Am

J Psychiatry

/36:3,

Psychiatry 34:197-204, 4. Reisby N, Gram LF, and pharmacokinetic 272,

/979

CLINICAL

1977 Bech P. et al: Imipramine: clinical variability. Psychopharmacology

134:790-793,

D, Friedman antidepressant

Mi, et al: Relationship between plasma levels. Am I Psychiatry

1977

Rapid-Cycling

Affective

SAMUEL

G.

SIRIS,

M.D.,

Disorder HARVEY

During R.

Imipramine

CHERTOFF,

M.D.,

clinical

more

descriptions

recently

several

bipolar

disease

None cycling

of these course

The

present

have

been

reports, with the

cases

of

studied

however, use ofan

communication

ing affective disorder with imipramine had postpartum depression. Case

of 10 48-hour other

cyclers, rapidly

details

a rapidly

and cycling

biologically has linked antidepressant

(2-4). a rapidly agent.

fluctuat-

which occurred after treatment been initiated in a woman with

a

Report

Ms.

A, a 30-year-old

table psychiatric al weeks after conflict because

on breast

milk.

married

mother

of two,

had

no no-

difficulties until age 27. At that time, severthe birth of her first child, Ms. A experienced her son seemed to do better on formula than

This

was

soon

superseded

by persistent

feel-

ings of depression, irritability, anxiety, worthlessness, and loss of sleep. After several weeks of suffering, she sought psychiatric help and was treated first with amitniptyline, 75 mg/day, and then with desipramine, 75 mg/day. Although her sleep improved, her dysphonic mood, lack of interest, and diminished ability to function persisted for 4 months, at which time they gradually abated and she felt like her ‘normal self” again. Medication was then discontinued. She had no history ofepisodes ofacceleration, euphoria, or irritability. She remained well until the birth of her daughter 3 years later. When the child was 3 months old, Ms. A again expenienced a similar conflict over breast feeding, coupled with apprehension about her parents retiring and moving to another state. She became depressed once again, with prominent tearfulness, doubting, preoccupations about her lack of capacity, feelings ofguilt, decreased energy, decreased ability to concentrate, poor appetite, and middle and late insomnia.

Received

May

18, 1978; accepted

Dec.

AND

JAMES

M.

PEREL,

A Case

Report

PH.D.

On the 85th day ofimipramine

7, 1978.

©

Treatment:

treatment,

when

Ms. A was

due’ ‘ to come out of one of her depressed intervals, oral lithium carbonate was begun. The dose was rapidly stabilized to give a serum level ofO.7-0.8 mEq/liter. On day 86 of imipramine treatment, Ms. A switched back to her normal euthymic state and remained there. Imipramine was continued at 300 mg/day until day 122, when the dosage began to be tapered off. Imipramine was completely discontinued on day 186. Lithium treatment was continued for an additional 12 months, then discontinued, and the patient has remained well. Ms. A’s family history is remarkable in that her mother suffered two clinical depressions. One, which occurred during the first trimester of an unplanned pregnancy, resolved spontaneously. The second depression, at age 65, was treated with imipramine for 5 months before responding

is Assistant Professor of Clinical Psychiatry, Columbia College of Physicians and Surgeons, Department of Psychiatry, 722 West 168th St. , New York, N.Y. 10032, where Dr. Chertoff is Associate in Psychiatry and Dr. Perel is Associate Professor of Psychopharmacology.

