Year : 2015 | Volume
: 2 | Issue : 1 | Page : 53--56
Association of late-onset bipolar disorder with self-medication with "energy enhancing pills"
Aakanksha Singh, Sandeep Grover
Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh, India
Dr. Sandeep Grover
Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh
Self-medication is quite prevalent in South East Asia and particularly in India. However, little knowledge about the medicines often exposes the patients to the untoward side effects. There is a scanty literature on psychiatric side effects of these drugs and none in elderly population. Here, we report a case who presented with symptoms suggestive of bipolar affective disorder, which was found to be linked to his use of medicines available over-the-counter (OTC). His mental status improved with stoppage of OTC medications and use of low dose Quetiapine.
|How to cite this article:|
Singh A, Grover S. Association of late-onset bipolar disorder with self-medication with "energy enhancing pills".J Geriatr Ment Health 2015;2:53-56
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Singh A, Grover S. Association of late-onset bipolar disorder with self-medication with "energy enhancing pills". J Geriatr Ment Health [serial online] 2015 [cited 2022 Dec 8 ];2:53-56
Available from: https://www.jgmh.org/text.asp?2015/2/1/53/161386
Self-medication is defined as the consumption of medicinal products for the purpose of treating diseases or symptoms, or even promoting health, without a prescription provided by a medical professional.  There is lack of data on the psychological side effects of various classes of medications sold over-the-counter (OTC) and used by the patients as self-medications. In this case report, we present a case of late onset affective symptoms, which on evaluation were found to be possibly related to the use of energy enhancing medications consumed by patient after obtaining the same OTC and discuss the phenomenon of self-medication.
Mr. A, a 62-year-old graduate and married farmer of rural background, who was diagnosed with hypertension and diabetes mellitus about 10 years back presented to the outpatient unit with an illness of 12 months in form of intermittent periods of mood disturbance. Exploration of history revealed that about a 1 year prior to presentation he developed some generalized weakness without any other accompanying mood symptoms or disturbances in biofunctions. In the last few months, there was no change in his antihypertensive, lipid lowering agents and antidiabetic medications and his blood pressure was maintained within the normal range and blood glucose levels were also well controlled. For the complaint of generalized weakness, he consulted different local doctors and underwent investigations in the form of hemogram, renal function test, liver function test, and serum electrolytes, etc., all of which were found to be in the normal range. History and physical examination also did not suggest any evidence of diabetic neuropathy. The final opinion given to the patient by different physicians was that there is no basis for his weakness and it may be age-related and no intervention was suggested except for continuation of antihypertensive, lipid lowering agents, and antidiabetic medications along with multivitamins.
As he continued to remain distressed due to his symptoms he frequented different medical stores for some remedy. During one of such encounters, he was suggested to take energy enhancing drugs' by name of "sona-chandi capsules," which was available OTC along with few tablets of multivitamins and analgesics besides his usual dose of antihypertensive, oral hypoglycemic, and hypolipidemic drugs, which he was taking from last 10 years.
As per patient after taking the "sona-chandi capsules," he felt better and over the period of next days, he started taking 12-15 capsules of the same per day (i.e., 2-3 capsules after every 2-3 h) and perceived a sense of well-being.
After about 1-month of starting of these capsules, family members noticed that he was talking more than usual and at a fast pace, his sleep reduced to 50% and subjectively, he would feel full of energy. Over the next few weeks, he began to make plans of selling land and starting some other business, would go to market and buy expensive clothes for himself, sold gold ornaments of his wife and bought cosmetic goods for himself, started wearing T-shirts which he never tried even when he was young. This pattern continued for next 1 to 2 months, and family members found that he had collected a large stock of "energy enhancing capsules" in his almirah. He stopped supervising work of his farms and mostly appeared cheerful, more than his usual self.
After about 2 months of starting of the "sona-chandi capsules" and while still continuing on the same he began to interact less with family members, preferred to stay in his room throughout the day, would smoke biddis excessively (10-12/day) unlike his usual self and his self-care deteriorated. He would not allow family members to clean his room and appeared untidy and ill-kempt. His appetite also reduced by 50% and sleep disturbance continued as before. He would spend the entire day watching T.V. and appeared sad to his family members. This pattern continued for next 2 months when again had a switch of polarity and previously described symptoms reappeared. During the entire period, he continued to self-medicate himself with 10-12 "sona-chandi capsules" although exact details of the intake pattern during various phases of illness was not available. When family members objected to take excessive drugs, he began to hide the drugs, but continued to use without the knowledge of family members.
