Manic Symptoms as a Symptom of Antidepressant Discontinuation Syndrome in a Child

Case Report

A 12-year-old girl was referred to the child psychiaty clinic 9 months previously with complaints of unhappiness, withdrawal, and decrease in communication. It was learned in her history that the complaints had been present for 1 month, with decrease in appetite and academic achievement. Her psychiatric history was negative for prior traumatic experiences, repeated hospital admissions, stressful life events, or substance use. In the family history, it was learned that her mother used fluoxetine for major depression, and benefited from this treatment.

In the psychiatric examination, consciousness and orientation were normal. Communication with the interviewer was reduced, in combination with a decrease in attention and concentration. Memory, judgment, perception, and insight were normal. Speech was decreased. Flow of thoughts became slower, and thoughts of lack of value, not being loved, and inadequacy were predominant. Mood was low and affect was dysphoric. Findings from physical and neurological examinations were within the normal range. In laboratory investigations, thyroid function tests and biochemical values were normal. In the first interview, the patient's score on the Children's Depression Inventory was 21 points. According to Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV) it was considered that she met the criteria for major depressive disorder (MDD), single episode (American Psychiatric Association 1994). She started on 10 mg/day fluoxetine, and the dose was increased 2 weeks later to 20 mg/day. At control visits, remission was found in depressive symptoms at the end of the 3rd month, and it was learned that at the 7th month of her treatment, the family had discontinued treatment without any gradual decrease in dose, thinking that she had recovered. One week after discontinuation of the drug, symptoms such as sudden nervousness, picking quarrels with people she did not know, excessive talking, sleeping little, and an increase in sexual desire emerged and the family was referred to our clinic again. In the psychological state examination, it was established that the patient's mood had shifted to irritability, speed of thought was present, in thought content there was no impairment except for grandiose ideas, the need for sleep had decreased, and psychomotor agitation was present. The patient was diagnosed with manic attack. Valproate 1000 mg/day was initiated, and she was followed as an outpatient. The symptoms were not relieved and risperidone 1 mg/day was added to treatment. At the third week of treatment, all symptoms resolved, and her functionality returned to normal levels. Risperidone was discontinued and maintenance treatment with valproate was given. At 6 months follow- up, no psychiatric symptom was present in the patient.

Discussion

Antidepressant withdrawal hypomania or mania may occur rarely with almost any antidepressant drug after sudden withdrawal, tapered discontinuation, or even merely a decrease in dose. The true incidence of the syndrome is unknown (Andrade 2004). In a study of all the literature that was reviewed, 42 case reports were identified about this subject. Cases occured with all major antidepressant classes and more cases occurring in people with unipolar disorder are reported in the study. Mean age of the subjects was 39 years, and none of them was child (Narayan and Haddad 2012). Our subject was a 12-year-old girl with unipolar depression, who developed mania after abrupt stoppage of fluoxetine.

DSM-IV (American Psychiatric Association 1994) does not have a specific category for antidepressant withdrawal/discontinuation hypomania/mania. Narayan and Haddad (2012) concluded that antidepressant discontinuation hypomania/mania is a valid syndrome, and developed diagnostic criteria for an antidepressant discontinuation manic state. In these criteria, “manic state” refers to “mania” or “hypomania” and they specify that abnormally elevated or irritable mood be present with or without other manic symptoms. The criteria are:

According to these diagnostic criteria, our subject was diagnosed with antidepressant discontinuation manic state.

Goldstein et al. (1999) emphasize that these cases must be distinguished from the mania induced by antidepressants, physiological symptoms of antidepressant withdrawal, agitated depression, and manic episode occurring during the course of the disease. Antidepressant-induced mania is recognized in bipolar patients, appears to be more common with tricyclic antidepressants than with SSRIs, and occurs 4–6 weeks after use of antidepressants (Ali and Milev 2003; Gijsman et al. 2004). Agitated depression and akathisia according to antidepressant withdrawal could be misdiagnosed as hypomania (Narayan and Haddad 2012). The mania symptoms appeared 7 months after fluoxetine use was interrupted suddenly. Presence of mania-specific symptoms, absence of family history of bipolar disorder, and absence of physiological symptoms indicated that antidepressant withdrawal was a diagnosis for our patient.

In the adult population, the frequency and severity of the discontinuation syndrome is linked with the SSRI half-life. Fluoxetine has the longest half-life of the SSRIs, and has been shown to produce a milder discontinuation reaction than other SSRIs. There is no report in the literature of mania/hypomania following the discontinuation of fluoxetine. Children, who have a higher drug metabolism rate than adults, would be more vulnerable to side effects (Diler and Avci 2002).

To our knowledge, this is the first case report of a child who had a manic episode in association with the disontinuation of an SSRI. The data about the discontinuation syndrome specific to children and adolescents, especially about manic states, are limited, and further studies are required.

Disclosures

Drs Özcan, Özdemir, and Kütük have no conflicts of interest or financial ties to disclose.