Corticosteroids may induce psychiatric symptoms (agitation, fear, hypomania, insomnia, irritability, labile mood, pressured speech and restlessness) with incidence rates ranging from 1,8% to 57%. We present a case of corticosteroid-induced mania and psychosis.

Non-systematic review on corticosteroid therapy induced psychiatric symptoms. Analysis and comparison of a patient’s case with the existing literature.

Case report and a non-systematic review through databases as Pubmed, UpToDate, Medscape, between 2000 and 2020.

We present a female 70 year-old patient without psychiatric background, diagnosed with Rhizomelic Pseudopolyarthritis, who started treatment with prednisone 20 mg. During the third month of treatment the patient started progressively worse behavior changes (such as destruction of the neighbor’s property), developed persecutory delusions, decreased sleep and increased energy. The patient was committed to our psychiatric ward and started on diazepam 10 mg and olanzapine 15 mg per day. Despite introduction of antipsychotics, which has evidence for mood stabilization, the patient maintained the symptoms, so it was necessary to gradually reduce corticosteroids until symptomatic control.

Psychosis (24%), hypomania and mania (35%), are the most common psychiatric reactions to corticosteroid therapy. Several studies show that even a low dosage may induce psychiatric disturbances, most frequently during the first two weeks of treatment. However, as reported in this case, symptoms may occur at any time. Thus, a multidisciplinary team, as well as training of professionals from different specialties, such as psychiatry, rheumatology and endocrinology, are needed, since these syndromes may be confused with pure psychiatric conditions and consequently delay treatment and compromise prognosis.

No significant relationships.

The presence of psychotic symptoms is highest during acute episodes of bipolar mania. There is no evidence base regarding the implications of psychosis in the prognosis of bipolar disorder, despite common assumption that their occurrence reflects greater disease severity.

We aim to compare sociodemographic and clinical characteristics of inpatients admitted for bipolar mania with and without psychotic features.

Retrospective observational study of inpatients admitted between January 1st 2017 and 31 October 2020 in a psychiatry inpatient unit of a tertiary hospital. Descriptive analysis of the results was performed using the SPSS software, version 26.0.

Between 2017 and October 2020 there were 103 admissions due to mania bipolar I disorder, 53.4% (n=55) with psychotic symptoms. When compared with mania without psychosis, psychotic mania was associated to male gender (71.1% to 39.7%; c2(1, N = 103) = 10,06; p = 0.02) and younger age (t(103) = -2.43; p = 0.017). The proportion of compulsory admissions and average length of stay were similar between mania with psychosis and mania without psychosis. Also, having a manic bipolar episode with psychotic symptoms was not associated to being prescribed a long-acting injectable antipsychotic.

The presence of psychotic symptoms in bipolar manic episodes were associated to male gender and younger age but not to indirect measures of illness severity.

No significant relationships.

A 47 y.o. female patient was admitted to the female PICU with a manic episode. Upon admission she presented with mood elation, psychosis, pressured speech, lack of sleep and agitation.

To investigate negative prognostic factors such as the co-morbidity with a personality disorder in patients presenting with severe mania.

The patient was assessed regularly by the psychiatric team consisting of a CT doctor and one General Adult Consultant. Appropriate psychological assessments for mania and laboratory investigations took place.

The patient initially scored above 45 in the Young Mania Rating Scale (YMRS), establishing a diagnosis of severe mania. She was treated with Olanzapine titrated up to 20mg OD and augmentation with Lithium treatment. Lithium plasma levels were at 0,6. Due to the treatment resistant manic presentation a second antipsychotic agent was administered and the patient was also treated with Zuclopenthixol depot 400mg every two weeks. Clinical improvement was observed after 16 days from admission.

The clinical team wondered about the clinical challenges of the case. According to the literature having a Personality Disorder diagnosis is a negative prognostic factor for patients with mania and this is relevant to this case as well.

No significant relationships.

Bipolar Disorder (BD) is a severe recurrent disorder with a complex biogenetic and psychosocial etiology. The immune system cytokines in interaction with the CNS play a role in the pathophysiology.

To compare inflammatory cytokines between BD patients and controls during the manic episode; additionally, compare these cytokines with psychiatric symptoms and cognitive performance during follow-up.

We recruited 25 BD patients in mania with paired controls. We measured baseline IL-2, IL-4, IL-8, IL-10, GM-CSG, TNF- α, and TNF- γ in plasma. We used U-Mann-Whitney for group comparison and Spearman correlation between sub-group follow-up assessments and cytokines.

