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Acute Psychosis with Bupropion in a Healthy 28 y/o Female

This case presentation discusses a 28-year-old female who developed acute psychosis and other psychiatric symptoms after initiation of bupropion for smoking cessation. The similarities and differences to other case reports of bupropion-induced psychosis are explored, and recommendations for timely diagnosis and treatment are emphasized.

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Acute Psychosis with Bupropion in a Healthy 28 y/o Female

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  1. 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

  2. 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

  3. 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

  4. 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 Case Presentation

  5. 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 Case Presentation

  6. 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

  7. 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.

  8. Case Presentation • Assessment: Acute Psychotic Disorder (298.8) likely secondary to new addition of antidepressant • Plan: • Discontinue Bupropion • Follow up

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

  10. 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

  11. 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

  12. 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

  13. 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

  14. 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

  15. 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

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

  17. Discussion:What are the similarities? • Symptoms developed 7 days after start of medicine • Paranoia, and auditory hallucinations with intact orientation and insight • Complete resolution of symptoms with discontinuation of bupropion

  18. Discussion:What are the differences? • Young patient • No history of psychosis, depression, bipolar disorder, or illicit substance abuse • Sustained release formulation • Low dose of the medication • Use of anti-cholinergic agent

  19. Conclusion • Commonly used medications are not without side effects • High risk populations versus low risk individuals • Educating patients • Timely diagnosis and treatment

  20. Conclusion • Drug-Drug Interactions • Interaction with Levsin and Bupropion • Possible class effect

  21. Questions?

  22. References • Ames D, Wirshing WC, Szuba MP. Organic mental disorders associated with bupropion in htree patients. J Clin Psychiatry 1992;53: 53-55. • Golden RN, James SP, Sherer MA, et al. Psychosis associated with bupropion treatment. Am J Psychiatry 1985; 142:1459-1462. • Howard, W.T., Warnock, J.K. Bupropion-induced psychosis. Am J Psychiatry 1999; 156:2017-2018 • Neumann, M., Livak, V., Paul, H.W. Laux, G. Acute psychosis after administration of bupropion hydrochloride (Zyban). Pharmachopsychiatry 2002; 35:247-248. • Wang, Tzong-Shi, Shiah, I-Shin, Yeh, Chin-Bin, Chang, Chuan-Chia. Acute Psychosis Following Sustained Release Bupropion Overdose. Progress in Neuro-Psychopharmacology and Biological Psychiatry 2005:29:149-151. • Illustrations: • www.chemblink.com/products/34911-55-2.htm • www. Redpoll.pharmacy.ualberta.ca/drugbank • http://world.std.com/~eva/the-cry.jpg

  23. Practice Recommendations • Screen for concomitant psychiatric illness • Use cautiously with anti-cholinergics

  24. Further Discussion

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