Case 4: Depression and anxiety: Distinguishing unipolar and bipolar disorders
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Dr David Muzina: It's a 20-year-old single young man here in the Lake County area of Ohio who was essentially referred by both his primary care doctor and psychologist for a medication management of reported mood swings, anxiety and confusion. History of present illness is that this young man for about 14 months had been reporting feeling sad, or in his own words “even dead inside, like a zombie nearly every day”. These uncomfortable sensations were relieved only periods of maybe three to four days at a time when he felt more worried than sad, but during these more worried times, he was much more ruminative, more tired, more irritable, had trouble concentrating, because he said “I can't sort out my thoughts”. He ruminates a lot over his past, often going so far as to try to change the past in his mind to the point that he becomes confused about what was real and what he might have made up. He's been very preoccupied by the recent loss of a relationship with a girl that began back in high school. This young man spends a lot of time online looking at her MySpace social interaction page, and then would feel worse. He blames himself for everything that's wrong on his life, and struggles with thoughts that people are talking and thinking about him negatively. He does exercise and work out regularly, and although at the present time denies doing so, he has admitted that in the past, he's used several different herbal preparations, and things that he would buy at General Nutrition Centers, or on the Internet that included creatinine, protein supplements. He had been doing these things to promote muscle growth, and to increase his testosterone levels, because he heard that these things can make you feel tired. He does admit that he might have been more irritable, more aggressive and more volatile while taking the supplements for his workouts. But he's not doing them now. He's focused on the belief that he is too small, and although he's not using these supplements, refuses to throw them out, saying that this would be a waste of over $300.
In the last week, his father had given him some of his own sleeping medications to help him do so, without much success, otherwise this young man had not been medications for about the previous six months when he came to see me, although he admits to frequently feeling tense, keyed up, unable to relax, especially in the evenings and around bedtime. He had no intervention at all during the first six months or so of this current ongoing episode, until his family doctor was contacted. And at that time, was referred to the psychologist for counseling, who quickly made a back referral to the PCP believing that this young man needed a prescription for antidepressant medication.
This collaborative relationship between the psychologist and the primary care doctor led to ongoing psychotherapy, a trial of Sertraline dosed up to 100 milligrams daily for about three weeks, and then a switch to Venlafaxine dosed up to 225 milligrams, which he took for a slightly longer period of time, discontinuing both of these medications saying that they made him feel numb, disconnected, and he thought that they also made him more depressed. For his mom, she believes that he was drinking alcohol more regularly while on his medications, and that he also was probably not fully compliant with the antidepressants. The mother had been diagnosed in ongoing treatment for what she described as situational anxiety and depression, taking an SSRI. The paternal aunt also takes Sertraline for diagnosis of panic disorder, other than that, there's no known history of other mood disorders, specifically bipolar disorder or schizophrenia, and also no family history of suicide. This young man denied any history of childhood trauma, but had the unusual suspicion—I stop short of calling it a belief—that his parents were somehow hiding a birth defect from him that was in some manner related to his current issues and difficulties.
There is no medical history reported that is connected with these symptoms, specifically denying any history of cardiovascular disease or head injury. In the review of systems, his chemical dependency history I thought was minimized, he reported rare use of alcohol, and admitted to drinking more heavily during his senior year of high school, and denied any illicit substance abuse. There were no clear periods of euphoria or classic related manic symptoms. He's often been irritable, and has had a hard time separating the irritability from the depression. Mood reported as sad and worried, thought process I thought was logical, linear and goal directed. And cognitive testing, although it was limited to my brief mini mental status exam, was notable only for some difficulty doing serial seven, but he had a poor effort. He denied again suicide or homicidal ideation.
