Case study 1
This case report features a 30-year-old married woman seeking psychiatric care for her bipolar disorder. She relocated three months ago due to her husband’s job. Her social contacts in the new city were limited. One year ago, she emerged from a severe major depressive episode but continued to experience milder depressive symptoms. These included excessive sleep, loss of interest, worthlessness, and low energy. While not experiencing inappropriate sadness, she had daily mood elevations with bursts of energy, racing thoughts, and increased activity. These episodes lasted a few hours before returning to her low mood state. Her depression was impacting her marriage and work. She denied suicidal thoughts or desires.
Case study 2
A 41-year-old self-employed man with an eight-year history of depression and mood instability, along with migraines for one year. His depression worsened after redundancy and house repossession. Symptoms include persistent low mood, loss of motivation, and social withdrawal. Somatic symptoms include insomnia, loss of appetite, and weight loss. Periods of elevated mood involve overspending, inappropriate social behaviors, and decreased sleep. Intense anger and physical violence occur between mood swings. The diagnosis is Bipolar II Disorder. Quetiapine was prescribed, causing drowsiness and a sore mouth. Migraines occur during mood transitions. He also experiences chronic anxiety, agoraphobia, and social phobia since a traumatic event. Psychotherapy has moderate efficacy, but anxiety symptoms persist. Two suicide attempts occurred two years ago. He has no other medical conditions but experiences eczema during mood swings. Family history shows affective mood disorders and alcohol dependence. Previous treatments like fluoxetine, citalopram, lithium, and valproate were ineffective or had adverse effects. Current treatment includes lamotrigine, with plans to titrate to higher doses. Physical examination is normal, except for weight loss during low moods. Imaging tests show no abnormalities. The late withdrawal of citalopram and initiation of quetiapine posed therapeutic challenges. Citalopram withdrawal could have avoided manic mood exacerbations. Quetiapine is indicated for bipolar disorder treatment.
Case report 3
A 23-year-old female presents with moderate depressive symptoms, feeling low on energy and depressed. She struggles with attention, organization, and work tasks. These symptoms suddenly emerged after a period of heightened productivity and decreased sleep. In the past 2 years, she had two brief depressive episodes associated with job loss. Despite these challenges, she finds solace in socializing and maintains hope for a new job.
Notably, her first depressive episode was treated with methylphenidate (25mg to 50mg) and psychotherapy, resulting in improved mood. The second episode saw an increased dose to 100mg, improving depression but causing activation and sleep issues. Subsequently, she was referred to a psychiatrist for her third episode.
During her school years, she was diagnosed with ADHD, responding well to methylphenidate. However, in college, she experienced sleep problems and irritability, leading her to discontinue medication. Mindfulness and yoga became helpful for residual ADHD symptoms. Importantly, she had no history of suicidal thoughts, self-harm, hospitalization, or substance abuse.
In terms of comorbidities, she was diagnosed with type 2 diabetes, managed with metformin, and controlled high blood pressure with lisinopril. Her BMI indicated obesity, but other lab values were within normal limits. Family history revealed her maternal grandmother’s psychiatric hospitalization, her mother’s impulsive spending and unfinished projects, and paternal uncles with depression and alcohol abuse.
Case report 4
A surgeon developed the first manic episode at the age of 26. He has been treated initially with Valproate and Quetiapine. After 8 weeks he became symptom free, and his medication was gradually changed to lithium carbonate 1600 mg/day with a plasma level of 1.1 mmol/l. The quetiapine dosage was reduced to 300 mg/day. In the following months Quetiapine was discontinued and the patient continued the treatment only with lithium in the mentioned dosage. However, he developed a fine tremor of the fingers which affected his professional performance. When he became stable, he stopped taking the medication leading to a relapse. He was again hospitalized for 6 weeks and later continued treatment in out-patient setting for another 6 weeks before returning to work. This time the dosage of lithium has been reduced to 1000 mg/day with plasma level of 0.6 mmol/l. Initially a low dosage of Quetiapine was kept, to be discontinued 3 months later. Under the lower lithium dosage, the finger tremor disappeared, and the patient didn’t notice any site effects. He experienced mild depressive and hypomanic fluctuations, which were resolved by adjusting the medication dosage. The patient, who was highly trained and aware of his mood changes, has been symptom-free for 10 years, taking only lithium. He can successfully continue his profession and take care of his family. Regular monitoring showed changes in his thyroid function, which were successfully treated with medication.
Conclusion
This case study highlights several important aspects of bipolar therapy. Firstly, long-term or even permanent phase prophylaxis is necessary to prevent relapses. Secondly, medication should be tailored to the patient’s individual feedback regarding effectiveness and side effects and developed collaboratively with them. Only when the patient is satisfied with the medication’s effect can the required high compliance be achieved. Otherwise, there is a risk that the patient will reduce or even stop taking the medication, which can have serious consequences. Furthermore, this case study illustrates the high value of psychoeducation and symptom management, which are based on providing information and education to patients by treating physicians and therapists.