Topiramate-Induced Psychosis

Mr. A was a 32-year-old man with obsessive-compulsive disorder who was initially administered 25 mg/day of topiramate for mood stabilization and weight loss. Eight months later, his dose was increased from 150 mg b.i.d. to 200 mg b.i.d. Within 1 week of the increase, he became paranoid, believed he was “the messiah,” and intended to sacrifice himself as directed by God. He also developed disorganized and illogical thought processes and a flattened affect. He appeared to be responding to internal stimuli. Mr. A was transferred to our care 2 months later, after having no improvement with a reduction in his dose of topiramate and the use of risperidone, 6 mg b.i.d. After discontinuation of topiramate, he became less paranoid and more organized, and his affect brightened. He improved continuously throughout the day, and within 24 hours, his psychosis had resolved.