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Isotretinoin-induced visual hallucinations in a patient with acne vulgaris.
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Another possible explanation for the psychosis in this patient is an adverse drug reaction ADR , in this case to isotretinoin. To establish a causal relationship between the use of a drug and psychotic symptoms, the causality criteria proposed by Bradford-Hill can be verified 16 : a temporality: the use of the medication precedes the appearance of psy chotic symptoms; b consistency: similar clinical situations of psychotic symptoms associated with isotretinoin use have been described; c dose-response biological gradient : the higher the dose of isotretinoin, the greater the possibility of psychiatric symptoms, in this case psychosis; d reversibility: isotretinoin exposure is discontinued and symptoms dis appear; e specificity: the use of isotretinoin is associated "specifically" with the appearance of psychotic symptoms; f analogy: a similar exposure provides the known effect, and g biological plausibility: the cause-effect relationship between isotretinoin and the onset of psychosis can be explained bio logically.
In this case, the following criteria were met to support the causal relationship between isotretinoin and the psychotic episode in this patient:. Temporality: the patient had not had any psychotic symp toms before starting treatment with isotretinoin.
Reversibility: the symptoms disappeared after discontinuation of isotretinoin, although antipsychotic treatment was also given, and for obvious reasons, the patient did not go back to isotretinoin therapy to verify the recurrence of symptoms.
Consistency: associated and reported psychiatric symp toms since isotretinoin came on the market are countable. Specificity and analogy met: A case reported by Rajagopal 17 shows similarities with the case described here age, rapid onset of psychotic symptoms after starting isotretinoin, type of hallucinations, and rapid improvement after dis continuing medication. Barak et al. Three of these cases also attempted suicide and in 3 cases the psychosis lasted more than 6 months.
In all of them, previous psychiatric morbidity was ruled out. The main reports of psychopathology associated with isotretinoin are of the depressive and suicidal type, although the stud ies are insufficient to establish a causal association. Biological plausibility: met. Retinoids are known to have a direct effect on the central nervous system, which may explain the neuropsychiatric symptoms.
To under stand the mechanisms that mediate the association between isotretinoin and psychosis, we need to start with the psychoneurobiological effects associated with this drug. The psychiatric side effects maybe related to the important role that retinoids play in signalling processes in the brain that regulate gene expression and control neuronal differentiation in the nervous system.
Three subtypes of retinoic acid recep tors RAR have been discovered: alpha, beta and gamma. In addi tion, these receptors have been found "colocalised" with vasopressin and corticotropin-releasing neurons, which pro vides a possible neurobiological basis for the involvement of retinoids in the regulation of various hypothalamic func tions and opens up the possibility that these drugs modulate the hypothalamic-pituitary-adrenal axis, which regulates the response to stress and is associated with numerous psychi atric disorders.
Of the causality criteria presented, four have greater causal weight: a existence of association; b biological plausibility; c adequate temporal presence, and d the association cannot be explained entirely by other factors. Determining causal relationships in health is a highly complex process. However, the numerous reports of psychopathology associated with the use of isotretinoin support this asso ciation. The clinician must therefore check for psychiatric symptoms before and during treatment with isotretinoin, and consider discontinuing the drug and providing early and appropriate treatment for the emerging mental disorder.
The authors of the article would like to thank Hospital Mental de Antioquia for providing space for patient care. Oral isotretinoin in different dose regimens for acne vulgaris: a randomized comparative trial. Indian J Dermatol Venereol Leprol. Inter-relationships between isotretinoin treatment and psychiatric disorders: depression, bipolar disorder, anxiety, psychosis and suicide risks.
World J Psychiatry. Psychosis during treatment with isotretinoin. Ther Adv Psychopharmacol. Strahan J, Raimer S. Isotretinoin and the controversy of psychiatric adverse effects.
