Goldstein T R, Frye M A, Denicoff K D, Smith-Jackson E, Leverich G S, Bryan A L, Ali S O, Post R M
Department of Clinical Psychology, University of Colorado, Boulder, USA.
J Clin Psychiatry. 1999 Aug;60(8):563-7; quiz 568-9.
Development of manic symptoms on antidepressant discontinuation has primarily been reported in unipolar patients. This case series presents preliminary evidence for a similar phenomenon in bipolar patients.
Prospectively obtained life chart ratings of 73 bipolar patients at the National Institute of Mental Health were reviewed for manic episodes that emerged during antidepressant taper or discontinuation. Medical records were utilized as a corroborative resource. Six cases of antidepressant discontinuation-related mania were identified and critically evaluated.
All patients were taking conventional mood stabilizers. The patients were on antidepressant treatment a mean of 6.5 months prior to taper, which lasted an average of 20 days (range, 1-43 days). First manic symptoms emerged, on average, 2 weeks into the taper (range, 1-23 days). These 6 cases of antidepressant discontinuation-related mania involved 3 selective serotonin reuptake inhibitors (SSRIs), 2 tricyclic antidepressants (TCAs), and 1 serotonin-norepinephrine reuptake inhibitor. Mean length of the ensuing manic episode was 27.8 days (range, 12-49 days). Potential confounds such as antidepressant induction, phenomenological misdiagnosis of agitated depression, physiologic drug withdrawal syndrome, and course of illness were carefully evaluated and determined to be noncontributory.
These 6 cases suggest a paradoxical effect whereby antidepressant discontinuation actually induces mania in spite of adequate concomitant mood-stabilizing treatment. These preliminary observations, if replicated in larger and controlled prospective studies, suggest the need for further consideration of the potential biochemical mechanisms involved so that new preventive treatment approaches can be assessed.
抗抑郁药停用后出现躁狂症状主要在单相患者中报道。本病例系列为双相患者中类似现象提供了初步证据。
对美国国立精神卫生研究所73例双相患者前瞻性获得的生活图表评分进行回顾，以查找在抗抑郁药逐渐减量或停用期间出现的躁狂发作。病历用作佐证资料。确定并严格评估了6例与抗抑郁药停用相关的躁狂病例。
所有患者均服用传统心境稳定剂。患者在逐渐减量前平均接受抗抑郁治疗6.5个月，逐渐减量持续平均20天（范围1 - 43天）。首次躁狂症状平均在逐渐减量2周时出现（范围1 - 23天）。这6例与抗抑郁药停用相关的躁狂病例涉及3种选择性5-羟色胺再摄取抑制剂（SSRI）、2种三环类抗抑郁药（TCA）和1种5-羟色胺-去甲肾上腺素再摄取抑制剂。随后躁狂发作的平均时长为27.8天（范围12 - 49天）。仔细评估了诸如抗抑郁药诱导、激越性抑郁的现象学误诊、生理性撤药综合征和病程等潜在混杂因素，并确定其无作用。
这6例提示了一种矛盾效应，即尽管有充分的伴随心境稳定治疗，抗抑郁药停用实际上仍诱发躁狂。这些初步观察结果若能在更大规模的对照前瞻性研究中得到重复，提示需要进一步考虑其中潜在的生化机制，以便评估新的预防性治疗方法。
