Ayahuasca induced mania in patient with bipolar disorder: case report and targeted literature review

Introduction

Ayahuasca is a traditional psychoactive Amazonian brew, most commonly prepared from Banisteriopsis caapi and Psychotria viridis, which has been used for centuries in Amazonian ceremonial, spiritual, and medicinal practices [1]. Contemporary ritual use of ayahuasca has been expanding throughout the world for mental health purposes, and for spiritual and personal growth [2]. Its psychopharmacological effects result from the synergistic interaction between N,N-dimethyltryptamine (DMT) and β-carboline alkaloids. DMT modulates serotonergic and dopaminergic signaling primarily through agonism at serotonin receptors HT1A, 5HT2A, and 5-HT2C, dopamine D2 and sigma-1 receptors. β-carbolines act as reversible inhibitors of monoamine oxidase A (MAO-A) enzyme, enabling DMT oral bioavailability and exerting serotonin reuptake inhibitory effects [1], [3]. These mechanisms are thought to underlie its potential antidepressant, anxiolytic, neuroplastic, and anti-addictive properties [3], [4].

Aims

This report aims to explore the psychiatric effects of ayahuasca use, particularly its potential role in precipitating mania, corroborating ayahuasca antidepressant effect. This will be examined through the presentation of a case report involving a manic episode with mood-congruent psychotic features following ayahuasca consumption.

Methods

Clinical data were collected through consultation of the patient’s medical records and a targeted literature review was conducted. Articles were screened for relevance, with a focus on cases of ayahuasca associated mania and systematic reviews regarding the adverse effects of ayahuasca use.

Results

We present the case of a 37-year-old Portuguese female diagnosed with bipolar type I disorder and a history of two previous manic episodes requiring inpatient treatment. She was brought to the psychiatry emergency department following aggressive behaviour towards her mother. On presentation, she exhibited elevated mood, reduced need for sleep, increased energy and appetite, irritability, disinhibition, work absenteeism and disorganised behaviour including wrong-way driving. Mental state examination revealed pressured speech, flight of ideas and grandiose delusions, believing she possessed a gift to save the world and others. She was noted to have irregular adherence to psychopharmacological treatment and occasional cannabis use. During admission, she disclosed having consumed Ayahuasca at an organized group ‘spiritual retreat’ in the week preceding symptom exacerbation. Treatment optimisation included lithium dose adjustment, initiation of oral aripiprazole with subsequent transition to a long-acting injectable formulation due to concerns regarding treatment adherence, alongside quetiapine and lorazepam. Progressive clinical improvement was observed with remission of psychotic and manic symptoms and improved insight by discharge.

Literature review identified three published mania cases associated with ayahuasca and one associated with DMT.

Conclusions

Although ayahuasca has attracted growing interest for its potential therapeutic effects in mood and psychological disorders [1], this case underscores its capacity to precipitate manic decompensation in vulnerable individuals with bipolar disorder. This association may reflect the same underlying psychopharmacological mechanisms responsible for its proposed antidepressant properties. While severe psychiatric adverse reactions such as manic or psychotic episodes appear to be uncommon, they remain insufficiently understood and may occur more readily in individuals with personal or familial psychiatric vulnerability [5]. These findings reinforce the importance of careful psychiatric risk assessment, psychoeducation, and caution regarding ayahuasca use in populations at risk for bipolar disorder.

References

1. Sheth, R., Parikh, E., Olayeye, K., Pfeifer, K., & Khanna, D. 2024. The Effects of Ayahuasca on Psychological Disorders: A Systematic Literature Review. Cureus, 16(3).
2. Bouso, J. C., Andión, Ó., Sarris, J. J., Scheidegger, M., Tófoli, L. F., Opaleye, E. S., Schubert, V., & Perkins, D. 2022. Adverse effects of ayahuasca: Results from the Global Ayahuasca Survey. PLOS Global Public Health, 2(11).
3. White, E., Kennedy, T., Ruffell, S., Perkins, D., & Sarris, J. 2024. Ayahuasca and Dimethyltryptamine Adverse Events and Toxicity Analysis: A Systematic Thematic Review. International Journal of Toxicology, 43(3), 327–339.
4. Szmulewicz, A. G., Valerio, M. P., & Smith, J. M. 2015. Switch to mania after ayahuasca consumption in a man with bipolar disorder: a case report. International Journal of Bipolar Disorders, 3(1), 4.
5. Alcantarilla, L., García-Alcarria, E., & Almonacid, C. 2022. Episodios psicóticos inducidos por ayahuasca: revisión sistemática a partir de un caso. Revista de Neuro-Psiquiatría, 85(3), 224–234.