Case Report: Bipolar II or MDD?

May 16, 2015

An instructive case that ties in to an APA presentation on "Treatment and Research of Treatment-Resistant Depression and Bipolar Disorder."

APA CONFERENCE REPORTER

On May 17, 2015, Carlos A. Zarate, Jr, MD, will present on Update on the "Treatment and Research of Treatment-Resistant Depression and Bipolar Disorder" at this year’s American Psychiatric Association meeting in Toronto. The following Case Report ties in to Dr Zarate’s presentation.

Five years ago, "Alex," a 25-year-old white male, presented for outpatient assessment of severe depression. He had been having recurrent cycles of depression that alternated with cycles during which he seemed to be okay. His depressed phases routinely included thoughts of suicide, but as time went on he found himself full of rage during the depressed phases and worried that his suicidal thoughts were becoming more concrete.

History
He described his depression as routine, frequent, “my entire life,” including grade school. The earliest episode was in second grade, which he recalled with certainty: at that time he was “not meeting my own standards.” The duration of his depressive episodes varied: they could last for several months, or be much briefer lasting only a few hours, but averaged 2 to 4 weeks. Onset could be a day to a week; offset was often very fast, a day or less.

When asked about manic/hypomanic symptoms, he affirmed that he had trouble falling asleep once in a while, but he didn’t have a decreased need for sleep. He did not endorse racing thoughts; but he’d been told he was talking too fast numerous times, which he attributed to anxiety. He endorsed distractibility, and had difficulty getting things done. He endorsed crowded thoughts, especially while writing, while working on creative projects. When “feeling good about the world,” he could gets things done; but otherwise, had trouble completing tasks. He did not recollect phases of imprudence or risk taking. At age 22, he had “a really intense burst of rage,” and remembers punching a hole in his windshield.

He was first seen for mood problems at age 10. He was hospitalized at age 15 after an emotional struggle with his mother that led to a suicide attempt. He was hospitalized again at age 20 with “general feelings of instability.” Earlier diagnoses were MDD; bipolar II was a “rule-out” in the latter hospitalization. On that admission his regular medications were clonazepam, bupropion, and diphenhydramine.

Other antidepressant trials included escitalopram and venlafaxine. Trazodone had been used for sleep. Venlafaxine was “a nightmare”: he stopped going to class for over a week, and ate only 4 meals during that time; his suicidal thinking dramatically increased, which he described as “busy feelings in my head.” Escitalopram caused a flattening of mood, followed by depression. He had experienced 3 trials of psychotherapy, supportive or cognitive-behavioral. Nefazodone was not judged effective and had recently been tapered off.

Alex’s maternal grandmother was “permanently happy and jolly.” One of his mother’s brothers “battled depression,” the other two “drink too much”; his mother’s sister had “chronic judgement issues.”

On hospital admission at age 20, Alex’s TSH (thyroid stimulation hormone) level was 8.5; 2 days later, it was 3.7. He reported no family history of thyroid problems, nor was he aware of any other medical problems.

Alex was not much of a drinker although he became drunk about a year prior at his cousin’s wedding; otherwise he drinks socially, 1 to 2 drinks every few weeks. His use of marijuana was also sporadic-he usually did not keep it around; he had tried cocaine once.

At age 14, Alex experienced a sexual assault by an unrelated male; there had been no other major trauma. He attended college and earned Bs and Cs. He enjoyed art classes, vocal performance, and theater. Seasonal shifts in mood, energy, and productivity were prominent.

Assessment
Alex clearly had recurrent episodes of depression, although some were so short as to suggest mood instability rather than MDD. His regular mood recoveries argued against thyroid abnormalities as the basis of the longer depressive episodes.

He did not appear to have discrete hypomanic phases although he endorsed a scattering of hypomanic symptoms. However, these symptoms clearly did not occur together, or with a phase of expansive or irritable mood, or increased energy. Other bipolarity index elements included age of onset of depressions relatively young (not suggestive of bipolar disorder); equivocal family history, with mood disorders but no overt bipolar diagnoses; a highly recurrent course, with strong seasonality; and 4 prior antidepressant trials, one of which appeared to have caused thought acceleration and suicidal ideation.

Differential diagnosis at the time of his hospitalization at age 20 included recurrent MDD, bipolar NOS, and other considerations such as borderline disorder and attention-deficit disorder.

Treatment and symptom remission
Lamotrigine was initiated and titrated to 200 mg, at which point remission of depression symptoms was seen. Bipolar psychoeducation helped Alex recognized a history of and continued phases of increased activity, including cleaning the house at night, as well as phases of agitation, insomnia, and irritability.

Divalproex caused unremitting nausea; lithium made him “too flat.” He has done well for the past 2 years on olanzapine and topiramate for weight control, as well as lamotrigine.