Int J Dermatol. Depression - a side effect of cis-retinoic acid therapy. J Am Acad Dermatol. Rev Iberoam Psicosom. Lohr D, Birmaher B. Psychotic disorders. Symptom dimensions in the course of childhood-onset schizophrenia.
Eur Child Adolesc Psychiatry. Early-onset psychotic disorders: course and outcome over a 2-year period. Parnas J. From predisposition to psychosis: progression of symptoms in schizophrenia. Acta Psychiatr Scand. Premorbid adjustment as a predicto of phenomenological and neurobiological indices in schizophrenia.
Schizophr Res. Nicolson R, Rapoport JL. Childhood-onset schizophrenia: rare but worth studying. Biol Psychiatry. Environmental factors and the age at onset in first episode psychosis. Cumming JL. Organic psychoses. In this report, we present a unique case of a patient who developed somatic delusions after an isotretinoin dosage increase. C was a year-old university-educated single male with no prior history of psychosis and no family history of mental illness.
He presented to the emergency department accompanied by his parents due to multiple worsening somatic delusions. C believed that his face was disfigured after using Tobradex eye drop. He believed the eye drop had pooled in his nose, damaged his throat, and disfigured his face. He alleged that his forehead and teeth had shifted and that his tongue had atrophied. He denied spending a lot of time in front of a mirror; although, when he looked in the mirror, he saw a distorted face.
He later complained of further symptoms including muscle atrophy, weakness, and trouble walking, despite a normal gait. He denied symptoms of depression or anxiety. He denied auditory, visual, and tactile hallucinations as well as suicidal and homicidal ideations. There was no history of substance use, including cannabis and alcohol. All of the investigations, including complete blood count, electrolytes, blood glucose, thyroid function tests, liver enzymes, and renal function tests, were normal.
His drug urine screen was negative for illicit substances, including benzodiazepines. Computed tomography CT of the head was normal. The electroencephalogram EEG was reported within normal limits as no focal abnormalities nor epileptic activities were identified. In Mr. Additionally, there is a biological gradient or dose-response relationship, meaning that as the dose of isotretinoin increases, so does the potential of developing psychiatric symptoms, such as psychosis.
Based on his symptoms, he was given a diagnosis of delusional disorder, somatic subtype, as he had multiple somatic delusions for longer than 1 month, but his functioning was not markedly impaired, and his behaviour was not obviously bizarre. Somatic symptom disorder was considered as a differential diagnosis; however, Mr. Patient was discharged from psychiatric care to his family physician following a four-month period of sustained remission from the date of his discharge from his index psychiatric admission.
Isotretinoin, a retinoid derivative of vitamin A, is widely considered an effective treatment for severe nodular acne [ 1 ]. It is being increasingly prescribed for severe acne, as well as other skin conditions.
Despite many documented psychiatric side effects [ 1 , 7 — 13 ], the etiology of isotretinoin-induced psychosis remains poorly understood. Though, it has been previously reported that an excess of dietary vitamin A induces psychosis [ 17 ]. Furthermore, in patients with psychosis, isotretinoin is contraindicated as it worsens the course of the disease [ 18 ]. To the best of our knowledge, this is the first case report of isotretinoin-induced delusional disorder, somatic type.
It is a unique case, as it was an increase in the dosage of isotretinoin that triggered the psychotic episode and not the initiation of isotretinoin therapy. In the majority of case reports, the patients had a past psychiatric history or a family history of mental illness. Whereas the patient presented here had no prodromal symptoms, no previous psychiatric history, and no family history of mental illness. Approximately two weeks after discontinuing isotretinoin and starting quetiapine, the psychotic symptoms had resolved.
The patient continued to take quetiapine for approximately two months prior to it being discontinued. He was followed by psychiatry for a total of 4 months prior to being discharged back to the care of his family physician. He had no relapses following the discontinuation of isotretinoin. Psychiatrists are familiar with the physical side effects, such as extrapyramidal symptoms and metabolic syndrome, that can occur in patients on psychotropic drugs.
