OBJECTIVE: Paliperidone, an atypical antipsychotic, which is an active metabolite of risperidone, extracted from 9-hydroxy risperidone. It has a high affinity to Dopamine D2, Serotonin 5HT-2A receptors. It has antagonist effect on 1, 2 and H1 receptors. In this article, a 45-year-old female patient has been presented with a disease history of 15-years, whose mania findings started after paliperidone palmitate treatment.
CASE: Patient who were admitted to the hospital with schizoaffective disorder diagnosis in the past, It has been learned that she was hearing the commanding voices, and thinking that her husband cheats on her with her daughter and that he would hurt her for last one month. Despite the absence of mood symptoms associated with active psychotic features at this admission, schizoaffective disorder was considered due to the presence of mood symptoms in the past history. Because of the lack of protective treatment compliance, the patient was given paliperidone palmitate IM of 150 mg/day on Day 1 and 100 mg/day on Day 8 and lorazepam (2 mg / day) was added to the treatment. Classical euphoric mania symptoms were observed 2 weeks after an effective antipsychotic treatment, such as increased amount of talking, decreased amount of sleep, increase in desire for shopping, increased sexual desire, excessive cheerfulness, and increased self-confidence. As the mania symptoms continued even after 2 weeks of the administration of last dose to the patient with Young Mania Scale (YMS) of 27, the dose to be administered on Day 38 was skipped and oral lithium 1200mg/day had to be included in the treatment. The presence of insomnia and irritability in previous mood episodes and the observation of euphoric mood in the mood episode following the use of paliperidone by a patient with and a score of 10 on the Naranjo Drug Side Effect Scale for the assessment of side effects suggested that the present appearance was an absolute effect of paliperidone. The fact that the present affective elevation was observed during an effective antipsychotic treatment and during the combined use of benzodiazepine strengthened our hypothesis. For active psychotic findings that constitute a reason for hospitalization for the patient with YMS: 2, oral haloperidole 5mg/day was added to the treatment, instead of paliperidone palmitate IM. Upon improvement of the manic symptoms, the hospitalization was terminated.
DISCUSSION: Although the mechanism of atypical antipsychotic-induced mania and hypomania is not fully understood, studies have focused on frontal-dopamine discharge, which is caused by 5HT-2A receptor antagonism. As they show potential antidepressant features with serotonin discharge due to -2 antagonist effects, they are thought to induce mania. When the hospitalization documentation of the case was examined, previous mood episodes had been with irritable mood, however, after paliperidone palmitate application, episode had been with euphoric mood brought us closer to the final affective state was a independent situation from the current disease. Additionally, the fact that the present affective elevation was observed during an effective antipsychotic treatment and during the combined use of benzodiazepine strengthened our thesis.