Manic episode following lurasidone initiation in bipolar I disorder: a case report

Lurasidone is a second-generation antipsychotic approved for the treatment of bipolar depression. Although effective, antipsychotics may precipitate manic episodes in susceptible individuals. This report aims to describe a unique case of a patient with bipolar I disorder who developed acute mania following lurasidone titration, highlighting the need for vigilance during treatment initiation. We present the case of a 43-year-old man with a history of bipolar I disorder who presented with a severe depressive episode, characterized by depressed mood, insomnia, anhedonia, and suicidal ideation. Laboratory investigations revealed a subtherapeutic serum valproate level of less than 13 µg/mL (reference range: 50-100 µg/mL). Lurasidone therapy was initiated and gradually titrated to 120 mg daily. After 1 week, the patient exhibited increased energy and decreased sleep needs. By the second week, he developed a full manic episode, presenting an elevated mood, irritability, intrusive behavior, and sleeping only one to two hours per night. Following the immediate discontinuation of Lurasidone, alongside the optimization of his sodium valproate dosage and the reinitiation of paliperidone, the patient experienced a dramatic reduction in his manic symptoms. His clinical condition stabilized, and he was subsequently discharged. This case emphasizes the critical importance of close monitoring for manic symptoms following lurasidone initiation in patients with bipolar I disorder and inadequate mood stabilization.