l/02/$00.35

REPORTS

‘ ‘

Dr. Siris University

0002-953X/79/03/034

RESEARCH

Her symptoms were worse in the morning than in the evening. After 3 weeks of steady depression, she consulted a psychiatrist once again and started taking imipramine. After 12 days of imipramine treatment at a dosage of 100/mg day, she had a 48-hour period ofcheerfulness and increased energy, which made her think temporarily she was ‘ ‘back to her old self. ‘ ‘ This episode ended abruptly, however, and she returned to her depressed state for the next 2 weeks. On the 28th day, this time on a dosage of 175 mg/day of imipramine, she again came out of her depressed state for approximately 48 hours. During that interval she had a night in which she slept only 2 hours but woke feeling fully rested. She described feeling “better than my usual self’ and decided to join a bowling league but did nothing else unusual. This signaled the start ofa 2-month period during which she emerged from and then relapsed into a depressed state seven separate times. During this period her imipramine dose was raised gradually to 300 mg/day (4.4 mg/kg, with a steady-state plasma concentration of 180 ng/ml) without alteration of her cyclic mood pattern. Her nondepressed intervals ranged from 2 to 6 days and her depressed episodes from 3 to 7 days. The transitions between these states seemed unrelated to external events and occurred abruptly over a few hours, during which time Ms. A felt herselfeither ‘ ‘slipping” or “snapping out of it. ‘ ‘ When she was not depressed, Ms. A was at times euthymic and at other times mildly hypomanic, with more than her normal level ofenergy and enthusiasm, and she occasionally required as few as 2 hours ofsleep. Her judgment remained sound, however, and she was neither giddy nor irritable. She was unmistakably different when depressed: hopeless , devoid of pleasure , self-critical , nonfunctional, and thoroughly miserable.

Rapid-cycling mood disorders have been recognized as rare but dramatic and potentially informative manifestations of affective disease. A review of the world literature in 1965 by Bunney and Hartmann (I) re-

vealed

AND

6. Gram LF, Overo KF: Drug interaction: inhibitory effect of neuroleptics on metabolism of tricyclic antidepressants in man. Br Mcdi 1:463-465, 1972 7. Olivier-Martin R, Marzin D, Buschsenschutz E, et al: Concentrations plasmatiques de l’imipramine et de Ia desmethylimipramine et effet anti-depresseur au cours d’un traitement control#{233}. Psychopharmacologia (Berl) 41:187-195, 1975

effects 54:263-

1977

5. Nies A, Robinson age and tricyclic

BY

March

I 979

American

Psychiatric

Association

341

CLINICAL

AND

RESEARCH

Am

REPORTS

promptly to ECT. Retrospective analysis of the mother’s case history revealed two abrupt and otherwise unexplained 48-hour episodes of feeling active, confident, and enthusiastic while on imipramine. These episodes disappeared as suddenly as they had started.

treatment and antidepressant.

with

tricyclic

Discussion

rated

out

whose only characteristics

ium,

Ms. A had a postpartum depression that was phenotypically unremarkable. She met the Research Diagnostic Criteria (5) for a simple primary endogenous recurrent major unipolar depression. For 3 weeks her course had been well established. However, after starting

imipramine,

changes hypomania such

Ms.

between over

a cyclic

depressed

viously,

although

in response

15 major

and period.

either euthymia To our knowledge,

depression a 10-week

response

unipolar

A underwent

to

imipramine

patient clear

switches

to imipramine

(6, 7). It is also in bipolar

patients

that

being

with

which have been switch’ process ‘ ‘

similar

cases

or

(8).

910,

mania

attacks

with

or the of

mechanisms

‘ ‘

rapid-cyclers’

according

‘

to

criterion

of

ofTraining

BY THEODORE

WEISS,

Schedule M.D.,

LINDA

Masseter muscle electromyographic back reportedly improves speech

Received Weiss

Chairman,

Philadelphia, Baltimore,

Nov.

13, 1978;

accepted

Dec.

and

27:304-309,

4 or

on

M.D.,

FK,

Murphy illness: and drugs.

DL, et al: The “switch II. Relationship to cateArch Gen Psychiatry

1972

try 32:1357-1361,

10. Dunner DL, sive patients.

AND

Speech

JOHN

PAUL

frequency of manic1978 Arch Gen Psychia-

1975

Patrick Compr

V. Fieve RR: Rapid cycling manic Psychiatry 18:561-566, 1977

depres-

Dysfluency BRADY,

M.D.

