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Giasson-Gariépy and Jutras-Aswad Addiction Science & Clinical Practice 2013, 8:22http://www.ascpjournal.org/content/8/1/22 A case of hypomania during nicotine cessationtreatment with bupropion Karine Giasson-Gariépy1,2 and Didier Jutras-Aswad1,2* Antidepressants can increase the spontaneous risk of hypomania or mania when used for treatment in affectivedisorders. When prescribed as an antidepressant, bupropion is generally considered to have a lower relative riskof inducing mood shifts. We describe the case of a 67-year-old man known for dysthymic disorder in remission onquetiapine and venlafaxine who experienced a first lifetime episode of hypomania with the introduction of bupropionSR for smoking cessation. To the best of our knowledge, this is the first case report of bupropion-induced mood shiftwhen used specifically for nicotine cessation in a nonbipolar patient. This case highlights the need for clinicians whoprescribe bupropion for smoking cessation to perform regular and systematic mood follow-ups during treatment.
These follow-ups could even be more important when bupropion is selected to quit smoking in a patient alreadytaking an antidepressant.
Keywords: Nicotine, Smoking cessation, Bupropion, Antidepressant, Hypomania, Venlafaxine on venlafaxine XR (225 mg per day) and quetiapine XR Bupropion SR is a dopamine/norepinephrine reuptake in- (50 mg per day + an additional 25 mg twice daily as needed) hibitor licensed for use as a smoking cessation aid. Com- with no recent treatment regimen modification. Past psy- pared with other antidepressants, bupropion is generally chiatric history was significant for recurrent unipolar major considered to have a lower relative risk of inducing mood depressive episodes and cocaine abuse. Past substance use shifts , however there are no controlled studies speci- history included daily alcohol use since age 35. The number fically addressing this risk when prescribed for nicotine of standard drinks per day increased over the years but dependence treatment. Secondary mania induction in uni- averaged 14–20 in the two years preceding his sobriety polar depression treatment with bupropion has been in- period. Cocaine was used once per month from the age of frequently reported in the literature, but little is known 35 to 45 and approximately two times per year thereafter about the potential for mood shifts when bupropion is until his sobriety period. He reported no other recent regu- prescribed as a smoking cessation aid. We describe here a lar substance use. The patient had been stable psychiatric- patient who experienced a first lifetime episode of hypo- ally with no alcohol or cocaine use for seven months. There mania with the introduction of bupropion SR for smoking was no personal or family history of bipolar disorder, but cessation. To the best of our knowledge, this is the first prior long-term substance use history remains a potential case report of bupropion-induced mood shift when used confounding factor.
specifically for smoking cessation in a nonbipolar patient.
For smoking cessation, bupropion SR coupled with nico- tine replacement therapy (NRT) (14 mg patch daily) and Case presentation therapeutic groups were used. In March 2012, bupropion Mr. X was a 67-year-old man with nicotine dependence (45 SR (150 mg per day) was prescribed for three days and a packs-years), alcohol dependence in early full remission, preplanned quit date was set for day 4. As the treatment and dysthymic disorder in remission. He was maintained began, the patient noticed some feelings of excitement,which were amplified when the dose was increased to * Correspondence: 150 mg twice daily on the fourth day of treatment. From 1Research Center, Centre Hospitalier de l'Université de Montréal, Montreal, that point on, he reported the onset of euphoria, racing Quebec, Canada2Department of Psychiatry, Université de Montréal, Montreal, Quebec, thoughts, and decreased need for sleep. He subsequently 2013 Giasson-Gariépy and Jutras-Aswad; licensee BioMed Central Ltd.Jutras-Aswad This is an open access article distributedunder the terms of the Creative Commons Attribution License which permits un-restricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Giasson-Gariépy and Jutras-Aswad Addiction Science & Clinical Practice 2013, 8:22 relapsed to alcohol and cocaine use (on days 7 and 8) with mood shift, since the hypomanic symptoms noticeably minimization of the consequences of substance use. He took place before the cocaine/alcohol use. However, his mentioned no suicidality or psychotic symptoms. The pa- past substance use disorder could have been a predis- tient met his therapist during the smoking cessation group posing factor, as it has been associated with an increased on day 5, who noticed a change in the patient's affect and risk of antidepressant-induced mania/hypomania in bi- describing him as more anxious, tense, and keyed up. Sub- polar patients .
