Patient evaluation on intake

26-year-old man with a chief complaint of being “depressed, more or less”

Mainly experiences MDEs of varying lengths and severities, occurring since he was a teenager

Asks for a consultation because he has legal issues concerning an altercation that occurred recently

Psychiatric history

Significant MDEs consistent with recurrent MDD are evident

• – Some MDEs have been incapacitating and have interfered with school and work

• – Seems to have good inter-episode recovery, which allows him to return to class and work

When in the middle of an MDE, he admits to most MDD symptoms

• – Except he does not have suicidal thoughts

• – Admits to decreased sleep, despondent thoughts and mood, low interest in activities, poor energy and cognition

• – Says his self-esteem drops as he feels disgruntled, rejection-sensitive, and is guilt-ridden for no apparent reason

He admits to SAD symptoms where he

• – Is often nervous around new people and acquaintances

• – Experiences anticipatory anxiety and will avoid certain social events

• – The SAD appears separate from the MDEs where these anxiety symptoms occur regardless of his affective state

The main reason for consultation is that he has a legal issue regarding drinking while driving that he feels was likely fueled by psychiatric symptoms

• – At the time of the infraction, he had been started on an SSRI for the MDD and SAD symptoms

  • This caused his mood to elevate excessively and in a sustained fashion over several days

• – With this, he felt invincible and that the law did not apply to him

• – During this episode he was also in an altercation at a bar when he purposefully antagonized another patron

  • This is extremely out of character for his usually quiet, socially anxious demeanor

Despite being a shy, avoidant, SAD person during this period, he lost all anxiety, fear, and avoidance tendencies

• – During these spells, he experienced a moderate amount of talkativeness, distractibility, racing thoughts, hyperactivity, hyposomnia, impulsivify (flirting, drinking more than usual, fighting) and grandiosity (becomes invincible, arrogant, back-talking, and challenging of authority [police, bystanders, etc.])

These mood-elevating events were complicated by the fact that AUD criteria were likely met during these times

• – While in college, he admitted to heavy alcohol use on weekends

• – When depressed, he may use cannabis intermittently

Has now completed college and has few friends in the immediate area

Family is very supportive

Wants to be a writer, specifically a news reporter, and is planning on applying to graduate school

Currently presents in a euthymic state at his first office appointment

Social and personal history

Graduated high school and college

Is not gainfully employed but is considering graduate school now

Drug and alcohol history as noted

He does not smoke and uses low amounts of caffeinated drinks

His family is supportive

Medical history

There are no acute or chronic medical issues

Family history

GAD is reported for his mother

No bipolar family members

Medication history

Via his PCP, he has had two short SSRI trials with sertaline (Zoloft) 50 mg/d and paroxetine (Paxil) 20 mg/d, both of which caused mood elevations with problematic behaviors and drinking

Took a few doses of mood stabilizing divalproex sodium (Depakote) but was too sedated to continue its use

Prescribed the BZ anxiolytic clonazepam (Klonopin) in the past without misuse

Psychotherapy history

None

Patient evaluation on initial visit

Recurring MDD since late teens with comorbid SAD are evident

Possible hypomanic spells in last two to three years versus antidepressant-induced activating side effects versus alcohol intoxication-induced mood disorder

All mood elevations reported seem secondary to SSRI and/or alcohol use

He has not had a chance to be compliant with medication treatment due to side effects

He has no suicidal ideation and no signs of psychosis

He is euthymic now and functioning well psychosocially