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Overlooked mania

Vol. 6, No. 7 / July 2007

The article “Depression, medication and ‘bad blood’” (Current Psychiatry, May 2007) discussed a case of reduced white blood cell (WBC) count in a patient the authors ultimately diagnosed as having a mood disorder with depressive features secondary to a general medical condition. However, I believe the authors missed the extent of the patient’s manic features.

The first clue was that the patient had “become increasingly irritable and volatile, often arguing with a staff nurse and other patients.” This behavior possibly was iatrogenic and caused by venlafaxine treatment. The authors added lithium at a low dose of 300 mg bid (no lithium blood levels given). This measure was done to increase WBC count, but it fortuitously may have helped reduce manic symptoms. At follow-up, “after 3 months of continuous hospitalization,” the patient was still described as “at times oversensitive and combative.”

Missing manic symptoms because of nonclassical ways they can present is a major clinical concern. For example, a patient may feel irritable, hostile, or labile instead of expansive or euphoric. I wonder if this patient’s manic symptoms could have been better controlled with titrating the lithium dose and following up by monitoring blood levels.

Robert Barris, MD
East Meadow, NY

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