My thinking for this particular young man was that there were a number of diagnostic considerations, and in my consultation report, had thoughts primarily that this was a depressive disorder, or a mood disorder, and had considerations of a bipolar two picture, maybe with rapid cycling, versus the major depression and anxiety. The recommendations that I made for him first included getting some base line laboratories including metabolic panels and toxicology screens. I thought also that brain imaging was wise, and so recommendation was made for MRI I also made a recommendation in addition to continuing the psychotherapy to become involved in our five-week intensive counseling program, which is specific to mood disorders. I made a recommendation to treat him with a combination approach using Lamotrigine, the typical sort of up titration targeting 200 milligrams daily. The idea here not specifically to treat him for the acute symptoms that he's having, although it may help with the depressive symptoms. But for longer-term controlled mood, but in the meantime, recommendations to treat him for the depression and maybe the anxiety features that he has as well with quetiapine, and titrating that to 300 milligrams the first week.
Dr Donald Black: It's hard to say that this patient is actually treatment refractory, because he's never been adequately treated, because he doesn't seem to tolerate trials of these medications, and it sounds like his trials of Sertraline, the dose was probably too low to make much out of that. And I assume if he's been seeing this therapist for six months, it's either time to get a new therapist, or to stop it.
Dr Henry Nasrallah: Could he have actually been taking the anabolic preparations before he broke up with the girlfriend, and that his irritability and depression and aggressive volatile kind of presentation could have been instigated by anabolic steroid use?
Dr David Muzina: I think that's definitely possible, if not probable, Henry.
Dr. Henry Nasrallah: So the possibility does not rule out the possibility that this patient actually has a bipolar spectrum disorder, but it makes it even more likely that because has that predisposition, that there's a kind of steroid induced exacerbation, and also mixedness of his symptoms of bipolarity.
Dr Joseph Goldberg: Not to inspire a three-hour discussion but he would meet most of the RDC criteria for agitated depression, which doesn’t exist in DSM. But the inattention, the psychomotor agitation the questions are called crowded thoughts.
Dr David Muzina: Yes.
Dr Joseph Goldberg: whether you think of that as sort of a variant of psychosis or variant of bipolar, it’s not a simple unipolar presentation, and to whatever extent anything induced by substances may be a contributing factor? It would seem to me that from a management standpoint agitated depression just carries so much of a greater concern about acting on impulses in terms of level of care, in terms of the role for an antipsychotic and so on?
Dr Henry Nasrallah: Let me address that issue Joe, because I’m also very wary of the term agitated depression. To me anytime a so-called unipolar patient has agitated depression I like to rule out bipolar disorder with irritability, anger and hostility as the mixed features in that depression. And the MDQ which was used for in differentiating unipolar/bipolar for a lot of family care physicians--I know many of them are using it now--It really becomes irrelevant when you have a treatment approach that can actually hit either target. But what I’m saying is Dr. Muzina used quetiapine and lamotrigine for this patient and this regimen would work for either case. Quetiapine is as you know the only drug approved for bipolar depression and lamotrigine is not but many of us use it as an adjunct because it’s used for maintenance purposes.
But whether the patient is unipolar or bipolar doesn’t it kind of solve the problem now that we have an official indication for bipolar depression and that has shown after seven FDA studies quetiapine is also going to be approved for unipolar, major depressive order.
Dr Joesph Goldberg: You almost wonder if this guy isn’t paranoid. I mean, I worry about that kind of behavior, intrusive behavior in this guy and what else he’s doing so I think that’s another reason to be very enthusiastic about using an atypical antipsychotic.
Dr Henry Nasrallah: David, did you feel this patient, when you saw him, did he give you a feeling that he has some psychotic or prepsychotic features?
Dr David Muzina: He did.
Dr Donald Black: In someone in their late teens who has an agitated depression that that often is -- heralds the onset of a bipolar disorder.
Dr Henry Nasrallah: Don’t under estimate a young man with low self-esteem at this you know, stage of his life, so worried about his inaudible dysmorphic features, which reflect kind of a gruesome image. Losing a girlfriend that he got attached to—and yes it is I think pushing him to the limits of behavioral destruction there, without the depression anxiety, being obsessed about her, tracking her down. It’s kind of a mini form of stalking. But I don’t think that that necessarily predicts psychosis as much as the bipolar kind of stress, dealing with stress in a maladaptive manner. And I think medication and psychotherapy will get him out of it.