jectively, on that day, the patient noticed being more anx-ious and having less ability to concentrate, which could be early nicotine withdrawal symptoms or early hypomanic Although there are several hypotheses for the hypomanic symptoms. When seen by his psychiatrist 11 days after episode, our findings suggest the need to carefully monitor treatment initiation, the patient had decided to stop for mood shifts when bupropion is prescribed as a smoking substance use and bupropion for two days. He was get- cessation aid, even in nonbipolar patients and in particular ting back to his baseline level, reporting some residual when combined with other antidepressants. Smoking ces- anxiety. Venlafaxine and NRT were maintained, while sation represents a sensitive period during which many fac- his quetiapine XR dose was increased to 100 mg per day tors can alter mood (e.g. nicotine withdrawal, NRT, the regularly; bupropion was discontinued. One week later, stress of quitting smoking). These factors may modify the the patient's mood was stable, and he had not used any risk of mood shifts associated with bupropion.
Although the benefits of medication-assisted smoking cessation are clear, there is a need for frequent and system- atic monitoring of mood symptoms during treatment with The timing of symptoms suggests an association be- bupropion in the context of smoking cessation, even in pa- tween bupropion initiation and mood shift in this pa- tients not previously diagnosed with bipolar disorder. For tient. Bupropion can induce mood switches in bipolar patients who are already receiving antidepressant treat- depression, but possibly less frequently than other anti- ment, selecting bupropion over other smoking-cessation depressants [There are only a few cases reported of strategies should take into account the risk of mood shifts bupropion-induced mood shifts in unipolar disorders and interactions.
and of secondary mania induction To our know-ledge, bupropion-induced polarity changes in nonbipolar patients have not been reported during the management Written informed consent was obtained from the patient of smoking cessation, except for a case of mania after for publication of this case report.
abrupt treatment discontinuation Competing interests A clinical interaction between bupropion and venlafaxine This work was supported by the CHUM Department of Psychiatry; Université could also explain the hypomania. Venlafaxine is a sero- de Montréal Department of Psychiatry; and the CHUM Research Center tonin/norepinephrine reuptake inhibitor. When used as an (DJA). The authors have no conflicts of interest with this case study. Dr.
Jutras-Aswad has received research/education grant support from Pfizer, adjunct in bipolar depression, it is associated with an in- Janssen, Bristol-Myers Squibb, Mylan and Reckitt Benckiser Pharmaceuticals, creased risk of mood shifts compared with bupropion as well as presentation honoraria from Janssen, consultant honoraria from An open-label study found a 2.5-fold increase in plasma Merck and grant support from the CHUM Department of Psychiatry, Univer-sité de Montréal Department of Psychiatry and the CHUM Research Center.
levels of venlafaxine when bupropion is added, possibly via The authors are solely responsible for the writing of this case study.
CYP2D6 inhibition . A case series mentioned the needto decrease venlafaxine dose when bupropion was added Authors' contributionsDJA conceived the case report. DJA and KGG drafted the manuscript. Both for the treatment of major depressive disorder in order to authors read and approved the final manuscript.
diminish serotonergic side-effects ]. Despite this knownpharmacokinetic interaction, the evidence of its clinical Received: 12 July 2013 Accepted: 18 December 2013Published: 21 December 2013 implication remains limited. Combining therapeutic dosesof these antidepressants with overlapping mechanisms of action and pharmacokinetic interactions could also en- Post RM, Altshuler LL, Leverich GS, Frye MA, Nolen WA, Kupka RW, Suppes T,McElroy S, Keck PE, Denicoff KD, et al: Mood switch in bipolar depression: hance noradrenergic stimulating effects, which could con- comparison of adjunctive venlafaxine, bupropion and sertraline.
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doi:10.1186/1940-0640-8-22Cite this article as: Giasson-Gariépy and Jutras-Aswad: A case ofhypomania during nicotine cessation treatment with bupropion.
Addiction Science & Clinical Practice 2013 8:22.
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