Clinical Case #1: Roaccutane Side Effect
A 19 year old female with new onset of rapid mood swings (sad mood for minutes to one hour alternating with regular mood) of around one week duration. The episodes of sadness are associated with unexplained crying spells and suicidal thoughts without plans or attempts during. She reported to have paranoid thinking as well (i.e. persecutory beliefs concerning a perceived threat towards herself from one friend and some other people). No anxiety symptoms. No panic attacks. No hallucinations. No previous similar symptoms.
Question: What is the diagnosis? What to do?
Answer: The Diagnosis is possible Roaccutane related side effect. Our patient stopped the medication and her symptoms were decreasing at 15-day follow up visit.
In 2005, FDA alerted all doctors that “all patients treated with isotretinoin should be observed closely for symptoms of depression or suicidal thoughts and referred to a specialist if necessary. Discontinuation of the drug may not be sufficient; psychiatric evaluation and further intervention may be necessary to prevent patients from harming themselves.”
Between 1982 and 2000 the FDA has received reports of 394 cases of depression, and 37 suicides occurring in patients exposed to isotretinoin. In Australia from 1995 to 1998 the Adverse Drug Reactions Advisory Committee received 12 reports of depression in patients taking isotretinoin. Two cases were described as severe, in four there were psychotic features, in three there was suicidal ideation and there were three suicide attempts (with one completed suicide).
In a number of these case reports, including 25 documented by the FDA, cessation of the drug has been associated with resolution of the mood disturbance and reinstitution of treatment has been followed by recurrence of depression.
However, there is controversy about the causal relationship between isotretinoin and depression for many reasons- refer to attached reports. There are no clear recommendations concerning initiation of antidepressants.