Mania induced by initiation of antidepressants is well documented, as is a withdrawal syndrome following sudden discontinuation of antidepressants. Mania occurring after withdrawal of antidepressants, however, has only been reported infrequently.

We describe antidepressant-discontinuation mania in two older patients initially diagnosed with unipolar depression.

Case 1: Madam P is a 66-year-old Chinese housewife diagnosed with major depressive disorder (MDD) in 2012. She was started on Escitalopram 10mg nocte but discontinued it within 3 weeks without any adverse effects. Escitalopram was re-started in December 2013 when she became depressed again, but she stopped taking it again after three months. Two weeks later, she presented in a manic state. Her mood stabilized with Risperidone 1mg nocte.

Case 2: Mr W is a 76-year-old Chinese retiree diagnosed with MDD in 2009. He was stable on Venlafaxine 75mg nocte and Fluvoxamine 150mg nocte until November 2013, when he requested to stop Venlafaxine. It was tapered off over one month, leaving him on Fluvoxamine alone. Three weeks after stopping Venlafaxine completely, he was admitted for mania with psychotic features. He was stabilized on Sodium Valproate 1000mg nocte and Olanzapine 10mg nocte.

Most antidepressant classes, including SSRIs, TCAs and SNRIs, have been reported to cause antidepressant-withdrawal mania, but this is the first report of Escitalopram being implicated. It is unclear whether antidepressant-withdrawal mania indicates a latent bipolar disorder, with attendant implications on treatment. Cholinergic overdrive is postulated to be the underlying mechanism but more research is needed to understand this rare phenomena.