Charcoal Enhancement of Treatment for Tricyclic-Induced Mania

Induction of mania by tricyclic antidepressants (TCAs) is controversial, with indirect evidence for and against it. Unusual direct evidence of it was observed in a 77-year-old female patient having ingested an amitriptyline overdose. Mania developed while the TCA blood levels were high, and responded to a combination of charcoal and valproate. However, mania reappeared when charcoal was discontinued, and disappeared again when it was restarted. This time course suggests a therapeutic advantage for adding charcoal to valproate in treating tricyclic-induced mania. Presumably, charcoal might have removed a mania-inducing metabolite of amitriptyline. Moreover, repeated doses of oral activated charcoal accelerated the elimination of TCA from the blood stream to several times its original rate, which is consistent with interruption of the enterohepatic circulation. This enhanced elimination and improved outcome illustrate the value of repeated charcoal doses after TCA overdose, and suggest its use when mania develops in a patient who takes an antidepressant, at least amitriptyline or nortriptyline.

References

• 1 Wehr T A, Goodwin F K. Can Antidepressants Cause Mania and worsen the course of Affective Illness?.  Am J Psychiatry. 1987;  144 1403-1411
• 2 Goodwin F K, Jamison K R. Maintenance medical treatment in. Manic-Depressive Illness. New York; Oxford University Press 665-774
• 3 Lewis J L, Winokur G. The induction of Mania.  Arch Gen Psychiatry. 1982;  39 303-306
• 4 Angst J. Switch from depression to mania - a record study over decades between 1920 and 1982.  Psychopathology. 1985;  18 140-154
• 5 Prien R F, Klett C J, Caffey E MJr. Lithium Carbonate and Imipramine in prevention of affective illness.  Arch Gen Psychiatry. 1973;  29 420-425
• 6 Nemeroff C B, Evans D L, Gyuali L ,. et al . A double blind, placebo-controlled comparision of imipramine and paroxetine in the treatment of bipolar depression.  Am J Psychiatry. 2001;  158 906-12
• 7 Post R M. Mood Disorders: Treatment of Bipolar Disorders, in Comprehensive Text Book of Psychiatry. Edited by Sadock BJ, Sadock VA Lippincott Williams & Wilkins 2000: pp 1385-1430
• 8 Swartz C M, Sherman A. Treatment of TCA overdose with repeated charcoal.  Journal of Clinical Psychopharmacology. 1984;  4 336-340
• 9 Jones J, McMullen M J, Dougherty J ,. et al: . Repetitive doses of activated charcoal in treatment of poisoning.  Am J Emerg Med. 1987;  5 305-311
• 10 Farley T A. Severe hypernatremic dehydration after use of an activated charcoal-sorbitol combination.  J Pediatr. 1986;  109 719-727