Case report - Bupropion induced hypomania

Tanvir Singh, MD

Muhammad Rajput, MD

University of Toledo Medical Center,

Dept. Psychiatry, Toledo, Ohio, USA

Antidepressant induced switch episodes of   hypomania/mania can occur in patients with bipolar depression(1).Such switch episodes occur much less commonly in unipolar depression(2).Though all antidepressants have been implicated but Bupropion is one which is suppose to carry much less risk(3-4).Pubmed search revealed no previous case report of Bupropion induced hypomania in unipolar depression.

Contrary to this belief we are presenting a case which highlights Bupropion induced hypomania in a patient of unipolar depression in the true sense.

Miss W is 45 year old female who was seen in our clinic with complaints of depress mood, feeling of anhedonia, impaired concentration, worthlessness, disturbed sleep and appetite for more than a month. Past history was suggestive of chronic depression successfully treated with antidepressants monotherapy. No previous trial of mood stabilizers was reported.  Patient admitted to two previous suicide attempts though denied any current suicidal thoughts. She did not report any previous episode of hypomania/mania. Historically or at the time of assessment there were no delusions or hallucinations. Patient had extensive family history of psychiatric problems. Her biological mother and sister as well all of her children were suffering from unipolar depression. There was no family history of bipolar illness. General physical examination and all relevant lab work including thyroid function were within normal limits. She was diagnosed with Unipolar Depression and started on Bupropion (Wellbutrin XL) 150 mg po once daily.

When seen for follow up visit after three weeks of treatment, patient reported significant improvement in her symptoms of depression. She reported euthymic mood, improvement in concentration, no anhedonia and some improvement in sleep and appetite. Patient reported no side effects from medications. But five weeks after starting Bupropion patient reported elated mood, increased energy level, felt decrease need for sleep, racing thoughts. During assessment patient seem restless and was pacing all around the interview room (psychomotor agitation). Treatment team decided to stop Bupropion.Within few days of discontinuing the antidepressant patient mood reverted back to euthymia. It was obvious that patient had episode of medication induced hypomania. Follow up to this episode patient continue to be treated as unipolar depression only with history of medication induced hypomania.

The reason we decided to write this case report is to emphasize the need for prescribers to maintain high index of suspicion regarding medication induced hypomania even with Bupropion and even when patient has unipolar depression only.

References

1. Kilzeih N, Akiskal H.Rapid-cycling bipolar disorder: An overview of research and clinical experience.Psy Clin North Am 1999; 22; 585-608.
2. Peet M. Induction of mania with selective serotonin reuptake inhibitors and tricyclic antidepressants.Br J Psychiatry 1994; 164:549-50.
3. Sach GS, Lafer B, Stoll AL .A double blind trial of bupropion versus desipramine for bipolar disorder. J Clin Psychiatry 1994; 55:391-393.
4. Hayskal RF, Akiskal HS.Bupropion as a promising approach to rapid cycling bipolar II patients. J.Clin Psychiatry 1990; 51:450-55.

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