Acute Abdomen Following Abrupt Cessation of Imipramine - A Case Report

Sir, Psychotropic drugs appear to produce significant biochemical changes in the physiological system during their long term administration , that often become manifest only after their withdrawal. Various clinical states described are : rebound insomnia following discontinuation of benzodiazepines (Kale et al 1980) and mania after antide-pressant withdrawal (Mirin et al 1981). Such a switch process may be result of shifts in the balance between intracellular production , synaptic reuptake and metabolic degradation of monoamines (Schildkrautt et al 1976). There have been reports of gastrointes-tinal withdrawal symptoms like nausea, vomiting and abdominal discomfort with abrupt cessation of imipramine (Petti et al 1981). We present a case of affective disorder who developed acute abdomen following abrupt withdrawal of imipramine. Case Report Mrs. A. a 45 years old woman was referred with symptoms of sadness, anxiety, insomnia , feelings of inadequacy and guilt feelings of 2 months duration, in the absence of a precipitating factor. She had one attack of mania and two attacks of depressive psychosis in the last 3 years and was diagnosed as bipolar major affective disorder with present episode of endogenous depression. She had been taking Lithium (900 mg/day) for the past 9 months. In addition she was started on 150 mg of imipramine in 3 divided doses. She came out of depression in a period of 5 weeks. Her treatment was continued in the form of Lithium (900 mg/day) and Imipramine (100 mg/day) for another one month. Latter she was brought to clinic with symptoms of euphoria, increased talk, irritability, insomnia and doing household work hurriedly. Imi-pramine was stopped abruptly. Her daily dose of Lithium was increased to 1200 mg/day and hypnotic was added for sleep. After 36 hours of imipramine stoppage she attended medical emergency with symptoms of vomiting and severe generalized abdominal co-lieky pain. She was managed with antiemitic and antispasmodic drugs. Detailed physical examintion and investigations did not suggest any pathology. She could not be given any diagnosis for her acute abdomen. Her physical condition was attributed to abrupt withdrawal from imipramine. On follow up she had experienced similar abdominal symptoms when imi-pramine had to be withdrawn again when she developed symptoms of manic psycho-sis on a combination of Lithium and Imi-pramine. Such two experiences were quite convincing to suggest that her acute abdomen resulted from abrupt cessation imi-pramine. Many of the symptoms that have been considered side effects of imipramine treatment , e.g. …