Case outcome: interim follow-ups through two months

After two weeks of thiothixene (Navane) 10 mg/d, patient is showing global, gradual improvement, but calls with fever, rash, and upper respiratory tract infection (URI) symptoms

There is a fine intention tremor noted, but no leadpipe muscle rigidity or vital sign changes, and neuroleptic malignant syndrome (NMS) is ruled out

The URI resolves and the patient continues the typical antipsychotic and the nightly diphenhydramine (Benadryl)

Gradually there is no more thought disorder or other psychotic symptoms

Sadness is alleviated but irritability continues

Sleep is improved

Chief concern continues to be poor concentration and less productivity

Patient asks for cognitive-enhancing agents, but is warned again that some of her previous prescription stimulant use may have caused her apparent mixed features/psychosis

Collateral history obtained

• – Showing that the last stimulant use was several weeks before her presentation so that stimulant intoxication appears to be ruled out

• – However, it does appear that the stimulant use was chronologically related to the emergence of her mixed feature and psychotic symptoms noted earlier

• – It also appears to have led to tic-like movements that the patient reported

Attending physician’s mental notes: two months

Given frequent appointments, concern for side effects and tolerability being emphasized over efficacy, clinician availability via phone between appointments is needed

Patient appears content and willing to maintain monotherapy as long as empathic limits are set

Patient affect can likely be contained while waiting for full effects of psychotropics to occur

Residual symptoms will likely exist and quickly addressing the remaining irritability, depressive symptoms, and cognitive problems should help compliance and tolerability

Question

What would you do next?

Continue to use the thiothixene monotherapy

Continue the monotherapy discussed for a few months to clear all psychosis completely and then switch to a better mixed features, atypical antipsychotic

Continue the typical antipsychotic monotherapy indefinitely but add an antidepressant as needed if there is a failure of full depressive symptoms to remit

Case outcome: interim follow-ups through two months

Records continue to arrive and full medication trial history is elucidated chronologically as follows

• – Fluoxetine (Prozac) 40 mg/d, sertraline (Zoloft) 100 mg/d, XL – escitalopram (Lexapro) 10 mg/d, bupropion (Wellbutrin) 300 mg/d, buspirone (BuSpar) 30 mg/d full trials now documented

• – Methylphenidate (Ritalin) 30 mg/d trial noted

• – Carbamazepine (Tegretol) caused increased impulsivity and hair loss

• – Lithium caused GI upset

• – Clonazepam (Klonopin) low dose was effective for mood lability and agitation

• – Bilateral ECT treatment – short course only due to prolonged anterograde amnesia

• – Olanzapine (Zyprexa) 10 mg/d helpful but metabolic problems occurred

  • Weight increased 30+ lbs, triglycerides went above 600 mg/dL, and a statin was required

  • Quetiapine (Seroquel) caused metabolic issues to continue after a switch from olanzapine

• – Clozapine (Clozaril) 100 mg/d short trial caused threat of agranulocytosis

• – At one point, records suggest she was taking several medications per day, equalling 20+ pills per day

How does this history support or change your differential diagnosis?

It appears her initial working diagnosis was unipolar MDD perhaps with mixed features and/or psychosis

Perhaps the evolution of her illness was a transition from unipolar to bipolar symptoms, given the progression to mood stabilizers and atypical antipsychotic use

Perhaps the evolution of her illness was a transition from unipolar or bipolar illness toward a schizoaffective disorder (although she has no negative symptoms and mild psychosis at best)

The use of major tranquilizer and mood stabilizer medications suggest that despite her current advanced education and degrees, she has been significantly impaired and likely will experience relapses as she has a severe and persistent mental illness (SPMI) or personality disorder

She experienced relative stability on an SSRI, but addition of a stimulant appears to have activated the current mixed features and psychotic episode and caused movement disorder symptoms so that much of her symptoms appeared to be iatrogenic, and she is likely a unipolar depressive with mixed features or has a subtle personality disorder comorbidity