Giasson-Gariépy and Jutras-Aswad Addiction Science & Clinical Practice 2013, 8:22http://www.ascpjournal.org/content/8/1/22
A case of hypomania during nicotine cessationtreatment with bupropion
Karine Giasson-Gariépy1,2 and Didier Jutras-Aswad1,2*
Antidepressants can increase the spontaneous risk of hypomania or mania when used for treatment in affectivedisorders. When prescribed as an antidepressant, bupropion is generally considered to have a lower relative riskof inducing mood shifts. We describe the case of a 67-year-old man known for dysthymic disorder in remission onquetiapine and venlafaxine who experienced a first lifetime episode of hypomania with the introduction of bupropionSR for smoking cessation. To the best of our knowledge, this is the first case report of bupropion-induced mood shiftwhen used specifically for nicotine cessation in a nonbipolar patient. This case highlights the need for clinicians whoprescribe bupropion for smoking cessation to perform regular and systematic mood follow-ups during treatment.
These follow-ups could even be more important when bupropion is selected to quit smoking in a patient alreadytaking an antidepressant.
Keywords: Nicotine, Smoking cessation, Bupropion, Antidepressant, Hypomania, Venlafaxine
on venlafaxine XR (225 mg per day) and quetiapine XR
Bupropion SR is a dopamine/norepinephrine reuptake in-
(50 mg per day + an additional 25 mg twice daily as needed)
hibitor licensed for use as a smoking cessation aid. Com-
with no recent treatment regimen modification. Past psy-
pared with other antidepressants, bupropion is generally
chiatric history was significant for recurrent unipolar major
considered to have a lower relative risk of inducing mood
depressive episodes and cocaine abuse. Past substance use
shifts ], however there are no controlled studies speci-
history included daily alcohol use since age 35. The number
fically addressing this risk when prescribed for nicotine
of standard drinks per day increased over the years but
dependence treatment. Secondary mania induction in uni-
averaged 14–20 in the two years preceding his sobriety
polar depression treatment with bupropion has been in-
period. Cocaine was used once per month from the age of
frequently reported in the literature, but little is known
35 to 45 and approximately two times per year thereafter
about the potential for mood shifts when bupropion is
until his sobriety period. He reported no other recent regu-
prescribed as a smoking cessation aid. We describe here a
lar substance use. The patient had been stable psychiatric-
patient who experienced a first lifetime episode of hypo-
ally with no alcohol or cocaine use for seven months. There
mania with the introduction of bupropion SR for smoking
was no personal or family history of bipolar disorder, but
cessation. To the best of our knowledge, this is the first
prior long-term substance use history remains a potential
case report of bupropion-induced mood shift when used
specifically for smoking cessation in a nonbipolar patient.
For smoking cessation, bupropion SR coupled with nico-
tine replacement therapy (NRT) (14 mg patch daily) and
therapeutic groups were used. In March 2012, bupropion
Mr. X was a 67-year-old man with nicotine dependence (45
SR (150 mg per day) was prescribed for three days and a
packs-years), alcohol dependence in early full remission,
preplanned quit date was set for day 4. As the treatment
and dysthymic disorder in remission. He was maintained
began, the patient noticed some feelings of excitement,which were amplified when the dose was increased to
150 mg twice daily on the fourth day of treatment. From
1Research Center, Centre Hospitalier de l’Université de Montréal, Montreal,
that point on, he reported the onset of euphoria, racing
Quebec, Canada2Department of Psychiatry, Université de Montréal, Montreal, Quebec,
thoughts, and decreased need for sleep. He subsequently
2013 Giasson-Gariépy and Jutras-Aswad; licensee BioMed Central Ltd.Jutras-Aswad This is an open access article distributedunder the terms of the Creative Commons Attribution License which permits un-restricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Giasson-Gariépy and Jutras-Aswad Addiction Science & Clinical Practice 2013, 8:22
relapsed to alcohol and cocaine use (on days 7 and 8) with
mood shift, since the hypomanic symptoms noticeably
minimization of the consequences of substance use. He
took place before the cocaine/alcohol use. However, his
mentioned no suicidality or psychotic symptoms. The pa-
past substance use disorder could have been a predis-
tient met his therapist during the smoking cessation group
posing factor, as it has been associated with an increased
on day 5, who noticed a change in the patient’s affect and
risk of antidepressant-induced mania/hypomania in bi-
describing him as more anxious, tense, and keyed up. Sub-
jectively, on that day, the patient noticed being more anx-ious and having less ability to concentrate, which could be
early nicotine withdrawal symptoms or early hypomanic
Although there are several hypotheses for the hypomanic
symptoms. When seen by his psychiatrist 11 days after
episode, our findings suggest the need to carefully monitor
treatment initiation, the patient had decided to stop
for mood shifts when bupropion is prescribed as a smoking
substance use and bupropion for two days. He was get-
cessation aid, even in nonbipolar patients and in particular
ting back to his baseline level, reporting some residual
when combined with other antidepressants. Smoking ces-
anxiety. Venlafaxine and NRT were maintained, while
sation represents a sensitive period during which many fac-
his quetiapine XR dose was increased to 100 mg per day
tors can alter mood (e.g. nicotine withdrawal, NRT, the
regularly; bupropion was discontinued. One week later,
stress of quitting smoking). These factors may modify the
the patient’s mood was stable, and he had not used any
risk of mood shifts associated with bupropion.
