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 interepisode 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.
He experiences anticipatory anxiety and will avoid certain social events.
These symptoms are present regardless of his affective state.
He 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 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.
He 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.
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This case study presents a 26-year-old college graduate with a complex psychiatric history characterized by major depressive episodes, social anxiety, and a recent episode of mood elevation triggered by a selective serotonin reuptake inhibitor (SSRI). This analysis aims to address specific questions regarding the patient’s diagnosis, expected future course of illness, and treatment options for potential future depressive episodes.
The patient’s history does raise the possibility of bipolar disorder, even though the mood elevation episode was triggered by SSRI treatment. Bipolar disorder is characterized by the presence of manic or hypomanic episodes, often accompanied by depressive episodes. In this case, the SSRI-induced mood elevation, characterized by elevated mood, decreased need for sleep, distractibility, impulsivity, and grandiosity, aligns with the criteria for a manic episode. The fact that he experienced major depressive episodes since adolescence, combined with the SSRI-induced mania, suggests a possible diagnosis of bipolar disorder, specifically Bipolar II, which includes depressive and hypomanic episodes.
Considering the patient’s history, it is crucial to anticipate the future course of his illness. Bipolar II disorder tends to involve recurrent depressive episodes interspersed with hypomanic episodes. Given his family support and potential stressors associated with his career goals, the patient is at risk for future mood episodes. It is essential to monitor his mood regularly and educate him about recognizing early signs of depression or hypomania.
In the event of another depressive episode, treatment should focus on mood stabilization and preventing recurrence. Selecting an appropriate medication depends on individual response and side effect profiles. Options include mood stabilizers like lithium, anticonvulsants (e.g., lamotrigine), and atypical antipsychotics (e.g., quetiapine).
Lamotrigine is a viable choice due to its efficacy in preventing depressive episodes in bipolar disorder. Its mechanism of action involves inhibiting voltage-gated sodium channels, thereby stabilizing neuronal membranes. Lamotrigine’s specific receptor action is on sodium channels in the central nervous system, reducing glutamate release, which contributes to mood stabilization.
In conclusion, while the SSRI-induced mania complicates the diagnosis, the patient’s history supports the possibility of bipolar disorder, particularly Bipolar II. Monitoring and education are key to managing his future course of illness. Lamotrigine is a suitable option for treating depressive episodes due to its mechanism of action and efficacy in mood stabilization, but the choice should be made in consultation with the patient and a mental health professional.
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