(PO-122) (PO-122) Pharmacological Management of Psychogenic Polydipsia: A Clinical Review

Background:

Psychogenic polydipsia occurs in 6-20% of all psychiatric patients and causes significant morbidity and mortality (Dundas et al., 2007). Despite this, there remains a dearth of psychiatric literature regarding its pharmacological management, which we aim to ameliorate.

Methods:

We conducted a literature search on PubMed using the following search terms: “psychogenic polydipsia,” “psychogenic polydipsia treatment,” “psychogenic polydipsia management.” We included original trials, case reports, and reviews written in English and published between database inception and March 2021. We excluded studies focused on nephrogenic polydipsia, diabetes insipidus, syndrome of inappropriate antidiuretic hormone secretion, behavioral treatments, animal models, or pediatric subjects. We then compiled all pharmacological interventions included in the studies.

Results:

We identified 32 articles covering 21 different pharmacological treatments for psychogenic polydipsia. The most commonly discussed medication class was antipsychotics, with four antipsychotic medications reported: clozapine, olanzapine, risperidone, and haloperidol. The most frequently cited medication, overall, was clozapine. Additional treatments included acetazolamide, bupropion, captopril, clonidine, conivaptan, demeclocycline, enalapril, fluoxetine, irbesartan, lithium, losartan, naloxone, naltrexone, pindolol, propranolol, tolvaptan, and vasopressin.

Discussion:

To our knowledge, this is the first review to compile 21 different medications used to treat psychogenic polydipsia in psychiatric patients. The mechanistic theories of psychogenic polydipsia include, but are not limited to, dopamine receptor hypersensitivity, vasopressin osmostat alteration, and anterior hippocampal-induced stress diathesis (Ahmadi & Goldman, 2020). Current literature consists mostly of case reports and low-powered studies, without much emphasis on pharmacologic management. Therefore, the effectiveness of trialed medications and their therapeutic mechanisms is largely speculative. Serum sodium levels have been normalized using demeclocycline, lithium, and vaptans. Excessive water intake has been reduced by beta blockers, naltrexone, naloxone, angiotensin receptor blockers, bupropion, and atypical antipsychotics, albeit with inconsistent results (Dundas et al., 2007; Sailer et al., 2017). Clozapine and acetazolamide have literature supporting their role in correcting both hyponatremia and water seeking behaviors (Ahmadi & Goldman, 2020). Conversely, there is little support for the use of angiotensin converting enzyme inhibitors or clonidine (Dundas et al., 2007).

Conclusion:
The seemingly disparate pharmacological mechanisms among the identified treatments highlight the complex pathophysiology of psychogenic polydipsia, which requires further investigation. Furthermore, no research has adequately compared these medications to identify an effective or superior pharmacotherapy. Atypical antipsychotics, specifically clozapine, may be a promising treatment. This review serves as an impetus for more rigorous controlled studies regarding effective pharmacological management of psychogenic polydipsia.

References:

Ahmadi L, Goldman MB. Primary polydipsia: Update. Best Pract Res Clin Endocrinol Metab. 2020; 34(5):101469.

Dundas B, Harris M, Narasimhan M. Psychogenic polydipsia review: etiology, differential, and treatment. Curr Psychiatry Rep. 2007; 9(3):236-41.

Sailer C, Winzeler B, Christ-Crain M. Primary polydipsia in the medical and psychiatric patient: characteristics, complications and therapy. Swiss Med Wkly. 2017; 147:w14514.