532
BIOL PSYCHIATRY 1990;28:532-534
Mania as a Side Efiect of Phototherapy Josef Schwitzer, Christian Neudorfer, Hans-Giinther Blecha, mid W. Wolfgang Fleischhacker
Introduction Bright whize light of 2.500 Lux intensity has been reported to be a successful treatment of seasonal affective disorders (SAD) (Rosenthal et al. !984; Wirz-Justice et al. 1986; Lewy et al. 1987; Garvey et al. 1988; Kasper et al. 1988). Interestingly, potential side effects of phototherapy are seldom discussed. In a 1988 review, Kasper et al. mention "Tension in the eyes, headaches and dysphoria." They state that the dysphoria resembles hypomanic ~ymptoms as is found in SAD patients in spring and summer. They also report that one of the patients they have treated against atypical SAD developed mania and that other authors have also pointed out that manic episodes can follow phototheraF). We were not able to find any of these cases in the recent literature. A summary of an NIMH. sponsored workshop on SAD and its treatment made no mention at all of side effects (Blehar and Rosenthal 1989). Hypomanic syndromes have been reported by Wirz-Justice et ai. (1986), Kasper et al. (1989, 1990), and Wehr et al. (1986). Mania as a side effect of treatment with antidepressants has been reported in the literature (Bunney 1978). It is sometimes referred to as the "switch process" (Baldessarini 1985). In one of the research protocols of our department, pa-
From the Department of Psychiatry, Innsbruck University Clinics, Austria. Address reprint requests to W. Wolfgang Fleischhacker, Innsbruck University Clinics, Department of Psychiatry, Anichstrasse 35, A-6020 Innsbruck, Austria. Received March 7, 1990; revised April 17, 1990.
© 1990 Society of Biological PsychiatD,
tients with therapy-resistant depressions that de not show the classical seasonally dependent course of SAD are given a trial of therapy with bright white full spectrum fluorescent light (2.500 Lux at 90 cm) from 8 AM t o 10 AM and from 6 PM tO 8 PM. The light originated from six fluorescent lamps (True-Lite, Durotest-Corporation, N J) which were placed in frames standing at the patients' eye level. Patients were instructed to stay within 90 cm of the lamps and to look directly into the light from time to time. We wish to report 2 patients who developed full blown mania as a consequence of phototherapy. Both patients suffered from major mood disorders (DSM-III-R, American Psychiatric Association 1987) with hypersomnia and hyperphagia in a nonseasonal course.
Case 1 Ms. S. is a 24-year-old unipolar patient who has had 4 depressive episodes in the last 8 years. Her family history for mood disorders is positive insofar as her mother suffers from unipolar depression and has attempted suicide twice. The patient's reported episode, the 5th, turned out to be resistant to three chemically different antidepressants given in appropriate doses over an appropriate period of time. The last antidepressant used was clomipramine. Her score on the Hamilton Depression Scale (HDS) (Hamilton 1960) was 36 on the day that light therapy was initiated. She received no concomitant psychotropic medication. After the fourth phototherapy session, the patient suddenly declared herself completely healthy and ~ble to solve all her
0006-3223/90/$03.50
Brief Reports
problems. She requested to be discharged immediately. When asked to wait for a doctor, she became extremely aggressive, threw things on the floor, and attacked the nurses. On examination, she demonstrated marked irritability_, flight of ideas, agitation, aggression, as well r.3 loss of critique and insight. The patient required iv haloperidol and diazepam to treat the acute agitated state. She was subsequently switched to oral neuroleptics and lithium. Antipsychotics were stopped 26 days after the initiation of treatment. The patient was discharged in remission. Lithium treatment was continued. Seven months later the same patient received another course of bright white light sessions against a new depressive episode. She had stopped lithium 3 months previously. She had not responded to pretreatmc~lt with amitriptyline. At that point we were not sure whether her first manic episode could be directly related to phototherapy and, after discussion within the therapeutic team and with the patient, it was decided to treat her with light again. As in the episode described above, antidepressants had been terminated 10 days prior to phototherapy. This time she "switched" into mania after 6 days and light had to be discontinued. Again neuroleptics treated the manic syndrome successfully. Case 2 Ms. P. is a 49-year-old patient who had had her first depressive episode at the age of 47. The family history for mood disorders was negative. Again, the patient's illness was nonresponsive to conventional antidepressant treatment. Clomipramine was stopped and phototherapy started 7 days later. Her baseline HDS rating was 34. On the fifth day of ligat-treatment, she spent $700 on clothes and presents for all he1 copatients and reacted with considerable anger and aggression when the staff tried to keep her from going shopping again. At that p,,Ant, she ~!so started verbally aggressive confrontations with other patients. She wanted to take over all responsibilities of the nursing staff and finally the organization of the whole department. By this time she had also developed flight of ideas, pres-
