Jakub Grabowski1, Leszek Bidzan1
1 Department of Developmental, Psychotic and Geriatric Psychiatry, Faculty of Medicine, Medical University of Gdansk, Gdansk, Poland.
Received: 24/11/2019 – Accepted: 29/01/2020
Tianeptine is used to treat symptoms of depression with coexisting anxiety. It is thought that, contrary to SSRIs, it reduces stress- induced behavioral and physical effects through the hypothalamo- hypophysial axis1,2. Cases of excessive consumption of tianeptine were described, suggesting its addictive potential. The mechanism of this process remains unknown, while withdrawal is difficult3.
A 53-year old female was frequently hospitalized because of alcohol addiction secondary to anxiety and depression symptoms. However, during two years, when the patient was taking tianeptine, she maintained alcohol abstinence. After a change in therapy, lack of the drug evoked a strong need to drink again, and further hospitalizations were needed. Tianeptine was again administered during the last hospitalization. Since then the patient has not been abusing alcohol, neither was she hospitalized anywhere in the region.
Three years after her last hospital stay, the patient came to our out-patient clinic asking to begin treatment. She claimed that due to depression she took tianeptine with positive results and suggested the need to increase the dosage significantly above the recommended one.
It soon turned out that the police had been leading an investigation against the patient on forging prescriptions for tianeptine. After having left the hospital for the last time, she was systematically increasing the dosage of tianeptine, due to intensifying anxiety. According to the patient, the maximum dosage equaled three pills three times a day (112.5 mg). She asked various specialists to prescribe it, but having difficulties to obtain a satisfying amount legally, she forged the prescriptions. Information provided by the police state that only during eleven months, 158 prescriptions were gathered, both legal and forged, out of which 143 were accepted, which stands for the total number of 9,180 pills. Therefore, it may be estimated that the patient was taking in that period at least 347 mg of tianeptine per day.
She declared a will to stop taking tianeptine. During the examination a subjective feeling of anxiety, tension and increased tiredness, difficulties with concentration, sleeping and mood disorders were reported. The Hamilton Anxiety Rating Scale was performed (14-item version) with a score of 18 points with insignificant somatic component. Life parameters were normal. She claimed she did not take tianeptine for a week, because other physicians, aware of the whole situation, refused to prescribe her the medicine. Ambulatory treatment with sertraline and buspirone was administered with good effect. A stable dosage was maintained with patient demonstrating a significant resistance against any suggestions down-titrate the drugs. At the same time, she negated the necessity to undertake a psychotherapeutic treatment.
Case reports revealed that the most common reason of dependence is the psychostimulant and euphorising effect3,4. However, in the presented case tianeptine was first prescribed in order to reduce anxiety and mood disorders, and later it was substituted by a combined treatment of buspirone with sertraline, both of them having anti-anxiety influence. During the period when tianeptine was withdrawn, she developed a psychological expression of anxiety, lacking any intense vegetative symptoms. Also, intensified anxiety was present before alcohol problems began. These elements make tianeptine dependence diagnosis doubtful and indicate rather a personality predisposition to substance misuse, than a special addictive mechanism of tianeptine itself, as suggested in other publications5,6.
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