Abstract
To the Editor:
T
Case Report
The patient was an 11-year-old male who had been brought to our department with complaints of “insomnia, talkativeness, increased energy, and spending.” He was inattentive, hyperactive, and euphoric, and it was reported that “he felt he could do anything.” Upon questioning, it was learned that the complaints had been present continuously for the past 3 months. The patient's grades had suffered, and within the past month he had verbalized suicidal ideations to his teachers. Mental status examination revealed auditory hallucinations, and grandiose delusions alternating with depressive ruminations and limited insight.
Past medical and psychiatric history were unremarkable, except growth failure that had led to a referral to the pediatrics department 4 months earlier. The patient was diagnosed with GH deficiency, and somatropin injections (0.5 mg/day) had been commenced 3 months earlier and titrated to 0.7 mg/day in the past month. Apart from mild inattention and irritability, no distinct depressive episode had been reported prior to treatment with GH. Family history was negative for psychopathology. Neurological examination ruled out papillary edema, and no signs or symptoms of intracranial hypertension were reported. Laboratory evaluations as well as electroencephalogram (EEG) were normal. Psychometric evaluation with the Childhood Mania Scale as completed by the parents revealed a score of 35 (chief complaints: auditory hallucinations, paranoid ideations, impulsivity, grandiosity, pressured speech, insomnia, increased energy, euphoria, and irritability). The baseline evaluation with Young Mania Rating Scale (YMRS) yielded a score of 38. Childhood Depression Inventory and other measures could not be completed because of the patient's excessive agitation. Children's Global Assessment Scale (CGAS) revealed moderate impairment (score: 45). Consequently, the patient was diagnosed with mood disorder with mixed features caused by somatropin according to Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV) criteria (American Psychiatric Association 1994). The pediatrics team and the parents of the patient refused a trial of somatropin cessation therefore treatment was started with risperidone 0.5 mg/day, later titrated to 1 mg/day, while the somatropin dose was reduced to 0.5 mg/day. A follow-up visit after 2 weeks revealed a YMRS score of 24 and a CGAS score of 55 (variable functioning). Because the patient continued to have persisting grandiose delusions and depressive ruminations, valproate 200 mg/day was added. At the 4th and 12th weeks, the patient's YMRS scores were noted to be 20 and 15, respectively, and depressive ruminations, suicidality, and frank grandiosity remitted, whereas mood was somewhat elevated with hyperactivity and slight irritability.
Discussion
Here, we report a case of mood disorder with mixed features in a prepubertal child. An evaluation with the Naranjo Algorithm yielded a score of 4 (possible adverse drug reaction) (Naranjo et al. 1981) and the patient responded partially to a trial of antipsychotics and mood stabilizers. Because of the lack of a somatropin washout trial, we could not ascertain causality. The relationship of mood disorder to somatropin treatment may be spurious, and may reflect an underlying vulnerability to stress, although the lack of family history and prior episodes argues otherwise. Alternatively, somatropin treatment in our case may have caused a mixed episode, presumably via elevated insulin-like growth factor (IGF)-1 and its effects on monoaminergic transmission. Recent observations of elevated IGF-1 in bipolar patients may support this proposition (Kim et al. 2013; Li et al. 2014). Our results should be confirmed with future studies.
Footnotes
Disclosures
No competing financial interests exist.