Common (Complex) Problems in Psychiatry:
A Case-Based Approach
Focus on Mood Disorders and Suicide
Descartes Li, M.D.
Associate Professor of Clinical Psychiatry
University of California, San Francisco
[email protected]
Major Depressive
Dysthymic Disorder
Bipolar I Disorder
Bipolar II Disorder
Bipolar Spectrum Disorders
Frequently patients may present with psychiatric
symptoms, but do not appear to fulfill criteria for
bipolar disorder.
They frequently present with diagnosable depressive
episodes, severe anxiety, or substance abuse.
However, they do not respond well to
Bipolar Spectrum Disorders:
Additional clues to diagnosis
Family history of bipolar disorder
Seasonal pattern
Psychotic major depressive episodes
Early age of onset of major depressive episode (<25)
Postpartum depression
Antidepresssant “wear off” (ie, acute response but
lacking in prophylactic efficacy)
Lack of response to 3 or more antidepressant
treatment trials
this discussion will likely contain references to off-label
uses of FDA approved medications
Patients with soft bipolar disorders frequently benefit
from treatment with mood stabilizers and/or low-dose
atypical neuroleptics.
55yo MWM postal worker
h/o recurrent depressions since age 22, progressively
more irritable and depressed for past 6m, insomnia (3-4
hours/night), ruminative thinking about work stressors,
?mildly paranoid thinking? (no manic or fam psych hx)
4m ago, not able to work, rx’d lorazepam 1mg at bedtime
 somewhat helpful
Since then, trials of sertraline 50mg daily for 5 d
agitation, insomnia worsened; bupropion 150mg daily for 2
d worsened agitation, insomnia
remote h/o fluoxetine  insomnia, agitation, remote h/o
amitriptyline  insomnia, agitation
Diagnosis? Management/treatment?
DSM-IV Diagnostic Criteria
Mixed Episode:
Rapidly alternating moods (sadness, irritability,
euphoria) accompanied by criteria for both a Manic
Episode and a Major Depressive Episode.
 Duration of 1 week.
 Frequently includes agitation, insomnia, appetite
dysregulation, psychotic features, and suicidal
 Symptoms are not due to the direct effects of a
substance, or a general medical condition.
Importance of differentiating unipolar from bipolar
Different treatment pharmacologically!
Antidepressant monotherapy in individuals with bipolar
disorder can lead to rapid cycling or mania induction
Rapid cycling (greater than 4 mood episodes in one
year) is particularly difficult to treat and can lead to poor
Mania, in addition to direct consequences, frequently
ends in a depressive episode that is even more
refractory to treatment.
38yo single Chinese woman with SLE and
chronic renal insufficiency
Depressed (“my entire life”)and depressed now
(moderately worse past 6m)
further hx: 2-3 periods last several months of elevated
mood, decreased need for sleep, increased spending,
usually in response for some situation (thought a coworker really liked her, or creatinine improved)
chronically (past several years) on prednisone 5-10mg
daily, reports that a trial of prednisone 20mg daily 
“Made me delusional”, severe insomnia
Diagnosis? Management?
Signs of subsyndromal mania: DIGFAST
D – Distractibility
I – Insomnia
G – Grandiosity (or inflated self esteem)
F – Flight of Ideas (or racing/crowded thoughts)
A – Activities (increased goal directed activities)
S- Speech (pressured)
T- Thoughtlessness (increased pleasurable
activities with potential for negative
consequences: sex, money, traveling, driving)
Bipolar Disorder Symptoms
Are Chronic and Predominantly Depressive
146 Bipolar I Patients
86 Bipolar II Patients
followed 12.8 yrs
followed 13.4 yrs
1% 2%
Study 1
% of Weeks
1. Judd LL, et al. Arch Gen Psychiatry 2002.59:530-537.
2. Judd LL, et al. Arch Gen Psychiatry 2003;60:261-269.
Study 2
Treatment Implications -- Medications
Mood stabilizers
Mainstay of treatment
Usually require lab monitoring
Start Lithium carbonate at 300mg qhs
Lithium carbonate, Valproate (Depakote), Carbamazepine
Lamotrigine (Lamictal), Topiramate (Topamax), Gabapentin
(Neurontin), Oxcarbazepine (Trileptal)
55yo MLF with NIDDM, mildly obese,
depressed and anxious chronically
with insomnia alternating with periods of hypersomnia.
