title: Charcoal enhancement of treatment for tricyclic-induced mania.
abstract: 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.
authors.affiliation: Department of Psychiatry, Southern Illinois University School of Medicine, Springfield, Illinois 62794, USA.
authors.forename: V
authors.initials: V
authors.lastname: Jain
authors.forename: C M
authors.initials: CM
authors.lastname: Swartz
mesh_terms: D000368:Aged; D000639:Amitriptyline / Q000009:adverse effects* / Q000097:blood; D000929:Antidepressive Agents, Tricyclic / Q000009:adverse effects* / Q000097:blood; D000931:Antidotes / Q000627:therapeutic use; D001714:Bipolar Disorder / Q000139:chemically induced* / Q000188:drug therapy*; D002606:Charcoal / Q000627:therapeutic use*; D003866:Depressive Disorder / Q000188:drug therapy; D062787:Drug Overdose / Q000150:complications / Q000188:drug therapy; D005260:Female; D006801:Humans; D009661:Nortriptyline / Q000009:adverse effects* / Q000097:blood; D016896:Treatment Outcome; D014635:Valproic Acid / Q000627:therapeutic use
chemical_list: D000929:Antidepressive Agents, Tricyclic; D000931:Antidotes; D002606:Charcoal; D000639:Amitriptyline; D014635:Valproic Acid; D009661:Nortriptyline