Over the period of a year, he had 3 episodes of hypomania and 2 episodes of depression, and when he was brought to our center, he was in one of the phases of hypomania.
There was no past history of any affective symptoms and other psychiatric disorders. Family history was suggestive of depression. Physical examination was grossly normal without any evidence of cushingoid features or hypothyroidism.
On the mental status examination, he was found to have increased rate of speech, labile affect, and poor insight. Cognitive functions and lobar function tests were within normal limits with Mini-Mental Status Examination score of 27 and frontal lobe assessment battery score was 15.
On investigation, his hemogram, serum electrolytes, fasting blood glucose, renal function test, liver function test, thyroid function test, and chest X-ray (posterior-anterior view) did not reveal any abnormality. Magnetic resonance imaging of the brain was suggestive of age-related mild cerebral atrophy, which was not sufficient to explain current symptomatology. Urine thin layer chromatography (TLC) was positive for opioids of nature other than morphine, codeine or metabolites of dextropropoxyphene.
Based on the history, mental status examination, and investigation findings he was diagnosed with a substance-induced mood disorder. He was asked to stop taking the "energy enhancing capsules" and was prescribed Quetiapine 50 mg/d which was increased to 100 mg/d after a week. Over 1-2 weeks, patient showed significant improvement and by the end of 1 month he was euthymic. Periodic urine screening for opioids and other chemicals was done and was found to be negative. He continued to maintain in remission during the follow-up duration of 9 months without any further complications.
Studies from different countries have reported varying rates of self-medications, depending on the primary symptoms, and the reported range varies from 3.2% to as high as 93.9%. , Studies from India suggest that self-medication is more common among those who are better educated and the most common sources of self-medication are previous prescription, advertisements on the television and newspapers, and information obtained from friends and relatives.  In terms of medications, a study from North India showed that analgesics are the most commonly used medications, followed by antacids, antibiotics, nutritional supplements, cough syrups, and antispasmodic medications.  Data also suggest that many people use medicines from complementary and alternatives modalities, with herbal medications being used commonly. ,
Many of the medications used for self-medications are available OTC in various chemist shops and chemists have no issues in selling the same. In fact, at times, the chemists are an important source of self-medications, as they themselves advise people to take certain medications.  Patients generally feel confident in pharmacist's knowledge about the medication being dispensed and pharmacists enjoy a positive public image in a number of countries. A study from Jordan showed that 78% of the general public believed that pharmacists play an important role in the provision of advice regarding the safety and efficacy of OTC choices and 63% would seek pharmacist's advice for minor conditions.  No such data are available with regard to the Indian population, but these practices are quite prevalent in India. In terms of psychotropic medications, availability of sedatives like benzodiazepines and other dependence-producing drugs like various opioids have also been noted. ,
Self-medication is under reported in India with very little information available about this phenomenon. Side effects of these OTC drugs are less commonly reported from India and we did not come across any case report of psychiatric side effect due to these drugs that too in elderly population. In the index case, the onset of the symptoms was temporally related to the self-medication with the energizing medications and the symptoms continued for a year during which patient continued to take the medications. Further, the symptoms abated with the stoppage of medications. The symptoms were very characteristic of bipolar disorder and there were no other associated factors which could explain the onset of the illness. In view of this a possibility of substance-induced mood disorder was considered.
An internet search with the search terms of "sona-chandi" shows that many products like sona-chandi bhasm and sona-chandi chyawanprash are available in the market, which are considered to be Ayurvedic preparations for enhancing sexual performance and general health respectively. However, we could not find exact details of the content of the "sona-chandi" capsules. Although patient's urine TLC was found to be positive for opioids while using the "sona-chandi" capsules, it can be said that this positive reaction could be due to small amount of opioids or due to cross-reaction with some other content in the capsule.
Our case adds to the limited existing data and suggests that whenever a patient presents with psychiatric manifestations at an atypical age, while taking the history, clinicians should always give due importance for evaluation of self-medications. Present case also suggests that while treating the elderly patients with various mental disorders, clinicians should discourage them to take OTC medications. Our case also suggests that there is a need for strict monitoring of sale of medications, with proper and mandatory labeling of the content, and sale of loose medicines should be banned from Indian market. Although, Ayurvedic and other streams of medicine are an important part of ancient Indian medicine, still some guidelines should be followed to maintain a quality control. An early and prompt action from regulatory authorities along with educating the common people about harms of self-medication can prevent harmful effects of these medicines.
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Conflicts of interest
There are no conflicts of interest.
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