Test your skills: Diagnosis and management of psychosis with bipolar mania

How would you treat this patient?

Mr S is 20-year-old single white college student experiencing his second lifetime hospitalization for assessment of acute psychosis. He has become increasingly isolated and does not attend class. Instead of sleeping, he writes obscure essays and gambles on the Internet. He believes that al-Qaeda has infiltrated the Internet and chosen him as a military operative, sending messages from tree stumps.
He has previously been diagnosed with attention-deficit/hyperactivity disorder (ADHD) and depression. Amphetamine/dextroamphetamine and escitalopram were prescribed. Mr S discontinued the latter because of weight gain and erectile dysfunction. An empty amphetamine bottle was found in his room (a urine toxicology screen is positive for amphetamine).

The patient’s older brother was diagnosed with bipolar disorder and completed suicide at age 28. His father’s recurrent episodes of depression are treated with antidepressants. His mother has panic disorder and is treated with selective serotonin reuptake inhibitors (SSRIs) and benzodiazepines.

Misdiagnosis in bipolar disorder

Was the initial diagnosis of ADHD and depression correct? For more information, go to Diagnosing and managing psychotic and mood disorders, a CME activity developed through the joint sponsorship of the University of Cincinnati and Dowden Health Media (DHM). It was edited and peer reviewed by Annals of Clinical Psychiatry and Current Psychiatry. This CME activity is supported by an educational grant from AstraZeneca.

The expert faculty consists of Henry A. Nasrallah, MD, Donald W. Black, MD, Joseph F. Goldberg, MD, David J. Muzina, MD, and Stephen F. Pariser, MD.

Learn how these psychiatrists assess the patient’s symptoms within the context of personal and family history clues and suggest treatment strategies that may improve outcomes for this patient.

• Is Mr S one of the many individuals whose initial diagnosis is incorrect? The National Depressive and Manic Depressive Association 2000 survey showed a nearly 70% misdiagnosis rate for patients ultimately shown to have bipolar disorder. The average patient with bipolar disorder sees at least 4 different physicians, and one-third of these patients wait at least 10 years before receiving a correct diagnosis.
• Could faulty diagnosis and inappropriate pharmacologic intervention contribute to Mr S’s deterioration and symptom exacerbation, complicating future management? In a patient with mixed features, what strategies can help the clinician select the most effective treatment regimen?
• Is it possible that antidepressant use may have induced this patient’s mania? Individuals with a family history of bipolar disorder have been shown to be particularly at risk of switching to hypomania, mania, mixed mania, or rapid-cycling mania.
• Could the presence of hypomania, characteristic of bipolar II, have resulted in a misdiagnosis of ADHD?
• Did stimulant abuse contribute to psychotic symptoms?
• What may be the effects of weight gain on treatment adherence? Do patients who stop medications because of weight gain admit nonadherence?

Additional questions considered by this panel of experts include:

• What additional laboratory tests should be performed, such as sleep studies?
• Should we help this patient lose weight?
• Should an EEG be conducted?

Practical pearls

If weight gain occurs as a treatment-related side effect, it may affect compliance.
In such cases, it may be appropriate to evaluate metabolic profiles and/or switch treatments (FIGURE).

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