Table 4 Timeline of important relevant events to varenicline administration and past admissions

Previous Admission

December 2020

Patient was transferred from another hospital where she has had brief admissions as a result of drug-induced psychosis. She was transferred to this hospital because a psychiatrist at the previous hospital felt that she was likely going through a manic phase. After assessment was considered to meet the criteria for a bipolar affective disorder. Patient was initiated on lithium carbonate which was subsequently not filled.

Previous Discharge

January 2021

She fully recovered from her bipolar disorder and mania had resolved. There was no evidence of hypomania or mania and no evidence of depression or suicidality.

Main Admission

Day 0

Patient was admitted to hospital and certified (x 2) under the mental health act. She presented to the hospital with her support worker with concerns about a foot infection and cuts from self-harm. She spoke with the ED triage and nurses about how men have been following her and very tearful when speaking about a recent episode where she says was attacked by these men. She talked about wanting a pregnancy test and STI testing because was not taking contraception. She stated that she has not been taking her bipolar medicine because it makes her feel very drowsy and does not like it. At triage, she stated that she gets very depressed, that she has overdosed on several drugs in the past and may do so again.

Day 1

Admitting diagnoses of bipolar I disorder, mania with psychosis and polysubstance use (stimulants, opioids, unintentional opioids, nicotine). On psychiatric assessment, she presented as very disorganized and manic with flight of ideas present. She was agitated and unable to cooperate with an interview. It was clear that she would benefit from hospital stabilization based on collateral information as detailed above as well as her presentation. There is also a possible contributing factor of her increased stimulant use over the past week, specifically crystal meth.

Day 4

Urine drug screen was positive for amphetamines, fentanyl, and benzodiazepines. Her lithium level was negligible.

Day 5

She reports noncompliance with her lithium and crystal meth use. She feels safe in hospital and denies any auditory/visual hallucinations.

Day 14

Varenicline dosage begun, patient reports intermittent bothersome AH, absconded from group walk to follow fellow patient out of concern.

Day 16

Patient developed symptoms of psychosis, likely secondary to varenicline. This was characterized by auditory hallucinations, paranoia and referential beliefs with intact insight.

Day 18

Varenicline discontinued and varenicline-induced psychosis resolved.

Discharge

Day 34

Patient was discharged.