Phenylpropanolamine and Psychosis

Abstract & commentary

Source: Goodhue A, et al. Exacerbation of psychosis by phenylpropanolamine. Am J Psychiatry 2000;157:1021-1022.

Phenylpropanolamine (ppa) is a common non-prescription decongestant, present in many combination cough and cold preparations. PPA, as with other decongestants such as pseudoephedrine, is pharmacologically similar to the class of psychostimulants that includes the amphetamines. These compounds increase the levels of catecholamines in the central nervous system. As such, there is a risk of the exacerbation of psychotic symptoms in vulnerable persons when taking one of these medications.

The current case report describes a case of psychosis associated with the use of PPA. Goodhue and associates describe a 31-year-old woman with a history of methamphetamine abuse who was initially admitted to the inpatient psychiatry unit with a depressed mood, command hallucinations, and paranoid delusions. The patient had been using methamphetamine heavily up until three weeks before admission. Her depressive symptoms had worsened two months before admission. Her psychotic symptoms had been present for many weeks but had been getting progressively more severe. The patient received paroxetine due to a history of a favorable response to it in the past, even in light of concomitant episodic methamphetamine use. The patient received perphenazine for her psychotic symptoms. By the third week, the patients depressive symptoms improved, followed by resolution of psychotic symptoms prior to hospital discharge.

The patient was again admitted six months later after experiencing a recurrence of command hallucinations and paranoia for two weeks. The urine drug screen was negative for amphetamines. During the three weeks prior to admission, the patient had been taking a combination of phenylpropanolamine (75 mg) and guaifenesin (400) mg, for congestion. She had also been taking cimetidine for 1 month for gastritis. While an inpatient, she continued to received paroxetine, perphenazine, and oral contraceptive pills. The congestion medication and cimetidine were stopped. The patient was discharged three days later with complete resolution of the voices and paranoia.

Comment by Michael F. Barber, PharmD

The current case report represents the first published evidence of PPA-induced psychosis. The patient in the case did have important factors that could have predisposed her to experiencing PPA-induced psychosis, namely a history of methamphetamine-associated psychotic symptoms as a result of her drug abuse. However, the case is important because it illustrates the potential of normally unsuspecting medications such as nonprescription decongestants to cause serious sequelae such as psychotic episodes. Clinicians should be aware of the potential of decongestants to cause psychosis in patients, particularly those with a history of psychosis. Thus, when selecting agents for cold symptoms in vulnerable patients, a great deal of caution must be undertaken when decongestants are deemed necessary. The amphetamines, which are structurally similar to ephedrine and pseudoephedrine (methamphetamine is commonly synthesized in clandestine labs using ephedrine as a substrate), are well known to cause dangerous psychotic episodes. While perhaps to a lesser extent, decongestants should be thought of as having similar potential for serious sequelae. Further, it is important for clinicians to recognize the fact that decongestants can also cause false positives for amphetamines on urine drug screens (although this did not happen in the current case report). This can affect the course of treatment for patients who present with apparent substance-induced psychoses, yet maintain that they have not ingested any illicit substances.