BIOL PSYCHIATRY 1990;28:532-534
533
sured speech, and grandiose delusions concerning her financial situation. She was also agitated with a tendency towards impulsive-aggressive behavior. She hardly slept and her symptoms were clearly accentuated in the morning hours. Phototherapy was stopped and neuroleptic treatment with 600 mg thioridazine was started. The dose was reduced to 300 mg after 9 days and medication was stopped after 3 .week:; at which time she was completely free of symptoms. Discussion Although hypomanic syndromes of unclear significance have been mentioned in previous reports on phototherapy (Wehr et al. 1986; Kasper et al. 1989; Wirz-Justice et al. 1986), mania has so far not been reported in the context of treatment with bright white light. The 2 cases described above illustrate that the induction of mania in patients that have so far shown a unipolar course of the illness potentially complicates phototherapy. This "switch process" is discussed as a possible adverse event during the treatment with tricyclic antidepressants. None of our patients had a history of this phenomenon, either after antidepressant therapy or after withdrawal of antidepressants. As our patients had been off antidepressants for 7-10 days, it is unlikely that antidepressant withdrawal has contriL.~utedto the emergence of manic episodes. The patients had their morning course of phototherapy from 8 AM to 10 AM, at a time when they had already been awake for some time. Sleep deprivation can therefore be discarded as an etiological factor of switching into mania. Sleep did not change during light treatment until the beginning of manic symptoms. Our observations show that therapy with bright white light can also induce the "switch process." Because our patients suffered from major mood diserders with hypersornnia and hyperphagia in a nonseasonal course, they are probably not directly comparable to the pztients reported by Wirz-Justice et al. (1986) and Wehr et al. (1986) who described SAD patients. One could therefore hypothesize that our patients represent two
534
BIOL PSYCHIATRY 1990;28:532-534
biologically distinct subgroups of mood disorders, the former being more prone to switching imo mania than the latter. Clearly, this needs to be substantiated oy further studies. As this form of therapy is becoming increasingly popular, we believe that a cautionary note is warranted especially in cases where patients use transportable light boxes that make nonclinically supervised home treatments possible. On the other hand, the observed phenomenon supports the view that biologically active light can alter the course of major mood disorders.
References American Psychiatric Association (1987): Diagnostic and Statistical Manual of Mental Disorders, ed 3 (.~vised). Washington, DC: American Psychiatric Association. Baldessarini RJ (1985): Chemotherapy in Psychiatry. Cambridge, Mass. and England: H~'vard University Press, p 226. Blehar MC, Rosenthal NE (1989): Seasonal affective disorders and phototherapy. Arch Gen Psychiatry 46:469-474. Bunney WE Jr (1978): Psychopharmacology of the switch process in aff¢ctive disorders. In Lipton MA, DiMascio A, Killam KF (eds), Psychopharmacology--A Generation of Progress. New York: Raven Press, pp 1249-1259.
Brief Reports
Garvey MJ, Wesner R. Godes M (1988): Comparison of seasonal and non-seasonal affective disorders. Am l Psychiatry 145:100-102. Hamilton M (1960): A rating scale for depression. J Neurol Neurosurg Psychiatry 23:56-62. Kasper S, Rogers SLB, Madden PA, Joseph-Vanderpool JR, Rosenthal NE (1990): The effects of phototherapy in the general population. J Affective Disord 18:211-219. Kasper S, Rogers SL, Yancey A, Schulz PM, Skwerer RG, Rosenthal HE (1989): Phototherapy in individuals with and without subsyndromal seasonal affective disorder. Arch Gen Psychiatry 46:837844. Kasper S, Wehr TA, Rosenthal NE (1988): Saisonal abhingige Dep~ssionsformen (SAD). Nervenarzt 59:200-214. Lewy AL, Sak RL, Miller S, Hoban TM (1987): Antidepressant and circadian phase-shifting effects of light. Science 235:352-354. Rosenthal NE, Sack DA, Gillin JC, et al (1984): Seasonal affective disorder: A description of the syndrome and preliminary findings with white light therapy. Arch Gen Psychiatry 41:72-80. Wehr TA, Jacobsen FM, Sack DA, Arendt J, Tamarkin L, Rosenthal NE (1986): Phototherapy of seasonal affective disorder. Arch Gen Psychiatry 43:870--875, Wirz-Justice A, Bucheli B, Graw P, Kielholz P, Fisch HI3, Woggon B (1986): Light treatment of seasonal affective disorder in Switzerland. Acta Psy. chtatr S cand 74:193-204.
