Attending physician’s mental notes: initial evaluation

Patient is 100% dysphoric overall, appears to be distraught, agitated, and has some subsyndromal manic symptoms and psychotic thought disorder (versus hallucinations)

• – Per DSM-5, once psychosis occurs, the patient is declared fully manic and a bipolar 1

• – Per new entity in DSM-5, this could be a (if bipolarity is being considered) “with mixed features specifiers” scenario

  • This specifier may occur in bipolar or MDD patients

  • In this case, three MANIA criteria must be met in presence of MDD

Obtaining an accurate history is difficult given her mental state

Could be an agitated depression, mixed features, borderline personality or stimulant intoxication

Key is initially to confirm with her family that patient is safe to be at home, given her lability and thought disorder

Then will need to corroborate her history by obtaining records

Patient also reports she has had marked side effects

• – To most antidepressants

• – May have had TD but reports many of these movements occurred more while taking stimulants

• – Has had problems with mood stabilizers increasing ammonia levels and causing rashes

• – Has had marked serotonin side effects

Will need to consider these symptoms as possibly hypochondriacal, legitimate, or that patient has a p450 isoenzyme deficiency causing marked side effects

She is on no medications now; she ideally needs a monotherapy with low side effects, benign p450 isoenzyme profile, with inherent ability to treat depression/mania, mixed features, and psychosis all in one

In case this is bipolar mixed features, unipolar mixed features, or iatrogenic escalated mania, her stimulants and antidepressants likely should be avoided and not restarted

Further investigation

Is there anything else you would especially like to know about this patient?

What is her longitudinal history?

• – She has been gainfully employed

• – She is intelligent

• – She is successfully married with a supportive spouse

• – She has clear exacerbations of her psychiatric symptoms and has required inpatient stays but apparently without suicidal ideas, intentions, or attempts

• – She appears to function well with inter-episode recovery

• – Almost every medication has caused side effects

• – Her exacerbation currently seems to involve increased irritability, intact self-esteem, and thought disorder, which is a novel presentation per the patient

• – She states typically she would be depressed with agitation and insomnia, but not with these possible psychotic features, which are alarming to her and a novel presentation

Attending physician’s mental notes: initial evaluation (continued)

The patient is clearly distressed and is overly focused on improving her ability to concentrate and function better

Stimulants increase the DA/NE activity of her brain and could make her lability or thought disorder worse

At the initial session, it is impossible to obtain old records and a decision to mitigate symptoms has to be made now

She appears to have mixed features and is minimally psychotic, although it is possible these have been iatrogenically started by use of stimulants without an appropriate mood stabilizer in place

As she has had difficulty on most medications and this history is sparse and complicated, a trial of an atypical antipsychotic is best positioned to cover all clinical scenarios: psychosis, mania, mixed features, agitation, intoxication, depression, and should avoid any further manic escalation

A mood stabilizer (carbamazepine[Equetro] or divalproex[Depakote]) will not cover psychosis or help her depression

Lithium cannot easily be loaded and utilized quickly due to toxicity and a narrow therapeutic window

Adding a stimulant may cause psychosis

Adding an antidepressant may cause more mixed–manic features

Choice of medication should include an agent that requires little CYP450 hepatic metabolism

The patient does not wish to gain weight