Although the benefits of medication-assisted smoking
cessation are clear, there is a need for frequent and system-
atic monitoring of mood symptoms during treatment with
The timing of symptoms suggests an association be-
bupropion in the context of smoking cessation, even in pa-
tween bupropion initiation and mood shift in this pa-
tients not previously diagnosed with bipolar disorder. For
tient. Bupropion can induce mood switches in bipolar
patients who are already receiving antidepressant treat-
depression, but possibly less frequently than other anti-
ment, selecting bupropion over other smoking-cessation
depressants [There are only a few cases reported of
strategies should take into account the risk of mood shifts
bupropion-induced mood shifts in unipolar disorders
and of secondary mania induction To our know-ledge, bupropion-induced polarity changes in nonbipolar
patients have not been reported during the management
Written informed consent was obtained from the patient
of smoking cessation, except for a case of mania after
for publication of this case report.
A clinical interaction between bupropion and venlafaxine
This work was supported by the CHUM Department of Psychiatry; Université
could also explain the hypomania. Venlafaxine is a sero-
de Montréal Department of Psychiatry; and the CHUM Research Center
tonin/norepinephrine reuptake inhibitor. When used as an
(DJA). The authors have no conflicts of interest with this case study. Dr.
Jutras-Aswad has received research/education grant support from Pfizer,
adjunct in bipolar depression, it is associated with an in-
Janssen, Bristol-Myers Squibb, Mylan and Reckitt Benckiser Pharmaceuticals,
creased risk of mood shifts compared with bupropion
as well as presentation honoraria from Janssen, consultant honoraria from
An open-label study found a 2.5-fold increase in plasma
Merck and grant support from the CHUM Department of Psychiatry, Univer-sité de Montréal Department of Psychiatry and the CHUM Research Center.
levels of venlafaxine when bupropion is added, possibly via
The authors are solely responsible for the writing of this case study.
CYP2D6 inhibition . A case series mentioned the needto decrease venlafaxine dose when bupropion was added
Authors’ contributionsDJA conceived the case report. DJA and KGG drafted the manuscript. Both
for the treatment of major depressive disorder in order to
authors read and approved the final manuscript.
diminish serotonergic side-effects ]. Despite this knownpharmacokinetic interaction, the evidence of its clinical
Received: 12 July 2013 Accepted: 18 December 2013Published: 21 December 2013
implication remains limited. Combining therapeutic dosesof these antidepressants with overlapping mechanisms of
action and pharmacokinetic interactions could also en-
Post RM, Altshuler LL, Leverich GS, Frye MA, Nolen WA, Kupka RW, Suppes T,McElroy S, Keck PE, Denicoff KD, et al: Mood switch in bipolar depression:
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The Am J Psychiatry 1991, 148:541.
the patient to this mood shift. We do not consider the
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patient’s substance use to be a contributing factor to his
relationship? Annf Clin Psychiatry 1993, 5:271–274.
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doi:10.1186/1940-0640-8-22Cite this article as: Giasson-Gariépy and Jutras-Aswad: A case ofhypomania during nicotine cessation treatment with bupropion.
Addiction Science & Clinical Practice 2013 8:22.
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