Antidepressant-associated mania: soon after switch from fluoxetine to mirtazapine in an elderly woman with mixed depressive features

Abstract

Mirtazapine augmentation to a serotonin-reuptake inhibitor has been proposed to boost antidepressant effects and more likely to induce manic switch. Such a combined antidepressant therapy strategy should be used carefully if the patient's refractoriness is attributable to mixed depressive features. Mixed depression is more difficult to be treated by antidepressant monotherapy and related to higher risk of manic switch during treatment. We report a case with no previous history of bipolar disorder, whereas developed full-blown psychotic manic symptoms soon after switch from fluoxetine to mirtazapine. The patient's premorbid characters and clinical presentations suggested an implicit bipolarity that predisposed her to a manic switch. Her manic switch was likely to be triggered by a simulated combined effect because of complex drug interactions during shifting from fluoxetine to mirtazapine. For patients in mixed depressive states, mood stabilizers are preferable to antidepressants.

Mania Associated with Mirtazepine Treatment and Mixed Depression

“…Other case reports already identifi ed some risk factors for the mirtazepine-associated switch to mania like doses higher than 45 mg [1] , combined treatment with SSRI [8] or organic origin of depressive symptoms [2] . Currently only one mirtazepine-associated case of a switch to mania in mixed depression was reported [6] . In contrast to that case, our patient was previously not treated with an SSRI before medication was changed to mirtazepine.…”

“…The 27-year-old male (1.71 m, BMI 23.2 kg / m 2 ) was admitted to our hospital due to a fi rst psychotic episode with formal thought disturbances, acoustic hallucinations and persecutory delusions fulfi lling the ICD-10 criteria of paranoid-hallucinatory schizophrenia. Psychometric testing revealed a PANSS (positive and negative syndrome scale) score of 115 (24 pos / 33 neg / 58 GP) which benefi ted signifi cantly from aripiprazole, a partial dopamine and serotonine receptor agonist [6] at 35 mg / day (serum level: 752 μ g / L) over a period of 7 weeks [PANSS: 10 pos / 24 neg / 45 GP; SANS (scale for the assessment of negative symptoms) score: 76]. The patient developed a post-psychotic MDE with depressed mood, psychomotor inhibition, feelings of inferiority and guilt as well as suicidal ideations correlated by a HAMD 21 (Hamilton depression scale) score of 19 and a CDSS (Calgary depression scale for schizophrenia) score of 17.…”

Akute Psychose nach Konsum von synthetischen Cannabinoiden

“…In Einzelfallberichten ist eine Induktion von manischen Symptomen nach Einnahme von schlaffördernden Antidepressiva wie Mirtazapin beschrieben worden [26,27]. Das Switch-Risiko ist jedoch stark von der angewendeten Dosierung und der Begleitmedikation abhängig [28,29]. Der Patient im vorliegenden Fall hatte keine Begleitmedikation, auch verneinte er mehr Mirtazapin als verordnet eingenommen zu haben.…”

Low Risk for Switch to Mania during Treatment with Sleep Promoting Antidepressants

“…3 of those patients were treated in monotherapy with the antidepressant dose ( ≥ 30 mg/day) of mirtazapine [24][25][26]. One of those patients may have been at higher risk of switching, because she was an older patient and the treatment with mirtazapine was started without a period of washout from fluoxetine (20 mg/ day) [26]. In 2 further patients, treatment with antidepressant dose of mirtazapine was combined with treatment using SSRIs [27,28].…”