The patient is a 26-year-old college graduate who is currently euthymic but who has a history of major depressive episodes. He has experienced major depressive episodes, mostly untreated, of varying lengths and severities since he was a teenager.
His symptoms have included insomnia, despondent thoughts, depressed mood, low interest in activities, poor energy, and impaired cognition. He says his self-esteem drops and he feels rejection-sensitive and guilt-ridden for no apparent reason. He has never had suicidal thoughts.
Some of the depressive episodes have been incapacitating and have interfered with school and work. He appears to have good inter-episode recovery and is able to return to class and work.
The patient also has symptoms of social anxiety. He is often nervous around new people and acquaintances, and he experiences anticipatory anxiety and will avoid certain social events. These symptoms are present regardless of his affective state.
The patient has asked for a consultation because he has legal issues regarding drinking and driving that he thinks were likely fueled by his psychiatric symptoms. At the time of the infraction (several months ago, just before graduating college), he had been started on a selective serotonin reuptake inhibitor (SSRI) for the depression and generalized anxiety disorder (GAD) symptoms.
Within days of starting, he experienced an elevated mood in a sustained fashion over several days. He lost all anxiety, fear, and avoidance. He was unusually talkative; had racing thoughts; was distractible, hyperactive, and impulsive; and had decreased need for sleep.
He exhibited grandiosity, in which he felt invincible and that the law did not apply to him; this led him to purposefully antagonize a man in a bar, drive while drinking, and challenge authority when police were called. The mood elevation is complicated by the fact that the patient admits to heavy alcohol use on weekends throughout college. The mood elevation abated with cessation of the SSRI treatment.
The patient has now completed college; he has few friends in the immediate area, but his family is very supportive. He wants to be a news reporter and is planning on applying to graduate school.
The patient has no family history of bipolar disorder; his mother has GAD. He is not currently taking any medications.
Vitals:
• Glasgow Coma Scale: 8
• Blood Pressure: 160/80
• Pulse: 76
• Respirations: 18
• Height: 5’10ʺ
• Weight: 190 lb
Please answer the questions listed below:
1. Does the patient’s history support a diagnosis of bipolar disorder even though his symptoms appear to have been triggered by a selective serotonin reuptake inhibitor?
2. What would be the expected future course of illness for this patient?
3. If the patient develops another depressive episode, how would you treat it?
4. What medication would you choose? (There could be many correct answers.) What is the mechanism of action (MOA) of this medication? (Be specific: What receptor does it work on? etc.)
5. Provide three references (published in the last 5 years) on the medication treatment of mood disorders.