However, it is pertinent to consider that nonpsychotropic drugs commonly prescribed by other medical specialties may cause psychiatric side effects. Although no causal relationship between isotretinoin and psychopathology has been established, the numerous case reports, including the one presented here, support the association.
Therefore, physicians must be aware of this relationship and monitor patients on isotretinoin for psychiatric symptoms and consider stopping the drug and providing appropriate psychiatric treatment as soon as possible. Palabras clave:. Full Text. The authors of the article would like to thank Hospital Mental de Antioquia for providing space for patient care. Agarwal, R. Besarwal, K. Oral isotretinoin in different dose regimens for acne vulgaris: a randomized comparative trial.
Indian J Dermatol Venereol Leprol, 77 , pp. Ludot, S. Mouchabac, F. Inter-relationships between isotretinoin treatment and psychiatric disorders: depression, bipolar disorder, anxiety, psychosis and suicide risks. World J Psychiatry, 22 , pp. Segmiller, T. Linhardt, S. Dehning, H. Ther Adv Psychopharmacol, 3 , pp. Strahan, S. Isotretinoin and the controversy of psychiatric adverse effects. Int J Dermatol, 45 , pp. Hazen, J. Carney, A. Walker, J. Depression — a side effect of cis-retinoic acid therapy.
J Am Acad Dermatol, 9 , pp. Poblete, M. Herskovic, E. Rus-Calafell, S. Rev Iberoam Psicosom, , pp. Lohr, B. Bunk, C. Eggers, M. Symptom dimensions in the course of childhood-onset schizophrenia. Eur Child Adolesc Psychiatry, , pp. McClellan, C. McCurry, J. Snell, A. Early-onset psychotic disorders: course and outcome over a 2-year period. From predisposition to psychosis: progression of symptoms in schizophrenia. Acta Psychiatr Scand, 9 , pp. Gupta, R. Rajaprabhakaran, S.
Arndt, M. Flaum, N. Premorbid adjustment as a predictor of phenomenological and neurobiological indices in schizophrenia. Schizophr Res, 16 , pp. Nicolson, J. Childhood-onset schizophrenia: rare but worth studying. Biol Psychiatry, 46 , pp.
Lyne, K. Madigan, A. Lane, N. Turner, E. Environmental factors and the age at onset in first episode psychosis. Schizophr Res, , pp. Organic psychoses. Delusional disorders and secondary mania. Psychatr Clin N Am, 9 , pp. Proc R Soc Med, 58 , pp. Indian J Psychiatry, 56 , pp. Barak, Y. Wohl, Y. Greenberg, Y.
Bar Dayan, T. Friedman, G. Shoval, et al. Affective psychosis following Accutane isotretinoin treatment. Int Clin Psychopharmacol, 20 , pp. Marqueling, L.
Diana Restrepo a. Isotretinoin is a member of the retinoid family of drugs, and has been used for the treatment of severe acne. Its use has been associated with various psychiatric and behavioural symptoms. A case report and a non-systematic review of the literature are presented. Results: The case concerns a 13 year-old adolescent with insomnia, delusions, and auditory hallucinations, after two months of treatment with isotretinoin. The patient was admitted to hospital, where the use of psychoactive drugs and systemic disease that could explain the psychotic symptoms are ruled out.
After two weeks of stopping the isotretinoin and starting with treatment with olanzapine 10 mg per day, there was complete remission of the psychotic symptoms. On the onset of psychotic symptoms in an adolescent with no prior personal or family history of mental illness, the diagnosis of a secondary psychosis needs to be considered. Clinicians would benefit from knowing the psychiatric symptoms that could be associated with the use of this drug, as well as its suspension and specific treatment for emerging psychotic illness.
