Can nasal decongestants trigger a manic episode?

Among the sympathomimetic drugs, phenylephrine, pseudoephedrine, and ephedrine are the ones that have been used most commonly in oral medication for the relief of nasal congestion. There are reports suggesting that psychiatric cases have been triggered by central nervous system stimulant drugs used as nasal decongestants. In this report, we would like to present a male patient with bipolar disorder undergoing two manic episodes, both triggered by cold medicine. A 25-year-old male patient was seen in the psychiatric outpatient clinic with increasing complaints such as raised level of energy, talkativeness, decreasing sleep, increasing libido, and visual and auditory hallucinations after using an cold medicine containing phenylephrine. Also, 2 years ago, he had a manic attack triggered after the use of cold medication. The patient's manic symptoms were stabilized with lithium 900 mg/day and olanzapine 15 mg/day and his functionality improved. According to his history, the psychometric tests, psychiatric evaluation, and the 6 months follow-up, he was diagnosed with "substance/ medication-induced bipolar and related disorder" according to DSM-5 diagnostic criteria. He had not suffered any mood or psychosis episodes before the use of nasal decongestants, no family history of bipolar disorder, a 16-month period of wellbeing without using a mood stabilizer between 2 episodes, and remission after 1-month anti-manic treatment after the cessation of the cold medicine, supporting the view that the adrenergic drugs with a central stimulant effect may have triggered the manic episodes.