Patient Profile: SarahOnset of illness:

rapid

Course: chronic remittent

Duration: 10 years

Aged 34

Single

Teacher

Each episode Sarah has feeling tearful with low self-esteem

Has trouble sleeping at night but sleep many hours at day time

Has nothing in her life which brings her enjoyment

Has suicidal ideas

Gained weight

Feeling despair

Isolation from friends and family

sense of worthlessness

Concentration difficulty

Symptoms are worsening over episodes

Sarah said

• When I am down, I want to be alone• I shut out everyone and hide• I cry for no reason• I don't know why I am scared• I can not see anything good in my future• My head is filled with dark thoughts• I no longer want to be here• I often think about ways to end this misery life• I have to fight the thoughts in my head• I feel like I cannot breath• The depression has given me the worst days in my life especially the

mornings , I hate my morning because of my depression and I hate myself.

• It was true that while I was sunk in gloom at morning, I could laugh, be animated in the evenings, entertaining friends with mimicry and hiding my true state of mind.

Previous treatment trials

• She responded rapidly to different SSRIs on start of treatment and within few days but soon she lost the response and she stopped drugs out of her despair.

• She tried to adapt herself for her symptoms .• Each episode lasted on average 5-7 months and

they had seasonal preference and disappeared suddenly.

• She had a lot of episodes and never free for more than few weeks.

Sarah diagnosed with major depression

Case study: diagnosis and treatment

Prescribed amitryptiline

100 mg

6-week follow-up

As usual she felt some improvement at first weeks

Then worsened again

Sarah is still experiencing depressive

symptoms although appears agitated

and restless

Sarah has had several heated arguments with

her mother

Sarah reports that she is still only getting

2-4 h sleep per night

Psychiatrist’s Decision

Increased dose 150 mg

One week later , Sarah

• Spent hours and hours on her computer• Did not sleep at all for days• She heard music in the distance all the time• She left her work• She started to self medicate herself with

amphetamine and cannabis• She wrapped wet towels around her head afraid

her brain was going to over heat from thinking so much

Two weeks later

• She thought she is more intelligent than Albert Einstein

• She thought she was going to walk through invisible time gap

• She thought she discovered the theory of everything

• She thought the ancient Egyptians knew she had discovered the theory of everything and they wanted her back in their time

• Her sex drive went through the roof and she called some of her colleagues at work for marriage at late night.

• She wrote to all journals and magazines in the country and TV stations

• She wrote to the prime minister and the US president

• She wrote to Pope in Vatican

• She thought she is going to get Nobel prize

• She thought she is a God

Congratulations

Sarah does not appear depressed now

Inpatient, one week later

Sarah hospitalised with acute

manic episode

More thorough

psychiatric history taken

Diagnosis changedto bipolar disorder

Premorbid : Sarah

On the other side , they described her also by some negatives as she is risk taker, impulsive, lack of reliability, steadiness and perseverance in work, a tendency to building castles in the air,

impatience, and a tendency to be easily annoyed.

She is described by her family and friends that she is a nice person and known between her friends with her Brilliant abilities, versatility, wealth of ideas, artistic capability,

sociability and supportive attitude for weak peoplehigh energy, remarkable capacity for productive work,

Hyperthymic temperament

Final diagnosis

She was a soft bipolar case

But now after strong ADD

drug

Severe manic

breakdown

Take home message

Lewinsohn et al 1995; Hirschfeld et al 2003

Bipolar disorder

frequently begins with a depressive

episode

Misdiagnosis as MDD

Correct diagnosis can be delayed by up to

10 years

• Patients with Bipolar disorders are missed , under-diagnosed and under-estimated

Admissionswitchedto lithium

Case study: treatment

Dose titrated

to 1.1 mEq/L

Slow resolution

of symptoms

Cognitive dulling

and tremors

Change intreatment?

Case study: treatment

Dose of lithium

reduced

Atypicalant

psychoticadded?

Few weeks later

Calm , cooperative, euthymic

She could concentrate again

her insomnia vanished

she lost weight

she went back to work