Abstract
Antidepressants such as citalopram are increasingly being used in adolescents [1, 2]. Although SSRIs appear to carry a lower risk for manic switch than tetracyclic antidepressants [3], a switch of mania has been reported in adults [4, 5]. We are not aware, however, of previous reports of a manic switch with citalopram in an adolescent, and report such a case.
A 13-year-old boy, with normal birth and developmental history, and no personal or family history of neuropsychiatric disorders, developed episodic behavioural abnormalities for a period of 10 months. The episodes, lasting a few minutes, were characterized by sudden onset of alteration in consciousness and aimless running. There were also episodes of recurrent hiccoughs with abdominal discomfort and jerky movements of the hip. He was diagnosed as having epilepsy and commenced on sodium valproate (300 mg/day). An electroencephalogram (EEG) showed generalized spike-wave complexes, but his CT scan was unremarkable. After 4 months, due to poor improvement, sodium valproate was changed to carbamazepine (400 mg/ day); after a further 6 months, carbamazepine was changed to oxcarbamazepine (300 mg/day) also due to a lack of efficacy. At this juncture, he was also commenced on citalopram (20 mg/day) with a suspicion that some of the abnormal behaviours could be pseudoseizures. Although his seizures gradually decreased with this regimen, he developed a new set of behavioural oddities characterized by excessive speech, reckless money spending, wandering tendency and middle insomnia. Psychiatric examination revealed hyperactivity, overabundant speech, euphoric affect and inflated self-esteem and confidence; his Young's mania rating scale score was 13 (total score = 60; generally considered cut-off of acute mania = 12). Hence, with the diagnosis of epilepsy (partial seizures) and citalopraminduced mania, he was commenced on olanzapine 5 mg/day along with ongoing oxcarbamazepine 300 mg/ day; the citalopram was discontinued. At the time of follow-up examination 1 month later, he was free of manic symptoms. Because a repeat EEG revealed bifronto-central spikes and sharp waves, with predominance over left side, the dose of oxcarbamazepine was increased to 450 mg/day.
Citalopram seems to be the most likely reason for the manic episode given that the patient had no bipolar diathesis as evidenced by either personal or family history of an affective illness. Likewise, the affective episode could not be conceptualized as either postictal or interictal psychiatric morbidity because the patient's seizures were well controlled before the emergence of such symptoms and because studies document that interictal psychosis usually appears several years after the onset of epilepsy [6]. While it is unknown whether organic factors might amplify the risk of manic switch, the fact that this patient had neither bipolar disorder before citalopram therapy nor family predisposition supports previous reports of citalopram-induced manic symptoms in patients with no known bipolar diathesis [4, 5]. Another intriguing issue is the onset of manic symptoms while the patient was on a mood-stabilizing antiepileptic agent, oxcarbamazepine. The findings of this report suggest the need for careful citalopram dose titration in adolescents with epilepsy.