We found a significant difference in IL-6 between subjects and controls (figure 1). During the follow-up, we found a correlation with psychiatric symptoms, cognition, and cytokines during manic episodes (Table 1). Table 1. Follow-up Correlation with cytokines during a manic episode.

(+): positive correlation; (-): negative correlation. WMT: working-memory test, PST: Processing-speed test.

IL-6 was significantly different in patients with BD during a manic episode regardless of the treatment they were taking. IL-10 at manic episode was negatively correlated to general psychiatric symptoms, IL-4 positive correlated to depressive symptoms, and cognitive performance was positively correlated to TNF- α and TNF- γ at follow-up.

No significant relationships.

A 49 y.o. male patient was admitted to the male PICU with a manic episode. Upon admission he presented with mood elation, pressured speech, lack of sleep, agitation and polydipsia.

To investigate the symptom of psychogenic polydipsia in mental health patients presenting with severe mania.

The patient was assessed regularly by the psychiatric team consisting of a CT doctor and one General Adult Consultant. Appropriate psychological assessments for mania and laboratory investigations took place. There was a referral to Endocrinology for further investigation of the symptom.

The patient initially scored above 40 in the Young Mania Rating Scale (YMRS), establishing a diagnosis of mania. Upon admission he was treated with Paliperidone 9mg OD and Sodium Valproate 1gr OD. The daily dose of the sodium valproate was increased. Concerning the polydipsia, the investigations by the Endocrinology department indicated the specific weight in urine within normal range. The mental health team proceeded in a cross-titration of Paliperidone to Aripiprazole. On the 10th day since admission the management of the manic symptoms was considered satisfactory. Nevertheless, the polydipsia continued to a certain extend.

After ruling out organic and pharmacological causes of the polydipsia, the mental health team wondered about the cause of the symptom. Further investigation is required in order to clarify whether the polydipsia could actually qualify as a symptom in severe mania.

No significant relationships.

The inter-critical phase in bipolar disorder may contain symptoms that do not meet the diagnostic criteria for a thymic episode. According to studies, these symptoms are common and usually associated with impaired psychosocial and family functioning.

Study the subsyndromal symptoms in remitted patients with bipolar disorder, and their functioning repercussions.

We conducted a cross-sectional, descriptive and analytical study, in the outpatient psychiatry department of the University Hospital in Sfax (Tunisia) among 30 remitted patients with bipolar disorder. We used: the Montgomery And Asberg Depression Rating Scale (MADRS), the Angst Hypomania Questionnaire and the FAST test to assess functioning levels.

The average age of our population was 44.37±15.45 years with a sex ratio (M/F) =0.66. Most of them lived in urban areas (60%) and half of them did not go beyond the primary school level. Most did not have a constant job (76.6%). The average number of previous thymic episodes was 2±1.33 times/year. A quarter of the patients (26.6%) had hypomanic symptoms in the intercritical phase and 20% had depressive symptoms. Hypomanic symptoms were correlated with tobacco use (p=0.035). Depressive symptoms weremore frequent in men (p=0.074). Functioninglevel was lower in subjects living in rural areas (p=0.065).

Our study suggests that residual symptoms were frequent with a significant functional impact. As a result, their identification and management are highly essential to improve the overall functioning of patients with bipolar disorder.

Tamoxifen is an antioestrogen agent used in breast cancer treatment. According to some guidelines, this molecular was also proposed for the treatment of acute mania. In fact, Tamoxifen inhibits the intracellular action of the protein kinase C (PKC), which is the direct target in the treatment of mania episodes. Lithium and valproate have also the same action.

We aimed to show the case of an acute mania under an inhibitor PKC treatment and insisted that other studies are recommended.

Case report description and research on medline, pubmed with the keywords: Tamoxifen, Bipolar disorder, protein kinase C,mania.

We reported a case of a 53-year-old woman with past history of unipolar depression. In 2018 when she was diagnosed with breast cancer. She received antidepressant drugs but she interrupted the treatment after a few months. She was treated for her breast cancer with mastectomy, radiotherapy, and 20 mg per day of Tamoxifen prescribed since Mars 2018. She had been admitted in June 2019 in our department for acute mania. The patient received Tamoxifen as it was prescribed. She was not taking any concomitant medications. No history of drug abuse was reported. Medical examination, laboratory, and radiological investigations did not indicate any medical pathology.

