it is chemically unrelated to other antiepileptic drugs and is the -ethyl analogue of the nootropic agent piracetam . it is postulated to act by binding to synaptic vesicle protein 2a ( sv2a ) and thereby modulation of one or more of its actions , ultimately affecting neural excitability . it has been found to be well - tolerated and has a favorable pharmacokinetic profile that includes minimal protein binding , lack of hepatic metabolism and twice a day dosing . the reported central nervous system adverse drug reactions ( adr ) of lev are somnolence , asthenia , coordination difficulties , and behavioral abnormalities . psychosis has been reported infrequently with lev with a reported frequency of less than 1% . here , we report a case of acute , reversible psychosis in a 52-year - old epileptic man on lev therapy . a 52-year - old male epileptic patient was brought to our tertiary care hospital with uncontrolled seizure . he was on carbamazepine , with a total dose of 1000 mg per day , since 1 year . he was apparently doing alright for some time and his quality of life had improved on carbamazepine . however , the seizures recurred once in every 2 - 3 weeks for the last 3 months because of which he was admitted in neurology department for further management and drug optimization . his blood investigations for electrolytes , renal function test , thyroid , liver function and other related tests were within normal limits . his computed tomography ( ct ) scan of brain showed left frontal calcified lesion suggestive of cysticercosis . his serum carbamazepine level was 10 g / ml . in view of his poor seizure control and serum carbamazepine level reaching the upper limits of normal , he was added on lev with an initial dose of 250 mg twice a day and was planned to increase the dose gradually over 2 - 4 weeks to reach a dose up to a total 1000 mg per day . however , by day 3 the patient developed severe behavioral abnormality characterized by agitation , emotional liability , hostility and depersonalization . psychiatric assessment revealed features of depression , mood and thought abnormality , suspicious and withdrawal state with visual hallucination suggestive of psychosis . delirium was ruled out as there was no fluctuation in sensorium , focal deficits and meningeal signs . as mentioned earlier , the lab investigations were done to rule out metabolic causes of this clinical presentation . the causal analysis showed a probable association ( score 5 ) of the reaction with lev . lev is a newer antiepileptic drug that has shown promise in a number of long term , open label , follow up clinical studies . the drug is reported to have significant safety margin with adr like dizziness , fatigue , headache , upper respiratory tract infection , and somnolence . although it has a favorable profile , behavioral adrs are reported in up to 13.3% of the drug users . of these , severe symptoms such as depression , agitation , hostility and psychotic behavior are experienced by 0.7% of the patients . lev psychosis is reported to be common in patients with preexisting psychotic disorder , also in patients on add - on therapy , and rapid titration when there is an underlying neurological disease . lev psychosis is also reported to be common in children with prior cognitive defects who receive prescription of the drug . our patient did not provide any history of preexisting psychotic disorder or family history of preexisting psychotic disorder . the psychosis episode was also evident at clinically permissible dose range and at the onset of therapy . previous case reports demonstrated the problem with either increase in the drug dose or after 10 days to one month of initiation of therapy . however , like the previous reports , our patient also recovered after prompt withdrawal of the drug . , there is no evidence to suggest that lev produces psychosis at significantly higher rates than other antiepileptic drugs . however , detailed clinical history and close monitoring with regard to psychiatric adverse effects should be advocated when starting treatment with lev . also , further studies to assess the behavioral profile of lev in large group of patients should be initiated .
levetiracetam ( lev ) is a relatively newer antiepileptic drug with novel mechanism of action . 
 it was introduced to the market in the year 2000 . 
 pre - marketing clinical trials of the drug reported good tolerability with a wide safety margin . on post - marketing updates , there are few reports of psychosis after treatment with the drug . here , we report a case of 52-year - old epileptic man who developed acute , reversible psychosis within 3 days of initiation of treatment . 
 the drug was prescribed at a dose of 500 mg per day . 
 after 3 days of treatment , the patient developed visual hallucinations , mood swings , withdrawal and suspicious behavior . 
 delirium was ruled out as there was no fluctuation in his sensorium or focal neurological deficits . 
 his lab investigations for electrolytes , renal function test , thyroid , liver function and other related tests levels were within normal limits . 
 a diagnosis of lev induced psychosis was reached based on clinical judgment and causality assessment .