ACUTE PSYCOSIS WITH BUPROPION IN A HEALTHY 28 Y/O FEMALE

2. ACUTE PSYCHOSIS WITH BUPROPION IN A HEALTHY 28 Y/O FEMALE Capt Justin Bailey, MD Presented by Capt Shannon Waters, MD 13 March 2007 USAFP

3. Introduction Case Presentation Discussion What other literature is out there? What are the similarities to the other case reports? What are the differences to the other case reports? Conclusion

4. Case Presentation CC: � I need to quit smoking.� HPI: 28 y/o female pt with a 7 pack-year hx of smoking desiring smoking cessation. PMH significant for an anxiety attack 6 months ago just prior to her husband�s deployment. ROS: unremarkable

5. Case Presentation PMH Anxiety attack Acne Bartholin�s gland cysts GI tract spasm UTI PSH None Medications Macrobid Levsin Allergies NKDA Social History 7 pkyr hx of smoking No ETOH/Illicit Drugs Husband deployed No h/o seizures or bulemia No h/o seizures or bulemia

6. Case Presentation Vitals: Temp: 98.9� F BP: 109/71 HR: 71 RR: 18 Ht: 66 inches Wt: 116 pounds Physical Exam: Normal Laboratory Values: None drawn

7. Case Presentation Assessment: Tobacco Dependence (305.1) Plan: Bupropion SR 100 mg po qd x 1 wk then increase to 100 mg po bid with a goal to stop smoking two weeks after initiation of medicine Nicotine patches recommended but not desired Pt to call with any concerns Started on a lower dose of the medicine because of patients small size (116lbs).Started on a lower dose of the medicine because of patients small size (116lbs).

8. Case Presentation: 1 Week Later T-con: �I can�t leave my house, someone is going to hurt me and my children�. In addition to paranoia she developed panic attacks, auditory hallucinations, and suicidal ideation. In spite of troubling symptoms she was oriented with intact memory. My nurse came and found me to let me know about this t-con. My nurse came and found me to let me know about this t-con.

9. Case Presentation Assessment: Acute Psychotic Disorder (298.8) likely secondary to new addition of antidepressant Plan: Discontinue Bupropion Follow up All of this is FYI, if people ask about it or you feel it adds, but with time constraints I left it out. The case was discussed with life skills, they didn�t add much bedsides stop the medicine, and is she going to kill herself. With all the symptoms patient felt like she knew they were all not real symptoms and while troubling did not feel inclined to due what they were suggesting. Agreed to a contract for safety and was given the psych pager number, my pager and the ER�s number. She never used any of them. I checked on her a couple time during the week as her symptoms resolved. All of this is FYI, if people ask about it or you feel it adds, but with time constraints I left it out. The case was discussed with life skills, they didn�t add much bedsides stop the medicine, and is she going to kill herself. With all the symptoms patient felt like she knew they were all not real symptoms and while troubling did not feel inclined to due what they were suggesting. Agreed to a contract for safety and was given the psych pager number, my pager and the ER�s number. She never used any of them. I checked on her a couple time during the week as her symptoms resolved.

10. Case Presentation: Follow Up 1 week later: symptoms resolved 2 months later: no residual symptoms

11. Discussion:What other cases exist? A Literary Review 1985 American Journal of Psychiatry: Golden et al Four institutionalized patients: underlying psychiatric illness High doses of immediate release bupropion Symptoms occurred at various intervals All patients had intact orientation and memory All patients recovered after discontinuation of bupropion

12. Discussion:What other cases exist? A Literary Review 1992 Journal of Clinical Psychiatry: Ames et al 3 similar cases 1999 American Journal of Psychiatry Howard and Warnock Letter to the Editor Bupropion induced psychosis in the elderly Howard Letter to the editor � and now some similarities are starting to emerge Howard Letter to the editor � and now some similarities are starting to emerge

13. Discussion:What other cases exist? A Literary Review Risk factors for acute psychosis Elderly Age History of Psychosis High doses of bupropion Immediate release versus sustained release Themes begin to emerge. History of psychosis -bupropion + Dopaminergic medications -being old (age not defined): with the exception of the last 2 cases -High plasma levels of bupropion Themes begin to emerge. History of psychosis -bupropion + Dopaminergic medications -being old (age not defined): with the exception of the last 2 cases -High plasma levels of bupropion

14. Discussion:What other cases exist? A Literary Review 2002 Pharmacopsychiatry Neumann M. et al Young tobacco dependent male Comorbid substance abuse Symptom resolution after discontinuation Amisulpride is a German atypical antipsychotic Amisulpride is a German atypical antipsychotic

15. Discussion:What other cases exist? A Literary Review 2005 NeuroPsychopharmacology and Biological Psychiatry Wang et al Young depressed patient Bupropion SR Overdose Resolution of symptoms following discontinuation

16. Discussion: Theories in the Literature Weak Dopamine Reuptake Inhibition Dopaminergic side effects: insomnia, nausea and vomiting L-dopa + bupropion increase occurrence of symptoms Increases of dopamine metabolite, homovanillic acid in patients who respond poorly to bupropion

17. Discussion: Theories in the Literature Structurally Similar to Amphetamines Symptoms Similar to Amphetamine toxicity Auditory hallucinations and paranoia while orientated