 49:362-a-363, July 2008
doi: 10.1176/appi.psy.49.4.362-a
© 2008 Academy of Psychosomatic Medicine
The Precipitation of Mania by Citalopram in a Patient With Interferon-Induced Depression
Andrew Robert Beckwith, M.D., Dept. of PsychiatryRoyal Adelaide HospitalL4 EHB North Tce.Adelaide, South Australia 5000
Key Words: Depression • Mania • Citalopram • Interferon
TO THE EDITOR: Pegylated interferon alpha (IFN- ) in combination with oral ribavirin has become the standard treatment for hepatitis C infection.1 Unfortunately, IFN-, in its pegylated and unpegylated forms, is associated with significant psychiatric side effects.2,3 Depression is often reported as the most common psychiatric side effect of IFN-,2 although mania and irritability are also well-documented side effects.4 It has become common practice to treat the depression caused by IFN- with antidepressant medication such as the selective serotonin reuptake inhibitors (SSRIs). Anecdotally, clinicians are also prescribing antidepressants prophylactically to prevent the development of depression in response to interferon in psychiatrically well patients. However, antidepressants such as the SSRIs, are not without side effects. SSRIs have been implicated in the precipitation of manic episodes in patients treated for depression.5 Herein described is a case of a patient who developed a manic episode while being treated for depression induced by IFN-.
Case Report
A 33-year-old woman, "Ms. B," was diagnosed with hepatitis C, genotype 3, by her hepatologist and was assessed as suitable for pegylated IFN- and ribavirin treatment. Her main risk factor for contracting hepatitis C was a past history of intravenous heroin dependence, which had been stabilized for a number of years on buprenorphine maintenance therapy. She had no past history of a mood disorder. She was monitored weekly by a registered nurse to assess for side effects of treatment, including psychiatric symptoms.
After 2 months of pegylated IFN- treatment, Ms. B developed symptoms of a major depressive episode (DSM–IV) and was referred for psychiatric management. She also developed concomitant anxiety symptoms, reporting a number of excessive worries about a range of issues, which would, at times, result in significant agitation.
She was treated with citalopram 20 mg for depression and quetiapine 25 mg at night for her anxiety symptoms. After 2 weeks of treatment, she developed a manic episode, with a predominately irritable mood, agitation, flight of ideas, and pressured speech. She had a reduced need for sleep and an increase in goal-directed behavior. Given the worsening of her mental state, she was admitted to the hospital. The citalopram was ceased, and her quetiapine was increased to 150 mg at night. Higher doses of quetiapine were not tolerated because they resulted in oversedation. The IFN- was withheld for 1 week. She responded rapidly to this regimen and was discharged after 5 days.
Ms. B was followed closely as an outpatient and had a weekly psychiatric review. After 1 week, her INF- was recommenced at half the normal dose, because she was eager to continue with treatment. She was maintained successfully on quetiapine 150 mg with acceptable control of her psychiatric symptoms. She continued to experience moderately reduced energy and mild impairment of concentration, but her mood was euthymic, and her appetite and sleep returned to normal. After 1 month, the IFN- was increased to the full dosage, and she completed 6 months of treatment with no adjustment of her quetiapine dose. Twelve months after cessation of IFN- treatment, she continued to experience a sustained virological response. The quetiapine was progressively withdrawn over the 6 weeks after the cessation of IFN-.
Discussion
This case highlights a potentially serious side effect of antidepressant medication in this population of patients, namely, that a manic switch can occur. In most patients treated for depression, a manic switch is a relatively rare event.5 However, patients taking IFN- are already at risk for development of mania caused by to the IFN-. Thus, this group of patients may be at particular risk of a manic switch in response to the addition of antidepressants. Further research is needed to investigate this issue, especially if psychiatrically well patients are to be offered prophylactic antidepressants.
Ms. B’s case raises the possibility that quetiapine may have a role in mood stabilization in patients being treated with IFN-. This is consistent with its role as a potential mood stabilizer in bipolar mood disorder.6 It is noteworthy that the dose used in our patient was relatively low compared with the typical doses used in bipolar mood disorder.
REFERENCES
- Kim AI, Saab S: Treatment of hepatitis C. Am J Med 2005; 118:808–815[CrossRef][Medline]
- Dieperink E, Willenbring M, Ho SB: Neuropsychiatric symptoms associated with hepatitis C and interferon alpha: a review. Am J Psychiatry 2000; 157:867–876[Abstract/Free Full Text]
- Kraus MR, Schäfer A, Csef H, et al: Psychiatric side effects of pegylated interferon alfa-2b as compared to conventional interferon alfa-2b in patients with chronic hepatitis C. World J Gastroenterol 2005; 11:1769–1774[Medline]
- Constant A, Castera L, Dantzer R, et al: Mood alterations during interferon-alfa therapy in patients with chronic hepatitis C: evidence for an overlap between manic/hypomanic and depressive symptoms. J Clin Psychiatry 2005; 66:1050–1057[Medline]
- Peet M: Induction of mania with selective serotonin reuptake inhibitors and tricyclic antidepressants. Br J Psychiatry 1994; 164:549–550[Abstract/Free Full Text]
- Calabrese JR, Keck PE Jr, Macfadden W, et al: A randomized, double-blind, placebo-controlled trial of quetiapine in the treatment of bipolar I or II depression. Am J Psychiatry 2005; 162:1351–1360[Abstract/Free Full Text]
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