Acute psychotic symptoms induced by topiramate

The incidence of psychosis during clinical trials of topiramate was 0.8%, n ot significantly different from the rate for placebo or reported rates of p sychosis in patients with refractory epilepsy. We observed psychotic sympto ms in five patients soon after initiation of topiramate therapy. We perform ed a retrospective chart review of the first 80 patients who began on topir amate after approval for clinical use, between January and April 1997. Symp toms suggestive of psychosis, including hallucinations and delusions, were sought for analysis. Cognitive effects such as psychomotor slowing, confusi on, and somnolence were not included. Five patients developed definite psyc hotic symptoms 2 to 46 days after beginning topiramate. Dosages at symptom onset were 50-400 mg/day. Symptoms included paranoid delusions in four pati ents and auditory hallucinations in three. Symptoms of psychosis and other psychiatric symptoms resolved quickly with discontinuation of topiramate in three patients, dose reduction from 300 to 200 mg/day in one and with inpa tient treatment and neuroleptics in another. One patient had a history of a uditory hallucinations, one of aggressive and suicidal thoughts, but three had no significant psychiatric history. Physicians should be aware of the p ossibility of psychotic symptoms, even in patients without a previous psych iatric history, when prescribing topiramate. Symptoms resolve quickly with discontinuation.