In our case, Tamoxifen had not ovoid the acute mania in spite of its Known anti-manic properties as reported in the literature. Possible neurobiological effect of tamoxifen on the nervous system should be studied to evaluate the safety of this treatment mainly in patients with bipolar disorder.

El objetivo del estudio era determinar el nivel de tratamiento no voluntario que los pacientes con trastorno del estado de ánimo y sus familias desean en caso de un episodio maníaco o hipomaníaco.

Se realizó una encuesta dentro de dos organizaciones de autoayuda durante dos convenciones que reunieron a más de 500 pacientes junto con familias y cuidadores. Se presentó una virieta clínica que describía a un paciente hipomaníaco no colaborador que comenzaba a poner en peligro su situación profesional y económica y causaba estrés excesivo en su familia, y se siguió por un cuestio-nario de ocho elementos. El nivel de tratamiento coercitivo visto como apropiado se midió por escalas analógicas visuales.

Los 503 respondientes discreparon parcialmente con la afirmación de que el paciente debía decidir por sí mismo sobre su hospitalización y favorecieron en parte algún tratamiento no voluntario sobre el rechazo del tratamiento. No hubo diferencias éntre los pacientes, los familiares y los cuidadores relacionadas con la aceptación de la hospitalización y el tratamiento coercitivos. Los respondientes asignaron un rol importante a los equipos de tratamiento y los miembros de la familia en las decisiones para el tratamiento coercitivo.

La mayor parte de los respondientes (incluida una mayona de los pacientes) apoya un grado moderado de tratamiento coercitivo en el caso de un estado hipomaníaco o maníaco. Las encuestas de opinión de las personas implicadas podrían influir en la prác-tica, la legislación y posiblemente las directivas previas que los pacientes o las organizaciones de pacientes podrían escribir.

– La diferenciación clínica transversal de la esquizofrenia o el trastorno esquizoafectivo de la manía psicótica incongruente con el estado de ánimo o la manía mixta es difícil, ya que faltan síntomas patognomónicos en estos trastornos.

– Comparar una serie de variables clínicas relacionadas con el estado de ánimo y la cognición en grupos de pacientes con diagnóstico del DSM-III-R de esquizofrenia, trastorno esquizoafectivo, manía psicótica incongruente con el estado de ánimo y manía mixta psicótica incongruente con el estado de ánimo.

– Se evaluó a 151 pacientes consecutivos en la semana anterior al alta utilizando la Entrevista Clínica Estructurada para el DSM-III-R, edición del paciente (SCID-P). La gravedad del trastorno psicopatológico se evaluó por la versión de 18 elementos de la Escala de Evaluación Psiquiátrica Breve (BPRS) y los síntomas negativos, por la Escala para la Evaluación de los Síntomas Negativos (SANS). El nivel de insight se evaluó con la Escala para Evaluar el Desconocimiento de los Trastornos Mentales (SUMD).

– No hubo diferencias en las tasas de tipos específicos de ideas delirantes y alucinaciones entre los sujetos con esquizofrenia, trastorno esquizoafectivo, manía psicótica y manía mixta psicótica. Las puntuaciones de los factores de la SANS fueron significativamente más altas en los pacientes con esquizofrenia que en los grupos bipolares. Los pacientes con estado mixto puntuaron significativamente más alto en depresión y excitación comparado con el grupo de esquizofrenia y, en menor medida, el grupo esquizoafectivo. Los sujetos con esquizofrenia mostraron puntuaciones más altas en la SUMD, indicando que su compromiso en la dimensión de insight era mucho mayor que el de los sujetos con manía psicótica o manía mixta.

– Los síntomas negativos más bien que los afectivos pueden ser un constructo útil para diferenciar entre la esquizofrenia o los trastornos esquizoafectivos y la manía psicótica o la mixta incongruente con el estado de ánimo.

El flupentixol es un medicamento antipsicótico con conocidas propiedades elevadoras del estado de ánimo. Su propensión a inducir síntomas maníacos no se ha investigado.

Describimos seis pacientes, cuatro con esquizofrenia y dos con trastorno bipolar, en los que el tratamiento de flupentixol se asoció con la emergencia de síntomas maníacos.

Se debería vigilar cuidadosamente a los pacientes tratados con flupentixol en cuanto a la emergencia de síntomas maníacos.