1312 Onset of Mania After Starting CPAP

Abstract Introduction Bipolar affective disorder (BAD) is a mood disorder characterized by episodes of mania. It typically starts in late adolescence and early adulthood. However, 5-10% of bipolar patients will start having symptoms later in their lives. Obstructive sleep apnea (OSA) is characterised by repetitive upper airway collapse during sleep, causing intermittent hypoxia, sleep fragmentation and cardiovascular sequelae. In moderate to severe OSA, CPAP remains the gold standard treatment. In this report, we will present a case of a 43-year-old patient who had his first manic episode after 3 months of starting CPAP for OSA. Report of case(s) Mr. R, a 43-year-old Man, presented to the emergency department with symptoms of euphoria, pressured speech, hyperactivity and grandiosity. He was admitted to the inpatient psychiatry ward and diagnosed with BAD Type 1, most recent episode manic. He has a family history of schizophrenia. Three months prior to admission, he had been diagnosed with sleep apnea. Collateral information indicates that the patient spoke of increased restlessness, “making new epiphanies”, decreased need for sleep, having “superpowers of the mind” and being preoccupied with oxygen in the brain immediately after CPAP initiation and progressed in the weeks leading to admission. Substance use was only notable for 2-3 liquor shots weekly. Conclusion To our knowledge this is the 6th case report regarding CPAP-related mania. While our patient developed mania requiring admission after 3 months of CPAP, the previous cases reflected mania starting as early as 10 days after CPAP initiation. Another case described manic onset after 2 months. Other cases involved almost only men, aged at least 40 years. Patients with untreated bipolar disorder may experience shortened REM latency and prolonged REM sleep. In people with OSA, they may exhibit hypoxemia, and slow wave and REM sleep suppression due to frequent arousals. The potential REM rebound and increased oxygenation post-CPAP initiation is a putative mechanism of precipitating mania. Post-CPAP normalization of serum testosterone has been hypothesized as another cause. This report presents a case of an OSA patient who developed his first manic episode after starting CPAP. Further research is needed to better understand the pathophysiology of any such association. Support (if any)