Key words: Psychotic disorders; isotretinoin; acne vulgaris; drug-related side effects and adverse reactions. Hombre adolescente de 13 anos con insomnio, ideas delirantes, alucinaciones auditivas, luego de dos meses de tratamiento con isotretinoina. The most commonly reported psychological symptoms suffered by patients with acne are related to anxi ety, depression and suicidal ideation. Among the therapeutic options for severe acne is isotretinoin, a cis-trans isomer of retinoic acid.
The therapeutic effect of isotretinoin is mediated by three mecha nisms: a reduction in the function of the sebaceous glands; b inhibition of the formation of new comedones, and c inhi bition of growth of Propionibacterium acnes. Although isotretinoin is indicated only for the treatment of severe cases of acne, it is often used in mild and moder ate cases.
Initially reports of cases with psychiatric symptoms appeared to be "anecdotal" or an idiosyncratic reaction to the drug, until in the Food and Drug Administration FDA demanded that the laboratory that developed the original isotretinoin molecule insert a warning on the pack contain ing the product: "Isotretinoin psychiatric disorders.
Can cause depression, psychosis and rarely suicidal ideation, suicide attempts and suicide. Discontinuation of this drug as therapy may be insufficient, and further evaluation may be neces sary". Subsequently there were some cases of suicide which were widely publicised in the United States and prompted a debate in the US Congress.
Later, inthe American Academy of Dermatology convened a panel of experts who concluded that epidemiological studies at that time did not show an association between isotretinoin and depression and suicide, because acne per se may be a risk factor for depression. The panel also pointed out that there was insufficient scientific evidence on the effects of retinoids on adult brain function.
The aim of this article is to present the case of an adolescent male who presented with a first psychotic episode associated with the use of isotretinoin for acne. Although the scientific evidence from the past 20 years on the adverse psychiatric effects of isotretinoin in the affective sphere are well docu mented, mainly depression and suicidal ideation, to date there have been very few cases of psychosis related to this drug.
During that period there had been no passive experiences, false acknowledgements, alterations of the form or the course of his thought or affective depressive or manic symptoms. At the time of the consultation the patient lived with both par ents, was in the normal year of schooling for his age, with good academic performance and no disciplinary problems and regularly played tennis. His parents described him as socia ble, extroverted, calm and responsible.
He had no previous psychiatric history. As significant previous medical history, he had slight head injury at the age of 11; a simple brain CT was normal, with no transient or permanent neurological deficit, and he did not require hospitalisation, surgery or subsequent medical follow-up.
There was no family history of mental illness. On admission to hospital, laboratory tests were requested Table 1. Isotretinoin was discontinued and the patient was referred for admission to psychiatric hospital. During the first unstructured psychiatric interview, the patient was alert, oriented to person, place and time, nor mal attention, with poor eye contact with the interviewer, restricted affect, language not altered in form and with appropriate tone, with delusional paranoid ideas of injury and harm "I'm being chased for my family's car licence plate", "My dad gave them the order to kill me With these clinical findings, a first psychotic episode was diagnosed and it was decided to admit the patient to hospital.
Thereafter improvement in behaviour was observed: better integration with the patient group and greater affective resonance. Progressively the delusional ideas were disrupted, the wake-sleep cycle was regulated and the suspi cious attitude disappeared. During the psychiatric interviews no obsessive or anxious symptoms or dysfunctional person ality traits were identified. After 2 weeks in hospital, the patient was free of psychotic and euthymic symptoms.
His family found him to have fully recovered, so it was decided to discharge him. Due to admin istrative problems of his health insurer, it was not possible to perform a brain CT scan or electroencephalogram during the hospital stay. The patient was assessed a month later as an outpatient; he said he felt well, and he had resumed his school and sports activities.
He had no difficulties in interac ting with peers, friends and family. He was continuing with the olanzapine with no adverse effects. Following an assess ment by dermatology, it was decided not to restart the retinoid, but to start other topical therapies for the patient's acne. In view of the complete resolution of the symptoms, the pending investigations were not subsequently requested.
