Dehydroepiandrosterone and Lithium Carbonate: Interaction Details

a) A 68 year-old male with no documented psychiatric history initiated dehydroepiandrosterone (DHEA) 100 milligrams (mg) daily and increased the dose to 200 to 300 mg daily for 6 months. Within 3 months, family members noted the onset of odd behavior with prominent symptoms of agitation, delusional thinking, decreased sleep and appetite, and spending sprees. The patient was not taking any prescribed medication but did ingest alcohol in amounts up to 1 case of beer daily. Another 3 months elapsed, leading to involuntary inpatient admission secondary to rapid, loud, pressured speech with grandiose thoughts. At admission, the patient reported that he had decreased alcohol intake to 2 beers daily due to family concerns about his behavior changes. There was no family history of bipolar disorder. Urinary drug screen was negative. Over the seven-day hospital stay, with the institution of valproic acid 500 mg twice daily, the patient's behavior and sleep patterns improved, and the patient believed DHEA led to his symptoms. There were no ethanol withdrawal symptoms. The patient was discharged with follow-up care from his primary care physician with a diagnosis of substance-induced mood disorder ¹.

b) A 24-year-old female diagnosed with schizophrenia was resistant to daily doses of haloperidol 20 milligrams (mg), fluphenazine 40 mg, lithium carbonate 1200 mg, and lithium carbonate 900 mg plus thioridazine 300 mg. The patient appeared Cushinoid with moon face, acne, facial hair, abdominal hair, and a 40 pound weight gain in the previous 8 months. Dehydroepiandrosterone (DHEA) measured as part of an endocrine panel was 725 micrograms/deciliter (mcg/dL) (normal: 100 to 400 mcg/dL). Dexamethasone 1 mg orally at bedtime resulted in substantial improvement within one week. The patient appeared calmer, more alert with improved psychotic symptoms and ability to concentrate. At two weeks, a repeated DHEA level was within normal range (328 mcg/dL). The author concluded that elevated DHEA levels were associated with severe psychosis resistant to conventional antipsychotic therapy ².

c) A 13-year-old male decompensated with a subsequent two-year period of emotional problems accompanied by heavy use of LSD, hashish, barbiturates, and alcohol. His mental status included bizarre, disorganized, delusional thinking, auditory and visual hallucinations, paranoia, lack of attention to personal hygiene, agitation, and combativeness. He was diagnosed with chronic paranoid schizophrenia; schizophrenia, chronic undifferentiated type, and schizoaffective disorder, excited type. He was resistant to daily doses of trifluoperazine 40 mg, chlorpromazine 400 mg, and imipramine 100 mg. He was also resistant to combination therapy with chlorpromazine 400 mg with thiothixene 80 mg, thioridazine 1000 mg, perphenazine 48 mg with lithium carbonate 1200 mg, clonazepam 4 mg, and carbamazepine 1200 mg daily. Baseline DHEA level exceeded 900 mcg/dL. A seven-day suppression test with dexamethasone 1 mg orally at bedtime resulted in a normal DHEA level of 200 mcg/dL. By day 5, psychosis improved and the patient was well-oriented, conversational, and was making good eye contact. Once dexamethasone was discontinued, rapid decompensation and florid psychosis ensued despite "substantial amounts of psychotropic medications." DHEA increased to 536 mcg/dL. The author concluded that elevated DHEA levels were associated with florid psychosis resistant to conventional antipsychotic therapy ².