Should sertraline (selective serotonin reuptake inhibitor) be immediately stopped or gradually reduced and stopped in a patient experiencing a manic episode?

Management of Sertraline During Manic Episodes

Sertraline should be immediately discontinued in a patient experiencing a manic episode, as antidepressants may destabilize mood or incite manic episodes in bipolar patients. 1

Rationale for Immediate Discontinuation

When a patient develops a manic episode while taking sertraline, this represents a significant adverse event that requires prompt intervention:

• The American Academy of Child and Adolescent Psychiatry practice guidelines explicitly state that antidepressants like SSRIs may destabilize a patient's mood or incite a manic episode 1
• Manic symptoms associated with SSRIs may represent the unmasking of an underlying bipolar disorder or disinhibition secondary to the medication 1
• Sertraline-induced hypomania can occur as a genuine side effect of the medication, even in patients without risk factors for bipolar disorder 2

Clinical Approach

1. Immediate discontinuation of sertraline

   • When a manic episode occurs, the priority is to stop the triggering agent
   • Unlike typical SSRI discontinuation (where tapering is recommended), the presence of mania represents an urgent situation requiring immediate cessation

2. Monitor for both manic symptoms and discontinuation symptoms

   • Be aware that discontinuation symptoms may occur after stopping sertraline, but these are generally less concerning than ongoing mania
   • Discontinuation symptoms may include dizziness, nausea, fatigue, sensory disturbances, anxiety, and irritability 3

3. Initiate appropriate treatment for the manic episode

   • Consider FDA-approved agents for bipolar disorder such as lithium, valproate, or atypical antipsychotics 1
   • Avoid reintroducing any antidepressant until mood is stabilized with appropriate mood-stabilizing medication

Important Considerations

• A manic episode precipitated by an antidepressant is characterized as substance-induced per DSM criteria 1
• Distinguishing between behavioral activation (an SSRI side effect) and true mania/hypomania is important:
  • Behavioral activation typically occurs early in treatment (first month) or with dose increases
  • Behavioral activation usually improves quickly after SSRI discontinuation
  • Mania/hypomania may appear later and persist despite SSRI discontinuation 1

Common Pitfalls to Avoid

1. Gradual tapering of sertraline during a manic episode

   • While gradual tapering is typically recommended when discontinuing sertraline to prevent withdrawal symptoms 4, 3, this approach is contraindicated during a manic episode
   • Continuing sertraline, even at a reduced dose, may prolong or worsen the manic episode

2. Failure to recognize SSRI-induced mania

   • Some clinicians may mistake manic symptoms for increased energy or improvement in depression
   • Key features of mania include elevated/irritable mood, decreased need for sleep, grandiosity, racing thoughts, and increased goal-directed activity

3. Reintroducing sertraline too soon

   • Even after resolution of the manic episode, sertraline should not be reintroduced without careful consideration
   • If depression recurs, alternative treatments with lower risk of inducing mania should be considered

By immediately discontinuing sertraline in a patient experiencing a manic episode and implementing appropriate treatment for the mania, clinicians can effectively manage this serious adverse event and prevent further mood destabilization.