Manic symptoms, drug-induced

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There is, however, a unique risk in the bipolar form that antidepressant treatment may trigger a switch into mania. This may occur either as the natural outcome of recovery from depression or as a pharmacological effect of the drug. Particular antidepressants (the selective serotonin reuptake inhibitors) seem less liable to induce the switch into mania than other antidepressants or electroconvulsive therapy. Treatment for mania consists initially of antipsychotic medication, for instance the widely used haloperidol, often combined with other less specific sedative medication such as the benzodiazepines (lorazepam intramuscularly or diazepam orally). The manic state will usually begin to subside within hours and this improvement develops further over the next 2 weeks. If the patient remains disturbed with manic symptoms, additional treatment with a mood stabilizer may help. 

Because there are also some data that concurrent use of antidepressants can lead to rapid cycling in vulnerable patients, these agents may best be cautiously used on an as-needed basis or as adjuncts when there are early signs of breakthrough depressive, psychotic, or anxious symptoms. In particular, antidepressants do not prevent manic episodes, and may even precipitate them. The fact that many patients on antidepressants experience a manic phase, however, could be coincidental, rather than drug-induced. To definitively answer this question, we need to show that the number who switch to mania is higher on, as opposed to off, antidepressant therapy. Given these concerns, however, we advocate the initial use of a mood stabilizer alone to lessen the chance of a switch to mania in bipolar depressed patients. If this is insufficient, a mood stabilizer should be used concurrently with an antidepressant. 

The authors commented that the manic symptoms had probably been caused by glucocorticoids or glucocorticoid withdrawal. They concluded that patients with cluster headache and a history of affective disorder should not be treated with glucocorticoids, but with valproate or lithium, which are effective in both conditions. Lamotrigine, an anticonvulsive drug with mood-stabilizing effects, may prevent glucocorticoid-induced mania in patients for whom valproate or lithium are not possible (101). 

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