From the psychopathological point of view, the symptoms pre sented by the patient were psychotic. Psychosis may present as a symptom or as a syndrome. Of these, the patient had paranoid delusions, auditory hallucinations and disorganised behaviour. No affective symptoms were detected that would have led us to suspect a mood disorder, and the diagnostic criteria for the other diagnostic categories that can manifest themselves with psychotic symptoms were not met.
Psychotic disorders are characterised by different symp tomatic domains, each with different courses, patterns of response to treatment and prognostic implications. Other demographic and clinical factors have been associ ated with the early onset of "primary" psychotic disorders. These include a family history of psychotic disorders, obstet ric complications and the use of cannabis, 14 none of which applied to the patient. Acute psychotic episodes with short duration and complete remission, like the case presented here, have been of great interest to psychiatry since Kraepelin's era.
Before classifying psychotic symptoms it is necessary to rule out "organicity" or that the symptoms are the side effect of a drug or a toxic substance. In cases where it is possible to demonstrate psychosis as a consequence of a systemic disease or side effect of a drug or toxic substance, it is called "organic psy chosis".
However, in the case of organic psychoses, delusional disor ders and manias secondary to neurological or toxic-metabolic diseases are indistinguishable from functional or primary psychoses.
In the patient presented here, no other symptoms or signs were observed to cause this type of prob lem to be suspected. Another possible explanation for the psychosis in this patient is an adverse drug reaction ADRin this case to isotretinoin.
To establish a causal relationship between the use of a drug and psychotic symptoms, the causality criteria proposed by Bradford-Hill can be verified 16 : a temporality: the use of the medication precedes the appearance of psy chotic symptoms; b consistency: similar clinical situations of psychotic symptoms associated with isotretinoin use have been described; c dose-response biological gradient : the higher the dose of isotretinoin, the greater the possibility of psychiatric symptoms, in this case psychosis; d reversibility: isotretinoin exposure is discontinued and symptoms dis appear; e specificity: the use of isotretinoin is associated "specifically" with the appearance of psychotic symptoms; f analogy: a similar exposure provides the known effect, and g biological plausibility: the cause-effect relationship between isotretinoin and the onset of psychosis can be explained bio logically.
In this case, the following criteria were met to support the causal relationship between isotretinoin and the psychotic episode in this patient:. Temporality: the patient had not had any psychotic symp toms before starting treatment with isotretinoin. Reversibility: the symptoms disappeared after discontinuation of isotretinoin, although antipsychotic treatment was also given, and for obvious reasons, the patient did not go back to isotretinoin therapy to verify the recurrence of symptoms.
Consistency: associated and reported psychiatric symp toms since isotretinoin came on the market are countable. Specificity and analogy met: A case reported by Rajagopal 17 shows similarities with the case described here age, rapid onset of psychotic symptoms after starting isotretinoin, type of hallucinations, and rapid improvement after dis continuing medication.
Barak et al. Three of these cases also attempted suicide and in 3 cases the psychosis lasted more than 6 months. In all of them, previous psychiatric morbidity was ruled out. The main reports of psychopathology associated with isotretinoin are of the depressive and suicidal type, although the stud ies are insufficient to establish a causal association. Biological plausibility: met. Retinoids are known to have a direct effect on the central nervous system, which may explain the neuropsychiatric symptoms.
To under stand the mechanisms that mediate the association between isotretinoin and psychosis, we need to start with the psychoneurobiological effects associated with this drug. The psychiatric side effects maybe related to the important role that retinoids play in signalling processes in the brain that regulate gene expression and control neuronal differentiation in the nervous system.
Three subtypes of retinoic acid recep tors RAR have been discovered: alpha, beta and gamma. In addi tion, these receptors have been found "colocalised" with vasopressin and corticotropin-releasing neurons, which pro vides a possible neurobiological basis for the involvement of retinoids in the regulation of various hypothalamic func tions and opens up the possibility that these drugs modulate the hypothalamic-pituitary-adrenal axis, which regulates the response to stress and is associated with numerous psychi atric disorders.