BIOL PSYCHIATRY 1990;28:532-534
Mania as a Side Efiect of Phototherapy Josef Schwitzer, Christian Neudorfer, Hans-Giinther Blecha, mid W. Wolfgang Fleischhacker
Introduction Bright whize light of 2.500 Lux intensity has been reported to be a successful treatment of seasonal affective disorders (SAD) (Rosenthal et al. !984; Wirz-Justice et al. 1986; Lewy et al. 1987; Garvey et al. 1988; Kasper et al. 1988). Interestingly, potential side effects of phototherapy are seldom discussed. In a 1988 review, Kasper et al. mention "Tension in the eyes, headaches and dysphoria." They state that the dysphoria resembles hypomanic ~ymptoms as is found in SAD patients in spring and summer. They also report that one of the patients they have treated against atypical SAD developed mania and that other authors have also pointed out that manic episodes can follow phototheraF). We were not able to find any of these cases in the recent literature. A summary of an NIMH. sponsored workshop on SAD and its treatment made no mention at all of side effects (Blehar and Rosenthal 1989). Hypomanic syndromes have been reported by Wirz-Justice et ai. (1986), Kasper et al. (1989, 1990), and Wehr et al. (1986). Mania as a side effect of treatment with antidepressants has been reported in the literature (Bunney 1978). It is sometimes referred to as the "switch process" (Baldessarini 1985). In one of the research protocols of our department, pa-
From the Department of Psychiatry, Innsbruck University Clinics, Austria. Address reprint requests to W. Wolfgang Fleischhacker, Innsbruck University Clinics, Department of Psychiatry, Anichstrasse 35, A-6020 Innsbruck, Austria. Received March 7, 1990; revised April 17, 1990.
© 1990 Society of Biological PsychiatD,
tients with therapy-resistant depressions that de not show the classical seasonally dependent course of SAD are given a trial of therapy with bright white full spectrum fluorescent light (2.500 Lux at 90 cm) from 8 AM t o 10 AM and from 6 PM tO 8 PM. The light originated from six fluorescent lamps (True-Lite, Durotest-Corporation, N J) which were placed in frames standing at the patients' eye level. Patients were instructed to stay within 90 cm of the lamps and to look directly into the light from time to time. We wish to report 2 patients who developed full blown mania as a consequence of phototherapy. Both patients suffered from major mood disorders (DSM-III-R, American Psychiatric Association 1987) with hypersomnia and hyperphagia in a nonseasonal course.
Case 1 Ms. S. is a 24-year-old unipolar patient who has had 4 depressive episodes in the last 8 years. Her family history for mood disorders is positive insofar as her mother suffers from unipolar depression and has attempted suicide twice. The patient's reported episode, the 5th, turned out to be resistant to three chemically different antidepressants given in appropriate doses over an appropriate period of time. The last antidepressant used was clomipramine. Her score on the Hamilton Depression Scale (HDS) (Hamilton 1960) was 36 on the day that light therapy was initiated. She received no concomitant psychotropic medication. After the fourth phototherapy session, the patient suddenly declared herself completely healthy and ~ble to solve all her
0006-3223/90/$03.50
Brief Reports
problems. She requested to be discharged immediately. When asked to wait for a doctor, she became extremely aggressive, threw things on the floor, and attacked the nurses. On examination, she demonstrated marked irritability_, flight of ideas, agitation, aggression, as well r.3 loss of critique and insight. The patient required iv haloperidol and diazepam to treat the acute agitated state. She was subsequently switched to oral neuroleptics and lithium. Antipsychotics were stopped 26 days after the initiation of treatment. The patient was discharged in remission. Lithium treatment was continued. Seven months later the same patient received another course of bright white light sessions against a new depressive episode. She had stopped lithium 3 months previously. She had not responded to pretreatmc~lt with amitriptyline. At that point we were not sure whether her first manic episode could be directly related to phototherapy and, after discussion within the therapeutic team and with the patient, it was decided to treat her with light again. As in the episode described above, antidepressants had been terminated 10 days prior to phototherapy. This time she "switched" into mania after 6 days and light had to be discontinued. Again neuroleptics treated the manic syndrome successfully. Case 2 Ms. P. is a 49-year-old patient who had had her first depressive episode at the age of 47. The family history for mood disorders was negative. Again, the patient's illness was nonresponsive to conventional antidepressant treatment. Clomipramine was stopped and phototherapy started 7 days later. Her baseline HDS rating was 34. On the fifth day of ligat-treatment, she spent $700 on clothes and presents for all he1 copatients and reacted with considerable anger and aggression when the staff tried to keep her from going shopping again. At that p,,Ant, she ~!so started verbally aggressive confrontations with other patients. She wanted to take over all responsibilities of the nursing staff and finally the organization of the whole department. By this time she had also developed flight of ideas, pres-
