Induction of mania by tricyclic antidepressants (TCAs) is controversial, with indirect
evidence for and against it. Unusual direct evidence of it was observed in a 77-year-old
female patient having ingested an amitriptyline overdose. Mania developed while the
TCA blood levels were high, and responded to a combination of charcoal and valproate.
However, mania reappeared when charcoal was discontinued, and disappeared again when
it was restarted. This time course suggests a therapeutic advantage for adding charcoal
to valproate in treating tricyclic-induced mania. Presumably, charcoal might have
removed a mania-inducing metabolite of amitriptyline. Moreover, repeated doses of
oral activated charcoal accelerated the elimination of TCA from the blood stream to
several times its original rate, which is consistent with interruption of the enterohepatic
circulation. This enhanced elimination and improved outcome illustrate the value of
repeated charcoal doses after TCA overdose, and suggest its use when mania develops
in a patient who takes an antidepressant, at least amitriptyline or nortriptyline.
References
- 1
Wehr T A, Goodwin F K.
Can Antidepressants Cause Mania and worsen the course of Affective Illness?.
Am J Psychiatry.
1987;
144
1403-1411
- 2 Goodwin F K, Jamison K R. Maintenance medical treatment in. Manic-Depressive Illness. New
York; Oxford University Press 665-774
- 3
Lewis J L, Winokur G.
The induction of Mania.
Arch Gen Psychiatry.
1982;
39
303-306
- 4
Angst J.
Switch from depression to mania - a record study over decades between 1920 and 1982.
Psychopathology.
1985;
18
140-154
- 5
Prien R F, Klett C J, Caffey E MJr.
Lithium Carbonate and Imipramine in prevention of affective illness.
Arch Gen Psychiatry.
1973;
29
420-425
- 6
Nemeroff C B, Evans D L, Gyuali L ,. et al .
A double blind, placebo-controlled comparision of imipramine and paroxetine in the
treatment of bipolar depression.
Am J Psychiatry.
2001;
158
906-12
- 7 Post R M. Mood Disorders: Treatment of Bipolar Disorders, in Comprehensive Text
Book of Psychiatry. Edited by Sadock BJ, Sadock VA Lippincott Williams & Wilkins 2000:
pp 1385-1430
- 8
Swartz C M, Sherman A.
Treatment of TCA overdose with repeated charcoal.
Journal of Clinical Psychopharmacology.
1984;
4
336-340
- 9
Jones J, McMullen M J, Dougherty J ,. et al: .
Repetitive doses of activated charcoal in treatment of poisoning.
Am J Emerg Med.
1987;
5
305-311
- 10
Farley T A.
Severe hypernatremic dehydration after use of an activated charcoal-sorbitol combination.
J Pediatr.
1986;
109
719-727
Conrad Swartz, Ph.D., M.D.
Department of Psychiatry
Southern Illinois University School of Medicine
PO Box 19642, Springfield, IL 62794-9642
USA
Phone: +1 (217) 545-3935 x 44468
Fax: +1 (217) 545-2275
Email: cswartz@siumed.edu
