Pramipexole is a dopaminergic agonist used in the treatment of Parkinson’s disease and restless leg syndrome. Although there is a lack of pharmacological options to treat drug-induced parkinsonism, not many studies have been made on the use of pramipexole in its management. There is also evidence on pramipexole effectiveness on major depressive episodes, particularly for bipolar and treatment-resistant depression.

To describe a case of drug-induced parkinsonism treated with pramipexole in a complex patient with bipolar disorder type I and obsessive-compulsive disorder, long-term treated with antipsychotics and valproate.

We present the case of a 51-year-old woman admitted in our psychiatric inpatient unit mainly to treat a bipolar depression. She also presented a parkinsonian syndrome, and a neurological study was conducted. As a negative DaTSCAN concluded its cause to be pharmacological, we decided to stop lurasidone and initiated pramipexole.

Guidelines suggest that drug-induced parkinsonism should be managed by discontinuing causative drugs or switching to another agent. However, we decided to use pramipexole with the aim of not only treating the parkinsonian syndrome but helping manage the depressive episode. We observed a remission of the depressive symptoms and an improvement in the parkinsonian symptoms.

Although the best way to treat drug-induced parkinsonism is to avoid its causative agents, in clinical practice it is not always possible as some patients have resistant and complex psychiatric syndromes. We suggest considering pramipexole in its management, especially when dealing with a patient with a comorbid unipolar or bipolar depression. Further research is necessary to clarify its utility.

No significant relationships.

Femme de 63 ans, hospitalisée dans le service de psychiatrie de l’hôpital Henri-Mondor (Créteil) pour un épisode dépressif majeur d’intensité sévère sans caractéristiques psychotiques, dans le cadre d’un trouble dépressif récurrent, résistant à l’escitalopram 20 mg/j et à la venlafaxine 300 mg/j. Une cure de cinq séances d’électro-convulsivotérapie (ECT) a été conduite, avec une efficacité partielle, interrompue pour mauvaise tolérance, et suivie d’une rechute rapide. L’introduction du pramipexole (1,4 mg/j) a été suivie d’une rémission complète, rapide (en 15 jours) et durable (après deux mois de traitement), en association à la lamotrigine (100 mg/j à la fin de notre prise en charge).

Femme de 68 ans, hospitalisée dans notre service pour un épisode dépressif majeur d’intensité sévère sans caractéristiques psychotiques, dans le cadre d’un trouble bipolaire de type 3, résistant à plusieurs lignes de traitement bien conduites, dont un tricyclique (clomipramine). Au début de notre prise en charge, elle est traitée par acide valproïque et quiétiapine. Amélioration rapide (en 15 jours) sous pramipexole (1,76 mg/j), en association à la lamotrigine (50 mg/j à la fin de notre prise en charge) et l’acide valproïque (750 mg/j). Dans ces deux cas, le pramipexole a été efficace sans être associé à un antidépresseur, pour des patients ayant une indication d’ECT. Il n’a pas été constaté d’effets indésirables. La présentation clinique était centrée sur le ralentissement psychomoteur, l’anhédonie, l’apragmatisme, l’anesthésie affective. Ces dimensions symptomatiques pourraient être liées aux dysfonctions du système dopaminergique [4]. Ce tableau clinique pourrait être prédictif de l’efficacité des agonistes dopaminergiques.

The association of sleep disorders and post-traumatic stress disorder (PTSD) is almost universal. Nightmares are not only one of the most commonly associated but also featured as a diagnostic criterion for PTSD. PTSD-related nightmares are particularly distressing, may impair functioning and increase risk of suicide. No specific pharmacologic agent has been demonstrated to impair dreaming. Inhibition of PTSD-related nightmares with pramipexole has not heretofore been described. Such a case is presented.

Case study - This 60 year-old male with PTSD and trauma-related nightmares upon introduction of pramipexole 0.5mg PO qHS for Restless Leg Syndrome (RLS) had total elimination of dreams, which recurred upon discontinuation of this agent as a result of insomnia and increased anxiety. A lower dose of 0.375mg qHS provided optimal RLS-symptom control and overall improved tolerance despite nightmare recurrence.

Abnormalities on Neurological examination: Recent recall: 2 of 4 objects without improvement with reinforcement. Able to spell the word “world” forwards but not backwards. Abstract thought impaired. Chemosensory testing: Anosmia and normogeusia. Motor: Drift: mild right pronator drift with right cerebellar spooning and right abductor digiti minimi sign. Reflexes: 3+ brachioradialis and biceps bilaterally, absent ankle jerks. Other: CT scan with and without contrast: normal.

Nightmares related to PTSD may occur during Rapid Eye Movement (REM) sleep and non-REM sleep. Underlying sympathetic activation may lead to disruptive motor behavior similar to that seen in REM sleep behavior disorder. The exact mechanism of action by which inhibition of dreams occurred with use of pramipexole is unclear. Such a response is consistent with prior documented evidence of REM sleep suppression with low-dose pramipexole such as it‘s efficacy in reducing the intensity and frequency of nightmares and dream enactment related to REM sleep behavior disorder. Further research on therapeutic interventions that target nightmares directly may be beneficial for the management of patients with PTSD.