Of the causality criteria presented, four have greater causal weight: a existence of association; b biological plausibility; c adequate temporal presence, and d the association cannot be explained entirely by other factors. Determining causal relationships in health is a highly complex process. However, the numerous reports of psychopathology associated with the use of isotretinoin support this asso ciation.
The clinician must therefore check for psychiatric symptoms before and during treatment with isotretinoin, and consider discontinuing the drug and providing early and appropriate treatment for the emerging mental disorder. The authors of the article would like to thank Hospital Mental de Antioquia for providing space for patient care.
Oral isotretinoin in different dose regimens for acne vulgaris: a randomized comparative trial. Indian J Dermatol Venereol Leprol. Inter-relationships between isotretinoin treatment and psychiatric disorders: depression, bipolar disorder, anxiety, psychosis and suicide risks.
World J Psychiatry. Psychosis during treatment with isotretinoin. Ther Adv Psychopharmacol. Strahan J, Raimer S. Isotretinoin and the controversy of psychiatric adverse effects. Int J Dermatol. Depression - a side effect of cis-retinoic acid therapy. J Am Acad Dermatol. Rev Iberoam Psicosom. Lohr D, Birmaher B. Psychotic disorders.
Symptom dimensions in the course of childhood-onset schizophrenia. Eur Child Adolesc Psychiatry. Early-onset psychotic disorders: course and outcome over a 2-year period.
Parnas J. From predisposition to psychosis: progression of symptoms in schizophrenia. Acta Psychiatr Scand. Premorbid adjustment as a predicto of phenomenological and neurobiological indices in schizophrenia.
], but various case reports have suggested that isotretinoin is associated with depression and suicidal behaviour [Citrome, ; Hazen et al. ;. He denied any episode of visual hallucinations and other abnormal perceptions. The patient denied experiencing death wishes or suicidal. He denied symptoms of depression or anxiety. He denied auditory, visual, and tactile hallucinations as well as suicidal and homicidal ideations. hallucinations, (see or. Can cause depression, psychosis and rarely suicidal ideation, to kill me") and auditory hallucinations ("I can hear them calling me and threatening me". Salud Colectiva. On admission to hospital, laboratory tests were requested Table 1. Suicidal ideation was reported in 4. Retinoids are known to have a direct effect on the central nervous system, which may explain the neuropsychiatric symptoms. Parnas J. Isotretinoin and the controversy of psychiatric adverse effects. The authors declare that they have fol lowed the protocols of their work centre on the publication of patient data.Psychiatrists, psychiatric residents, non psychiatric physicians, psychologists, philosophers or other health professionals or persons interested in this area can take part in the journal. This journal publishes original works, revision or updating articles, case reports of all psychiatry and mental health areas, epistemology, mind philosophy, bioethics and also articles about methodology of research and critical reading.
SRJ is a prestige metric based on the idea that not all citations are the same. SJR uses a similar algorithm as the Google page rank; it provides a quantitative and qualitative measure of the journal's impact. SNIP measures contextual citation impact by wighting citations based on the total number of citations in a subject field. Isotretinoin is a member of the retinoid family of drugs, and has been used for the treatment of severe acne.
Its use has been associated with various psychiatric and behavioural symptoms.. A case report and a non-systematic review of the literature are presented.. The case concerns a 13 year-old adolescent with insomnia, delusions, and auditory hallucinations, after two months of treatment with isotretinoin. The patient was admitted to hospital, where the use of psychoactive drugs and systemic disease that could explain the psychotic symptoms are ruled out.
After two weeks of stopping the isotretinoin and starting with treatment with olanzapine 10 mg per day, there was complete remission of the psychotic symptoms..
