Asian Journal of Psychiatry 29 (2017) 164–165

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Asian Journal of Psychiatry

journal homepage: www.elsevier.com/locate/ajp

Letter to the Editor

Utility of lurasidone in bipolar disorder type IV patient—A case report MARK

Dear Editor,1. Introduction

Lurasidone, a newly approved atypical antipsychotic, has been approved by the U.S Food and Drug Administration (FDA) for schizophrenia and
bipolar I depression as monotherapy and as adjunctive therapy with lithium and valproate (Latuda prescribing information, 2013; Belmaker, 2014).
The concept of bipolar spectrum disorder can be derived from the Kraepelin era when he introduced the term of “Manic-depressive illness”
(Kraepelin, 1921). Gerald Klerman in 1981 reintroduced the term bipolar spectrum disorder and has presented subtypes of bipolar spectrum disorder
(Klerman, 1987). DSM-V has also acknowledged substance/medication- induced bipolar disorder as a distinct entity which corresponds to type IV of
Gerald Klerman classification of bipolar disorder. Despite being well known entities, there are few studies of treatment specifically for bipolar III
disorder or other bipolar spectrum disorder patients (Piver et al., 2002). Here we present a case report in which lurasidone was found to be effective
in a patient with bipolar disorder type IV.

2. Case report

Mrs. M, a 62-year old lady with nil contributory family history and no comorbid medical illness has history of one depressive episode 5 years back
with improvement in depressive symptoms with tablet escitalopram 10 mg/d and capsule fluoxetine 20 mg/d while being treated at some other
center, however, she developed switch to manic symptoms. Clinical condition improved after stopping antidepressants and initiating tablet sodium
valproate 1 g/d along with tablet trifluoperazine 10 mg/d. Thereafter, she developed two depressive episodes within a gap of one year about 3 years
back and was treated with antidepressants without the cover of mood stabilizers. She discontinued medications one year back and presented to our
center with depressive symptoms of six months duration. She was diagnosed with bipolar disorder type IV with the current episode being moderate
depression as per Gerald Klerman classification of bipolar disorder with Montgomery Asberg Depression Rating Scale (MADRS) score 21. Her
physical examination including vitals were within normal limit. Blood investigations, ECG and MRI brain did not reveal any abnormality. Tablet
lithium 800 mg/d and tablet escitalopram 10 mg/d were initiated. Serum lithium level estimation was 0.74 mEq/L. Due to persisting symptoms,
tablet escitalopram was initially optimized to 20 mg/d and later augmented with gradually increasing the dose of capsule fluoxetine. Patient’s
response remained suboptimal with adequate trial of escitalopram and fluoxetine in the combination of lithium 800 mg/d, hence antidepressants
were tapered and gradually stopped and tablet lurasidone 20 mg once a day was initiated with food along with tablet lithium 800 mg/d. Within one
week patient showed improvement and by the end of two weeks, MADRS score declined to zero. The patient is currently on follow up since last six
months and is sustaining improvement. No side effects were reported so far.

3. Discussion

Converging evidence from a number of studies suggests that at least 25% of patients with recurrent unipolar depression are incorrectly diagnosed
and may be better classified as having a broadly defined bipolar spectrum disorder (Angst et al., 2005). This would have been the situation in our
case also had we missed the history of drug −induced mania, this patient would have been wrongly diagnosed as unipolar depression.
The clinical relevance of bipolar spectrum disorder is that these patients will respond to mood stabilizers and/or neuroleptics instead of anti-
depressants (Ghaemi et al., 2002). In addition, bipolar spectrum patients are more likely to experience antidepressant-induced mania and long-term
rapid-cycling caused by antidepressants, with a worsening course of illness over time (Ghaemi et al., 2003). Despite being clinically relevant, there
are no randomized controlled trials of treatment specifically for bipolar III disorder or other bipolar spectrum disorders (Piver et al., 2002).
Most of the studies till date have examined the use of lurasidone in bipolar I disorders patients. Failure of response to standard antidepressant
therapy with prompt response to lurasidone in our patient of bipolar disorder type IV with current episode of moderate depression could point to the
utility of lurasidone in bipolar spectrum disorder beyond the classical type I and type II disorder. However, further research is warranted in this area
before its being routinely prescribed in other bipolar spectrum disorder patients apart from bipolar I disorder.

Conflicts of interest

None.

References

Angst, J., Sellaro, R., Stassen, H.H., Gamma, A., 2005. Diagnostic conversion from depression to bipolar disorders: results of a long-term prospective study of hospital admissions. J.

http://dx.doi.org/10.1016/j.ajp.2017.05.020
Received 20 May 2017
1876-2018/ © 2017 Elsevier B.V. All rights reserved.
Letter to the Editor Asian Journal of Psychiatry 29 (2017) 164–165

Affect. Disord. 84 (2–3), 149–157.

Belmaker, R., 2014. Lurasidone and bipolar disorder. Am. J. Psychiatry 171, 131–133.
Ghaemi, S.N., Ko, J.Y., Goodwin, F.K., 2002. Cade’s disease and beyond: misdiagnosis, antidepressant use and proposed definition for bipolar spectrum disorder. Can. J. Psychiatry 47,
125–134.
Ghaemi, S.N., Hsu, D.J., Soldani, F., Goodwin, F.K., 2003. Antidepressants in bipolar disorder: the case for caution. Bipolar Disord. 5, 421–433.
Klerman, G.L., 1987. The classification of bipolar disorders. Psychiatr. Ann. 17 (January (1)), 13–17.
Kraepelin, E., 1921. Manic-Depressive Insanity and Paranoia. E & S Livingstone, Edinburgh.
Latuda prescribing information, July 2013, http://www.latuda.com/LatudaPrescribingInformation.pdf.
Piver, A., Yatham, L.N., Lam, R.W., 2002. Bipolar spectrum disorders. New perspectives. Fam. Physician 48, 896–904.

⁎
Kavita Nagpal , Manoj Kumar, Rajesh Kumar
Indira Gandhi Employee State Insurance Corporation (IGESIC) Hospital, Jhilmil Colony, Delhi 110095, India
Institute Of Human Behaviour and Allied Sciences, G.T.B Hospital Road, Dilshad Garden, Delhi 110095, India
Indira Gandhi Employee State Insurance Corporation (IGESIC) Hospital, Jhilmil Colony, Delhi 110095, India
E-mail address: kvnagpal@yahoo.co.in

⁎
Corresponding author.

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