Black cohosh induced mania in a recurrent depression patient

The herb named black cohosh, or Actaea racemosa (formerly named Cimicifuga racemosa), that is also known as black snakeroot, squawroot, rattle root, rattle weed, or bugbane is native to North America. The roots and rhizomes of this herb are frequently used in the treatment of menopausal symptoms and menstrual dysfunction. Many studies have demonstrated that this herbal drug, when standardized properly to its terpene glycoside fraction, is effective in alleviating menopausal symptoms. Adverse effects are extremely uncommon, and there are no known significant adverse drug interactions. Some investigators proposed that the mechanism of action of black cohosh might involve the serotonergic and dopaminergic pathways. We present a manic patient with psychotic and mixed features due to black cohosh use for her premenstrual symptoms.

Case: A 36 years old female having a history of recurrent depression for 15 years was prescribed duloxetine 30 mg daily and modafinil 100 mg daily, by a psychiatrist 4 months ago. Her depressive complaints were partially improved in two months. Approximately 2 months after antidepressant administration, her gynecologist administered black cohosh to reduce her premenstrual symptoms. In ten days after black cohosh use, she felt well and stopped antidepressant medication, but kept using black cohosh. She developed manic symptoms in 3 weeks after her treatment with black cohosh was started. Her husband informed that the patient became restless, was talking excessively and started making plans for being a politician; however, she was being hopeless, depressive, and sad at times. A few days later, she became suspicious about her neighbors and her husband and she informed the police that her husband had plans to kill her. Thus, she has taken to our emergency service and hospitalized with the diagnosis of mania with psychotic and mixed features. Her affective and psychotic symptoms disappeared in one month with quetiapine XR 800 mg daily and valproic acid 100 mg daily. In summary, the mechanism of action of black cohosh has not been fully understood. It is likely involved with the nervous system through central nervous activity, serotonergic, or dopaminergic pathways. Our case with history of recurrent depressive episodes showed that pharmacological effects of black cohosh might induce a manic episode with psychotic features because of its pharmacological effects on central nervous system. It seems as an important issue to pay attention to use of black cohosh in patients with mood disorders.