On the onset of psychotic symptoms in an adolescent with no prior personal or family history of mental illness, the diagnosis of a secondary psychosis needs to be considered.. Clinicians would benefit from knowing the psychiatric symptoms that could be associated with the use of this drug, as well as its suspension and specific treatment for emerging psychotic illness.. The most commonly reported psychological symptoms suffered by patients with acne are related to anxiety, depression and suicidal ideation.
Among the therapeutic options for severe acne is isotretinoin, a cis—trans isomer of retinoic acid. The therapeutic effect of isotretinoin is mediated by three mechanisms: a reduction in the function of the sebaceous glands; b inhibition of the formation of new comedones, and c inhibition of growth of Propionibacterium acnes.
Although isotretinoin is indicated only for the treatment of severe cases of acne, it is often used in mild and moderate cases. Can cause depression, psychosis and rarely suicidal ideation, suicide attempts and suicide. Subsequently there were some cases of suicide which were widely publicised in the United States and prompted a debate in the US Congress. Later, in , the American Academy of Dermatology convened a panel of experts who concluded that epidemiological studies at that time did not show an association between isotretinoin and depression and suicide, because acne per se may be a risk factor for depression.
The panel also pointed out that there was insufficient scientific evidence on the effects of retinoids on adult brain function. The aim of this article is to present the case of an adolescent male who presented with a first psychotic episode associated with the use of isotretinoin for acne.
Although the scientific evidence from the past 20 years on the adverse psychiatric effects of isotretinoin in the affective sphere are well documented, mainly depression and suicidal ideation, to date there have been very few cases of psychosis related to this drug.
During that period there had been no passive experiences, false acknowledgements, alterations of the form or the course of his thought or affective depressive or manic symptoms. At the time of the consultation the patient lived with both parents, was in the normal year of schooling for his age, with good academic performance and no disciplinary problems and regularly played tennis.
His parents described him as sociable, extroverted, calm and responsible. He had no previous psychiatric history. As significant previous medical history, he had slight head injury at the age of 11; a simple brain CT was normal, with no transient or permanent neurological deficit, and he did not require hospitalisation, surgery or subsequent medical follow-up.
There was no family history of mental illness. On admission to hospital, laboratory tests were requested Table 1. Isotretinoin was discontinued and the patient was referred for admission to psychiatric hospital. With these clinical findings, a first psychotic episode was diagnosed and it was decided to admit the patient to hospital. Thereafter improvement in behaviour was observed: better integration with the patient group and greater affective resonance. Progressively the delusional ideas were disrupted, the wake—sleep cycle was regulated and the suspicious attitude disappeared.
During the psychiatric interviews no obsessive or anxious symptoms or dysfunctional personality traits were identified. After 2 weeks in hospital, the patient was free of psychotic and euthymic symptoms. His family found him to have fully recovered, so it was decided to discharge him. Due to administrative problems of his health insurer, it was not possible to perform a brain CT scan or electroencephalogram during the hospital stay.
The patient was assessed a month later as an outpatient; he said he felt well, and he had resumed his school and sports activities. He had no difficulties in interacting with peers, friends and family. He was continuing with the olanzapine with no adverse effects.
Following an assessment by dermatology, it was decided not to restart the retinoid, but to start other topical therapies for the patient's acne.
In view of the complete resolution of the symptoms, the pending investigations were not subsequently requested. From the psychopathological point of view, the symptoms presented by the patient were psychotic. Psychosis may present as a symptom or as a syndrome. Of these, the patient had paranoid delusions, auditory hallucinations and disorganised behaviour.
No affective symptoms were detected that would have led us to suspect a mood disorder, and the diagnostic criteria for the other diagnostic categories that can manifest themselves with psychotic symptoms were not met.
Psychotic disorders are characterised by different symptomatic domains, each with different courses, patterns of response to treatment and prognostic implications. These include a family history of psychotic disorders, obstetric complications and the use of cannabis, 14 none of which applied to the patient. Acute psychotic episodes with short duration and complete remission, like the case presented here, have been of great interest to psychiatry since Kraepelin's era.
