A Case of Mania Following the Use of Pramipexole

“Ms. B” was a 41-year-old woman with a history of bipolar II disorder that began with an episode of depression at the age of 16. During the early illness course, she received several serotonin reuptake inhibitors alone or in combination with lithium, valproic acid, and carbamazepine that led to the development of hypomania and rapid cycling. She had also experienced spontaneous hypomanic spells over the past 3 years. Her usual duration of hypomania was 2 days (range 1–7 days).

Because of the refractory nature of depression over the previous couple of years that had failed to respond to adequate trials of medications, including lamotrigine, oxcarbazepine, and modafinil, we decided to add pramipexole to valproic acid 750 mg b.i.d. (serum level 110 μg /ml). The starting dose of 0.125 mg was escalated over a 3-week period to 1.5 mg a day, to which there was a partial response. As the dosage was increased to 2 mg, Ms. B developed mania characterized by symptoms of euphoria, irritability, paranoia, decreased requirement of sleep, poor judgment, increased libido, and excessive spending of money. The manic symptoms lasted 2 months, but subsided within a week of discontinuation of pramipexole.