Mania, psychoses associated with

The catecholamine hypothesis of mood disorders suggests that increased DA and norepinephrine (NE) activity contribute to hyperactivity and psychosis associated with the severe stages of mania, and reduced activity causes depression. A y-aminobutyric acid (GABA) deficiency theory has been proposed for mania since it inhibits NE and DA activity. Glutamate and aspartate, excitatory amino... 

In clinical psychiatric terms, the affective disorders can be subdivided into unipolar and bipolar disorders. Unipolar depression is also known as psychotic depression, endogenous depression, idiopathic depression and major depressive disorder. Bipolar disorder is now recognised as being heterogeneous bipolar disorder I is equivalent to classical manic depressive psychosis, or manic depression, while bipolar disorder II is depression with hypomania (Dean, 2002). Unipolar mania is where periods of mania alternate with periods of more normal moods. Seasonal affective disorder (SAD) refers to depression with its onset most commonly in winter, followed by a gradual remission in spring. Some milder forms of severe depression, often those with an identifiable cause, may be referred to as reactive or neurotic depression. Secondary depression is associated with other illnesses, such as neuro-degenerative or cardiovascular diseases, and is relatively common. 

Hypocalcemia has been associated with causing anxiety, mood irritability, mania, psychosis, and delirium. 

Both typical and atypical antipsychotics are effective in approximately 70% of patients with acute mania associated with agitation, aggression, and psychosis, and atypical antipsychotics are better tolerated. 

The hypnogram of a patient with an underlying psychiatric illness may be characterized by a delay in sleep onset, the presence of residual muscular activity causing frequent awakenings, fragmented sleep, reduced REM and slow-wave sleep, and day-time drowsiness. Such disorders are generally not associated with a recent or transient event and the cause cannot usually be identified. Often such changes in the sleep architecture are associated with major psychiatric disorders such as depression, mania, psychosis or severe anxiety states. 

Venlafaxine (Effexor), approved by the FDA in December 1993, was described in more detail early in this chapter. It is one of the newer antidepressants implicated in causing suicidality. It is a NSRI that also strongly inhibits the reuptake of epinephrine. Its profile is very similar to the SSRIs in producing stimulation, including anxiety, nervousness, insomnia, anorexia, and weight loss. It causes the various emotional and behavioral abnormalities that go along with stimulation, such as agitation and mania, and has been associated with hostility, paranoid reaction, psychotic depression, and psychosis. It can cause hypertension. 

The FDA provided a summary of 52 adverse psychiatric reactions reported over the prior year for Concerta and Ritalin, including cases of overstimulation (agitation and mania), depression, psychosis, aggression and violence, and suicidal behavior (FDA, 2006b). Notice the similarity to the dangerous effects that the FDA previously recognized as associated with the newer antidepressants. The similarity between stimulant and antidepressant adverse effects is probably due to the stimulating effects of the newer antidepressants. 

Four cases in which psychosis developed after relatively small amounts of marijuana were smoked for the first time have been reported (112). All required hospitalization and neuroleptic drug treatment. Each had a mother with manic disorder and two had psychotic features. The authors noted that marijuana is a dopamine receptor agonist, and mania may be associated with excessive dopaminergic neurotransmission. The use of marijuana may precipitate psychosis or mania in subjects who are genetically vulnerable to major mental illness. 

Previous case reports have suggested that psychosis and mania can be the result of starting thyroid hormone replacement at too high a dosage (617). Two further cases of mania associated with levothyroxine have been reported (618,619), suggesting that caution should be exercised when prescribing levothyroxine, especially in elderly people. 

The most important adverse effects of efavirenz involve the CNS. Up to 53% of patients report some CNS or psychiatric side effects, but fewer than 5% discontinue the drug for this reason. CNS symptoms may occur with the first dose and may last for hours. More severe symptoms may require weeks to resolve. Patients commonly report dizziness, impaired concentration, dysphoria, vivid or disturbing dreams, and insomnia. Episodes of frank psychosis (depression, hallucinations, and/or mania) have been associated with initiating efavirenz. Fortunately, CNS side effects generally become more tolerable and resolve within the first 4 weeks of therapy. 

There are isolated reports of psychosis, mania and seizures associated with the use of bupropion and fluoxetine and an isolated report of the serotonin syndrome with bupropion and sertraline. Hypersexuality has also been reported with bupropion and fluoxetine or sertraline. 

Cases of hypomania (Fahmi et al. 2002 Guzelcan et al. 2001 Nierenberg et al. 1999 O Breasail and Argouarch 1998 Shuster 1999), mania (Moses and Mallinger 2000), psychosis (Laird and Webb 2001 Lai and Iskandar 2000 Shimizu et al. 2004), and delirium (Khawaja et al. 1999) have been associated with the use of St. John s wort. In many of these reports, patients were noted to have psychiatric histories or concomitant diagnoses of psychiatric disorders. 

The commonest diagnoses associated with sl36 are schizophrenia, mania, drug-induced psychosis and personality disorder (Borschmann et ai, 2010). 

It is well established that monotherapy with various antidepressants or mood stabilizers is relatively ineffective (i.e., they are necessary but not sufficient) for treating mood disorders with associated psychosis. Thus, psychotically depressed patients are best managed with a combination of antipsychotic-antidepressant or with electroconvulsive therapy. Although antipsychotics have a more rapid onset of action than lithium in an acute manic episode, we are unaware of clinical trials that examine the differential effect of antipsychotics or lithium for nonpsychotic versus psychotic mania. This topic is discussed further in... 

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