(1). We examined the efficacy of this method and the effects of training session frequency in an older patient with speech dysfluency.

(EMG) biofeedfluency in stutterers

Case

8, 1978.

©

Report

The patient was a 64-year-old woman with mild congenital choreoathetoid encephalopathy (cerebral palsy). The cerebral palsy had not impaired her functioning, but at age 62 her speech had worsened, and her jaws started clamping shut when she spoke. She had to compress her cheeks inward with both hands to facilitate speech flow. Inpatient evaluation revealed no clear reason for her deterioration, and several medications (haloperidol , perphenazine , amantadine,

is Assistant Professor and Dr. Brady is Professor and Department of Psychiatry, University of Pennsylvania, Pa. 19104. Dr. Carson is an intern at Sinai Hospital, Md.

0002-953X/79103/0342/03/$00.40

Never-

us to identify

trial.

Wehr 1, Goodwin FK: Tricyclics modulate depressive cycles. Chronobiologia 4:161, 9. Mass 1W: Biogenic amines and depression.

This work was supported by Alcohol, Drug Abuse, and Mental Health Administration Research Scientist Development Award MH70906 to Dr. Weiss from the National Institute ofMental Health, and by National Institutes of Health grant RR-00040 from the Division of Research Services.

342

a lithium

8.

Biofeedback

F. CARSON,

inconclusive.

encourage

sepa-

to lith-

1973

Bunney WE Jr. Goodwin process” in manic-depressive cholamines, REM sleep,

7.

affective episodes per year. As a group these pawere observed to benefit less from lithium than bipolar patients. However, this represented a of patients who were known to be bipolar before

Effects

Dr.

their

been

1967

29:420-425,

linking imipramine administration and the clinical syndrome exhibited by Ms. A is not implausible. Dunner and associates (10) examined the case records of 390 bipolar patients and found that 13% were more tients other group

would

yet

response

Jones FD, Maas 1W, Dekirmenjian H, et al: Urinary catecholamine metabolites during behavioral changes in a patient with manic-depressive cycles. Science 179:300-302, 1973 4. Post RM, Stoddard FJ, Gillin JC, et al: Alterations in motor activity, sleep, and biochemistry in a cycling manic-depressive patient. Arch Gen Psychiatry 34:470-477, 1977 5. Spitzer RL, Endicott I, Robins E: Research Diagnostic Criteria (RDC) for a Selected Group of Functional Disorders, 2nd ed. New York, Biometrics Research, New York State Psychiatric Institute, 1977 6. Pnien RK, Klett Ci, Caffey EM: Lithium carbonate and imipramine in prevention of affective episodes. Arch Gen Psychiatry

implicated in the manic-depressive (7, 9), so that a causal relationship

‘

is ofcourse

attempt

not

favorable

3.

occur

may be shortened Imipramine,

amine

case,

has

A’s

or manic treatment

I. Bunney WE Jr. Hartmann EL: Study ofa patient with 48-hour manic-depressive cycles. Arch Gen Psychiatry 12:611-618, 1965 2. Jenner FA, Gjessing LR, Cox JR. et al: A manic depressive psychotic with a persistent 48 hour cycle. Br J Psychiatry I 13:895-

well-documented

patients

Ms.

experience and

1979

REFERENCES

pre-

persistent

prophylactically

biogenic

our

otherwise

described

manic

a single

theless,

March

of hypomanic they are under

antidepressants

for study.

136:3,

not being treated with a tnicyclic subset of affectively ill patients

manifestations occur while

mood

being treated with lithium evidence suggests that

cycle time of some bipolar by tricyclic antidepressants

interacts

been

more

treated

imipramine than in those placebo (6), and preliminary

course,

into

have

known

in an

has not been

as

were The

J Psychiatry

I 979

American

Psychiatric

Association