Mirtazapine-Induced Mania in a Case of Poststroke Depression

A 68-year-old man had a right hemisphere stroke 2 years before being referred by his neurologist for psychiatric treatment. The patient was withdrawn and neglectful of his personal hygiene, he had poor appetite, and his sleep was interrupted by early-morning awakening. He also had memory difficulties and became lost in familiar surroundings. The initial examination revealed a disheveled individual who was oriented only to person. His speech was fluent and coherent, but he was slow to respond. Memory for recent events was impaired. He expressed feelings of worthlessness and helplessness and passive death wishes. Mini-Mental State Examination score was 17. He presented mild residual left-side weakness. He had no previous history of depression. Medical history was positive for insulin-dependent diabetes mellitus, coronary artery disease, and hypertension. Brain MRI revealed ischemic events in anterior portion of right frontal lobe and deep right temporal lobe. He had failed adequate trials of fluoxetine (titrated up to 60 mg daily for 5 months) and paroxetine (titrated up to 60 mg daily for 4 months). Paroxetine was discontinued, and after a washout of 10 days we initiated mirtazapine 15 mg at bedtime. Hamilton Rating Scale for Depression score was 27 before mirtazapine treatment. Three days later he became agitated, showing pressured speech and decreased need for sleep. The family reported that the patient went out in the streets without proper clothing and walked for miles without stopping. After returning home he refused insulin injections, accused his wife of having an affair, and became physically aggressive. He was subsequently admitted to our neuropsychiatric service and mirtazapine was discontinued. Treatment with carbamazepine and haloperidol was instituted, with gradual abatement of his manic excitement.