BIOL PSYCHIATRY 1990;28:532-534
533
sured speech, and grandiose delusions concerning her financial situation. She was also agitated with a tendency towards impulsive-aggressive behavior. She hardly slept and her symptoms were clearly accentuated in the morning hours. Phototherapy was stopped and neuroleptic treatment with 600 mg thioridazine was started. The dose was reduced to 300 mg after 9 days and medication was stopped after 3 .week:; at which time she was completely free of symptoms. Discussion Although hypomanic syndromes of unclear significance have been mentioned in previous reports on phototherapy (Wehr et al. 1986; Kasper et al. 1989; Wirz-Justice et al. 1986), mania has so far not been reported in the context of treatment with bright white light. The 2 cases described above illustrate that the induction of mania in patients that have so far shown a unipolar course of the illness potentially complicates phototherapy. This "switch process" is discussed as a possible adverse event during the treatment with tricyclic antidepressants. None of our patients had a history of this phenomenon, either after antidepressant therapy or after withdrawal of antidepressants. As our patients had been off antidepressants for 7-10 days, it is unlikely that antidepressant withdrawal has contriL.~utedto the emergence of manic episodes. The patients had their morning course of phototherapy from 8 AM to 10 AM, at a time when they had already been awake for some time. Sleep deprivation can therefore be discarded as an etiological factor of switching into mania. Sleep did not change during light treatment until the beginning of manic symptoms. Our observations show that therapy with bright white light can also induce the "switch process." Because our patients suffered from major mood diserders with hypersornnia and hyperphagia in a nonseasonal course, they are probably not directly comparable to the pztients reported by Wirz-Justice et al. (1986) and Wehr et al. (1986) who described SAD patients. One could therefore hypothesize that our patients represent two
534
BIOL PSYCHIATRY 1990;28:532-534
biologically distinct subgroups of mood disorders, the former being more prone to switching imo mania than the latter. Clearly, this needs to be substantiated oy further studies. As this form of therapy is becoming increasingly popular, we believe that a cautionary note is warranted especially in cases where patients use transportable light boxes that make nonclinically supervised home treatments possible. On the other hand, the observed phenomenon supports the view that biologically active light can alter the course of major mood disorders.
References American Psychiatric Association (1987): Diagnostic and Statistical Manual of Mental Disorders, ed 3 (.~vised). Washington, DC: American Psychiatric Association. Baldessarini RJ (1985): Chemotherapy in Psychiatry. Cambridge, Mass. and England: H~'vard University Press, p 226. Blehar MC, Rosenthal NE (1989): Seasonal affective disorders and phototherapy. Arch Gen Psychiatry 46:469-474. Bunney WE Jr (1978): Psychopharmacology of the switch process in aff¢ctive disorders. In Lipton MA, DiMascio A, Killam KF (eds), Psychopharmacology--A Generation of Progress. New York: Raven Press, pp 1249-1259.
Brief Reports
Garvey MJ, Wesner R. Godes M (1988): Comparison of seasonal and non-seasonal affective disorders. Am l Psychiatry 145:100-102. Hamilton M (1960): A rating scale for depression. J Neurol Neurosurg Psychiatry 23:56-62. Kasper S, Rogers SLB, Madden PA, Joseph-Vanderpool JR, Rosenthal NE (1990): The effects of phototherapy in the general population. J Affective Disord 18:211-219. Kasper S, Rogers SL, Yancey A, Schulz PM, Skwerer RG, Rosenthal HE (1989): Phototherapy in individuals with and without subsyndromal seasonal affective disorder. Arch Gen Psychiatry 46:837844. Kasper S, Wehr TA, Rosenthal NE (1988): Saisonal abhingige Dep~ssionsformen (SAD). Nervenarzt 59:200-214. Lewy AL, Sak RL, Miller S, Hoban TM (1987): Antidepressant and circadian phase-shifting effects of light. Science 235:352-354. Rosenthal NE, Sack DA, Gillin JC, et al (1984): Seasonal affective disorder: A description of the syndrome and preliminary findings with white light therapy. Arch Gen Psychiatry 41:72-80. Wehr TA, Jacobsen FM, Sack DA, Arendt J, Tamarkin L, Rosenthal NE (1986): Phototherapy of seasonal affective disorder. Arch Gen Psychiatry 43:870--875, Wirz-Justice A, Bucheli B, Graw P, Kielholz P, Fisch HI3, Woggon B (1986): Light treatment of seasonal affective disorder in Switzerland. Acta Psy. chtatr S cand 74:193-204.
