In this paper, we report the development of a psychotic depressive episode after using varenicline for smoking cessation in a patient with the diagnosis of bipolar disorder. Case presentation A 47-year-old male was admitted to our psychiatry outpatient clinic with the symptoms of insomnia, agitation, and suicidal ideations during the last 4 days before his admission. His initial examination revealed paranoid ideas about his wife’s deception. He was arguing with his wife and was trying to keep her in their house. He was repeatedly calling his siblings due to his ideas and feelings that bad things might happen to them. He had been

suffering Inhibitors,research,lifescience,medical from severe insomnia during the previous 4 days. He also described suicidal ideas racing in his mind. He did not attempt any suicide during this period. The patient described that his complaints had Inhibitors,research,lifescience,medical acutely begun after an increase in the daily dose of oral varenicline tablets which was prescribed to him 10 days before by a smoking cessation clinic. He was prescribed 1 mg/day varenicline in the first week of his treatment, and then the dose was find more increased to 2 mg/day. Thus, he had been using 2 mg/day oral varenicline tablet for the last 3 days when he first presented to our psychiatry outpatient clinic. During the initial days, the patient’s

tobacco consumption dropped from Inhibitors,research,lifescience,medical 25 Inhibitors,research,lifescience,medical to 10 cigarettes/day. However, he had started to experience mild agitation. Other psychiatric symptoms such as insomnia, paranoid ideas and suicidal ideas had emerged on day 7. His past psychiatric history revealed the diagnosis of bipolar disorder for the last 25 years. His first episode was depressive which necessitated hospitalization. Then he was treated for 12 manic or hypomanic episodes and 7 depressive

Inhibitors,research,lifescience,medical episodes until his admission. His last episode was 3 years ago, depressive in nature and he had responded well to 400 mg/day oral amisulpirid. He was under 200 mg/day oral amisulpirid treatment when he was admitted to our clinic. He had a cousin who committed suicide in his twenties most probably due to a depressive episode. His medical history was nonsignificant. In his mental state examination he was oriented Isotretinoin to time, person, and place. His associations were slow, however, psychomotor agitation was easily recognized. His thought content included paranoid, depressive, and suicidal ideas. He was apparently dysphoric during his interview. In light of all of the available data presented above, the patient was diagnosed with bipolar disorder (current episode is depression with psychotic features) according to the DSM-IV diagnostic criteria. Then, varenicline was immediately stopped because it was considered as a triggering and maintaining factor in the current episode of the patient. He was prescribed 600 mg/day dose of quetiapine extended release oral tablets.