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Case report. Mr. A, a 40-year-old man, has suffered from bipolar schizoaffective disorder (ICD-10) since he was 18 years old. After 2 years of relative stability, he discontinued treatment with valproate and olanzapine in May 2002, against the advice of his psychiatrist, because he complained of sexual dysfunction. Shortly afterward, he developed a schizodepressive episode (ICD-10 F25.1) with mood-incongruent psychotic symptoms and a severe melancholic syndrome. After 2 months of hospital treatment, acute symptomatology had largely remitted. With combination treatment consisting of venlafaxine (150 mg/day), quetiapine (300 mg/day), and valproate (1200 mg/day), he was discharged to day-clinic treatment. When Mr. A asked for a change of medication to help with erectile dysfunction, it was decided to treat him with ziprasidone instead of quetiapine, but all other medication was continued. His ziprasidone dose was increased to 100 mg/day, while quetiapine treatment was tapered off. Eight days after ziprasidone was started, he developed a hypomanic syndrome with a decreased need for sleep (3 hours per night), talkativeness, recklessness, high self-esteem, and racing thoughts. These symptoms worsened, and on day 10, ziprasidone was discontinued and quetiapine was restarted. The hypomanic syndrome remitted within 24 hours. As the sexual dysfunction persisted and continued to be a major problem for Mr. A, he asked to be given ziprasidone again after 6 weeks because he hoped for fewer sexual side effects with ziprasidone. Ziprasidone (120 mg/day) was given for a second time, valproate and venlafaxine were continued, and quetiapine was slowly tapered off. After 8 days on ziprasidone, another hypomanic episode developed; this time, the patient’s mood appeared to be dysphoric rather than euphoric. After 12 days, ziprasidone was discontinued for a second time and amisulpride was initiated. Again, the hypomanic syndrome remitted within 24 hours.

Hypomanic Episodes After Receiving Ziprasidone