Exacerbation of Psychosis by Phenylpropanolamine

Ms. A was a 31-year-old woman with a history of methamphamine abuse who was initially admitted to the inpatient psychiatry unit with a depressed mood, command hallucinations, and paranoid delusions. She had been using methamphetamine heavily up until 3 weeks before admission. Her depressive symptoms, including anhedonia, decreased energy, increased sleep, suicidal ideation, and tearfulness, worsened 2 months before admission. In addition, her psychotic symptoms had been present for many weeks but had been getting progressively more severe. In the hospital, treatment with paroxetine was initiated because it had reportedly been effective previously in spite of episodic methamphetamine use. Ms. A was also treated with perphenazine. Her depressive symptoms improved, and her psychotic symptoms disappeared over 3 weeks. At discharge, she was no longer psychotic.

Six months later Ms. A was readmitted to the inpatient psychiatry unit after a 2-week recurrence of command hallucinations and paranoia. The results of a urine drug screening test were negative for methamphetamine; there was no historical evidence of resumed use. Approximately 3 weeks before admission Ms. A was prescribed a combination of phenylpropanolamine, 75 mg, and guaifenesin, 400 mg, for congestion. She had also been taking cimetidine for 1 month for gastritis. In the hospital she continued to received paroxetine, perphenazine, and oral contraceptive pills, which she had been taking as an outpatient. The congestion medication and cimetidine were stopped. Within 3 days the voices and paranoia had disappeared, and she was discharged.