Case Study Patient Intake and History

The patient is a 26-year-old college graduate who is currently euthymic but who has a history of major depressive episodes. He has experienced major depressive episodes, mostly untreated, of varying lengths and severities since he was a teenager. His symptoms have included insomnia, despondent thoughts, depressed mood, low interest in activities, poor energy, and impaired cognition. He says his self-esteem drops and he feels rejection-sensitive and guilt-ridden for no apparent reason. He has never had suicidal thoughts. Some of the depressive episodes have been incapacitating and have interfered with school and work. He appears to have good inter-episode recovery and is able to return to class and work. The patient also has symptoms of social anxiety. He is often nervous around new people and acquaintances, and he experiences anticipatory anxiety and will avoid certain social events. These symptoms are present regardless of his affective state. The patient has asked for a consultation because he has legal issues regarding drinking and driving that he thinks were likely fueled by his psychiatric symptoms. At the time of the infraction (several months ago, just before graduating college), he had been started on a selective serotonin reuptake inhibitor (SSRI) for the depression and generalized anxiety disorder (GAD) symptoms. Within days of starting, he experienced an elevated mood in a sustained fashion over several days. He lost all anxiety, fear, and avoidance. He was unusually talkative; had racing thoughts; was distractible, hyperactive, and impulsive; and had decreased need for sleep. He exhibited grandiosity, in which he felt invincible and that the law did not apply to him; this led him to purposefully antagonize a man in a bar, drive while drinking, and challenge authority when police were called. The mood elevation is complicated by the fact that the patient admits to heavy alcohol use on weekends throughout college. The mood elevation abated with cessation of the SSRI treatment. The patient has now completed college; he has few friends in the immediate area, but his family is very supportive. He wants to be a news reporter and is planning on applying to graduate school. The patient has no family history of bipolar disorder; his mother has GAD. He is not currently taking any medications. Vitals: • Glasgow Coma Scale: 8 • Blood Pressure: 160/80 • Pulse: 76 • Respirations: 18 • Height: 5'10ʺ • Weight: 190 lb Please answer the questions listed below: 1. Does the patient's history support a diagnosis of bipolar disorder even though his symptoms appear to have been triggered by a selective serotonin reuptake inhibitor? 2. What would be the expected future course of illness for this patient? 3. If the patient develops another depressive episode, how would you treat it? 4. What medication would you choose? (There could be many correct answers.) What is the mechanism of action (MOA) of this medication? (Be specific: What receptor does it work on? etc.) 5. Provide three references (published in the last 5 years) on the medication treatment of mood disorders.

Sample Solution

1. Does the patient's history support a diagnosis of bipolar disorder even though his symptoms appear to have been triggered by a selective serotonin reuptake inhibitor?

Yes, the patient's history strongly suggests a diagnosis of bipolar disorder, even though the initial presentation was triggered by an SSRI. Here's why:

Classic Manic Episode: The patient experienced a clear manic episode characterized by:
- Elevated mood
- Racing thoughts
- Decreased need for sleep
- Increased energy
- Grandiosity
- Impulsivity
- Psychomotor agitation
Prior Depressive Episodes: The history of recurrent depressive episodes further supports the diagnosis of bipolar disorder.
SSRI-Induced Mania: While SSRIs can trigger manic episodes in individuals with underlying bipolar disorder, they do not cause bipolar disorder.

2. What would be the expected future course of illness for this patient?

The future course of illness for this patient is uncertain. However, given the history of untreated depressive episodes and the occurrence of a manic episode, the following are possible outcomes:

Recurrence of Mood Episodes: The patient is at risk for future episodes of both depression and mania. The frequency and severity of these episodes can vary greatly.
Chronicity of Illness: Bipolar disorder is a chronic condition that often requires long-term management.
Social and Occupational Impairment: Untreated bipolar disorder can significantly impact the patient's social and occupational functioning.
Substance Use: Individuals with bipolar disorder are at increased risk for substance abuse, which can complicate the course of the illness.

3. If the patient develops another depressive episode, how would you treat it?

Treatment of depressive episodes in bipolar disorder typically involves a combination of pharmacotherapy and psychotherapy.

Pharmacotherapy: Mood stabilizers, such as lithium or anticonvulsants (e.g., lamotrigine), are generally the first-line treatment for bipolar depression.
Psychotherapy: Psychotherapies such as cognitive-behavioral therapy (CBT) and interpersonal and social rhythm therapy (IPSRT) can be helpful in managing symptoms and improving overall functioning.

4. What medication would you choose? (There could be many correct answers.) What is the mechanism of action (MOA) of this medication? (Be specific: What receptor does it work on? etc.)

Lamotrigine: This anticonvulsant medication is often used as a mood stabilizer in bipolar disorder. Its mechanism of action is complex and not fully understood, but it is thought to modulate glutamate and GABA neurotransmission.
Lithium: Lithium is a classic mood stabilizer. Its mechanism of action is also complex but is thought to involve stabilizing neuronal signaling pathways.

5. Provide three references (published in the last 5 years) on the medication treatment of mood disorders.

Findling, R. L., Calabrese, J. R., & Hirschfeld, R. M. (2018). Bipolar disorders. In H. Y. Meltzer & T. R. Insel (Eds.), The American Psychiatric Publishing Textbook of Psychopharmacology (5th ed., pp. 715-772). American Psychiatric Publishing.
Gutierrez, R., Calabrese, J. R., & Bowden, C. L. (2016). Pharmacotherapy of bipolar depression. Dialogues in Clinical Neuroscience, 18(4), 411-428.
Post, R. M., Luckenbaugh, D. A., & Ketter, T. A. (2019). Bipolar disorder. The Lancet, 393(10183), 2042-2054.

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