Past Issues

This is a 17-year-old Asian male patient with body weight of 65 kg. He had been admitted to our hospital for depressive mood, insomnia, loss of appetite, distractibility, fatigue, worthless feel-ing, suicidal ideation, and declined daily function for two weeks. He denied any history of major physical illness. He received mirtazapine with daily dose of 30 mg/day alone at bed time under the impression of major depressive disorder. About one hour after his first receiving medicine, this patient described to have symptoms of irre-sistible intermittent involuntary head jerking and shoulder shrugging with the frequency about sev-eral times in a few minutes, and tic-free intervals about seconds to minutes. He also described that he had experienced irresistible urge before doing the jerk-like movement with temporary relief right after doing it. Those symptoms were gradu-ally declined and lasted within one hour without further pharmacological management. Further neurological examination on the next day revealed no further abnormality, such as muscle weakness, rigidity, tremor, or paresthesia. The patient re-ceived only one dose (30 mg) of mirtazapine on the first day during his hospital course. We imme-diately switched mirtazapine 30 mg per night to daily escitalopram 10 mg under the impression of mirtazapine-induced tic attacks. Due to the high casual relationship and patient’s discomfort, we did not re-challenge the case with mirtazapine for proving the relation between mirtazapine and the emergence of tics.