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Brazilian Journal of Psychiatry

Print version ISSN 1516-4446On-line version ISSN 1809-452X

Rev. Bras. Psiquiatr. vol.39 no.1 São Paulo Jan./Mar. 2017

https://doi.org/10.1590/1516-4446-2016-2113 

LETTERS TO THE EDITORS

Vortioxetine-induced manic mood switch in patient with previously unknown bipolar disorder

Gonçalo Sobreira1 

João Oliveira1 

Sofia Brissos1 

1Centro Hospitalar Psiquiátrico de Lisboa, Lisbon, Portugal


Vortioxetine is a new antidepressant (AD) recently introduced in Europe. With an action profile that extends beyond traditional serotonin (5-HT) reuptake blockade, it is considered a 5-HT3A, 5-HT7, and 5HT1D receptor antagonist, 5-HT1B partial agonist, 5-HT1A agonist, and inhibitor of the serotonin transporter.1

Data on the safety of vortioxetine for treatment of depressive episodes in patients with bipolar disorder (BD) are still lacking. We found only one report of manic mood switch2 and an episode of hypomania in a patient with unknown diagnosis of BD in an analysis of randomized placebo-controlled trials and open-label extension studies.3

We report a patient with previously undiagnosed BD who experienced a manic switch (MS) after initiating AD treatment with vortioxetine.

A 41-year-old male with at least two previous depressive episodes and paternal psychiatric family history of puerperal psychosis and recurrent depressive disorder developed a severe depressive episode. Vortioxetine (10 mg/day) was introduced with trazodone (50 mg/day) as a sleep inducer. One week later, the patient developed a MS consisting of elated mood, racing thoughts, disinhibition, irritability, and paranoid and grandeur delusions. Due to marked behavioral changes and lack of insight, the patient was involuntary admitted and AD treatment was discontinued. At admission, he scored 46 on the Young Mania Rating Scale and 13 on the Hamilton Depression Rating Scale. Blood tests including toxicological and serological screening were negative, and pharmacological treatment with olanzapine (20 mg/day) and valproic acid (1,000 mg/day) was initiated; the patient attained a provisional response after 17 days (scores reduced to 7 and 4, respectively) and was discharged to outpatient treatment with a diagnosis of BD – severe manic episode with psychotic features. At the time of writing, the patient had developed a depressive switch and been started on outpatient treatment with lithium (800 mg/day).

Even though low doses of trazodone are considered safe in BD,4 a synergistic effect of its combination with vortioxetine inducing MS cannot be excluded. While vortioxetine appears promising as a second-line AD option, additional long-term data are still lacking,5 and clinicians need to be aware of the possible risks of MS when prescribing this AD in monotherapy or in combination to patients with BD.

References

1. Sanchez C, Asin KE, Artigas F. Vortioxetine, a novel antidepressant with multimodal activity: review of preclinical and clinical data. Pharmacol Ther. 2015;145:43-57. [ Links ]

2. Maud C. Vortioxetine in bipolar depression induces a mixed/manic switch. Australas Psychiatry. 2016;24:206-7. [ Links ]

3. Baldwin DS, Chrones L, Florea I, Nielsen R, Nomikos GG, Palo W, et al. The safety and tolerability of vortioxetine: analysis of data from randomized placebo-controlled trials and open-label extension studies. J Psychopharmacol. 2016;30:242-52. [ Links ]

4. Wichniak A, Jarkiewicz M, Okruszek Ł, Wierzbicka A, Holka-Pokorska J, Rybakowski JK. Low risk for switch to mania during treatment with sleep promoting antidepressants. Pharmacopsychiatry. 2015;48:83-8. [ Links ]

5. Connolly KR, Thase ME. Vortioxetine: a new treatment for major depressive disorder. Expert Opin Pharmacother. 2016;17:421-31. [ Links ]

Received: September 13, 2016; Accepted: September 28, 2016

Disclosure SB was a Medical Affairs Manager for Janssen from 2010 to 2013. During the last 3 years, she has received honoraria for lectures from Lundbeck and Janssen. The other authors report no conflicts of interest.

Creative Commons License This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.