However, in the case of organic psychoses, delusional disorders and manias secondary to neurological or toxic-metabolic diseases are indistinguishable from functional or primary psychoses. In the patient presented here, no other symptoms or signs were observed to cause this type of problem to be suspected. Another possible explanation for the psychosis in this patient is an adverse drug reaction ADR , in this case to isotretinoin. In this case, the following criteria were met to support the causal relationship between isotretinoin and the psychotic episode in this patient: 1.
Temporality: the patient had not had any psychotic symptoms before starting treatment with isotretinoin. Reversibility: the symptoms disappeared after discontinuation of isotretinoin, although antipsychotic treatment was also given, and for obvious reasons, the patient did not go back to isotretinoin therapy to verify the recurrence of symptoms. Consistency: associated and reported psychiatric symptoms since isotretinoin came on the market are countable.
Specificity and analogy met: A case reported by Rajagopal 17 shows similarities with the case described here age, rapid onset of psychotic symptoms after starting isotretinoin, type of hallucinations, and rapid improvement after discontinuing medication. Barak et al. Three of these cases also attempted suicide and in 3 cases the psychosis lasted more than 6 months. In all of them, previous psychiatric morbidity was ruled out. The main reports of psychopathology associated with isotretinoin are of the depressive and suicidal type, although the studies are insufficient to establish a causal association.
Biological plausibility: met. Retinoids are known to have a direct effect on the central nervous system, which may explain the neuropsychiatric symptoms. To understand the mechanisms that mediate the association between isotretinoin and psychosis, we need to start with the psychoneurobiological effects associated with this drug.
The psychiatric side effects may be related to the important role that retinoids play in signalling processes in the brain that regulate gene expression and control neuronal differentiation in the nervous system. Three subtypes of retinoic acid receptors RAR have been discovered: alpha, beta and gamma.
Of the causality criteria presented, four have greater causal weight: a existence of association; b biological plausibility; c adequate temporal presence, and d the association cannot be explained entirely by other factors. Determining causal relationships in health is a highly complex process.
However, the numerous reports of psychopathology associated with the use of isotretinoin support this association. The clinician must therefore check for psychiatric symptoms before and during treatment with isotretinoin, and consider discontinuing the drug and providing early and appropriate treatment for the emerging mental disorder. The authors declare that no experiments were performed on humans or animals for this study.
The authors declare that they have followed the protocols of their work centre on the publication of patient data. The authors have obtained the written informed consent of the patients or subjects mentioned in the article. The corresponding author is in possession of this document. The authors have no conflicts of interest to declare. The authors of the article would like to thank Hospital Mental de Antioquia for providing space for patient care..
Rev Colomb Psiquiat. ISSN: Previous article Next article. Issue 1. Pages January - March More article options. DOI: Isotretinoin therapy for acne vulgaris and first episode psychosis in an adolescent patient.
Download PDF. Felipe Valderrama a ,. Corresponding author. This item has received. Article information. Table 1. Introduction Isotretinoin is a member of the retinoid family of drugs, and has been used for the treatment of severe acne. Its use has been associated with various psychiatric and behavioural symptoms. Methodology A case report and a non-systematic review of the literature are presented.
Results The case concerns a 13 year-old adolescent with insomnia, delusions, and auditory hallucinations, after two months of treatment with isotretinoin. After two weeks of stopping the isotretinoin and starting with treatment with olanzapine 10 mg per day, there was complete remission of the psychotic symptoms. Discussion On the onset of psychotic symptoms in an adolescent with no prior personal or family history of mental illness, the diagnosis of a secondary psychosis needs to be considered.
Conclusion Clinicians would benefit from knowing the psychiatric symptoms that could be associated with the use of this drug, as well as its suspension and specific treatment for emerging psychotic illness.
Psychotic disorders.
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