There is also a question of PTSD, she sometimes
hears voices, cries easily during visits
previous trials of paxil, venlafaxine, bupr  ineffective
she is currently on ativan 1mg at bedtime, but still
symptomatic, insomnia
Please discuss diagnosis and treatment options.
Atypical Antipsychotics
Helpful with agitation, psychotic features, insomnia
Less risk of tardive dyskinesia compared with traditional
High rate of weight gain, dyslipidemia, hypercholesterolemia,
hyperglycemia (start at half tablet of smallest pill qhs, titrate up)
Olanzapine (Zyprexa) dosage: 2.5mg-20mg at hs
Quetiapine (Seroquel) dosage: 12.5mg-600mg at hs
Risperidone (Risperdal) dosage: 0.25mg-6mg at hs or bid
Ziprasidone (Geodon) dosage: 20-160mg a day
Aripiprazole (Abilify)
dosage: 5-30mg a day
24yo SWF waitress dx’d w/ bp do
Currently on lithium carbonate 900mg at bedtime
for the past year
3yrs ago, was hosp’d for acute mania, initially
treated with risperdal and depakote, but switched to
lithium one year ago b/o weight gain
no labs for 2 years
What laboratory tests do you want?
Lithium Carbonate: a review
Side effects: polyuria (nephrogenic diabetes insipidus),
hypothyroidism, acne vulgaris (oily skin)
Dose dependent, intoxication sx’s (cognitive
difficulties/confusion, tremor, ataxia)
Labs: pretreatment: CBC, lytes, lfts, creatinine, tft’s and then
5d after changing dosage and q6m: trough lithium level,
creatinine, tsh
55yo single, Afr-Am female admin asst, NIDDM
and bipolar d/o type I, rather brittle diabetes
Psychiatrically stable (ie, no hospitalizations) for past
10yrs on prolixin 1mg at bedtime, divalproex 1500mg
at bedtime, diazepam 20-25mg at bedtime
Previous doctor retired
remote h/o lithium –“I’ll never go back on that stuff
What laboratory tests do you want?
Divalproex review(valproate, Depakote):
Side effects: elevated lft’s, thrombocytopenia, weight
gain, sedation, rare pancreatitis, ?polycystic ovary
Labs: pretreatment- CBC w platelets, LFT's,
5d after dosage changes and q6m -cbc with plts, lfts,
weight , pancreatic enzymes prn abd pain, n/v,
24yo SWF waitress dx’d w/ bp do
Currently on lithium carbonate 900mg at bedtime
for the past year
“What other treatments besides medications are
available for individuals with bipolar disorder?”
Patients with mood disorders should be educated
about common triggers of manic or depressive
episodes: sleep deprivation, street drugs (particularly
amphetamines, cocaine, hallucinogenics),
psychosocial stress.
Treatment Implications – psychosocial
treatments for bipolar disorder
Cognitive-behavioral therapy
Interpersonal psychotherapy
Social rhythm therapy
44yo MWM independent business owner,
for the past 15 years, drinks ½ bottle of wine each
evening, but for the past 8-9 months, has had a couple of
cocktails before dinner also (other ½ bottle of wine
consumed by wife).
Upon further questioning, he also describes bouts of
increased energy, lots of business trips (confidentially
says he had some extramarital “indiscretions” on a few of
these trips), decreased need for sleep: “I was a
dynamo.” Intermittent depression most of his life.
Does he have bipolar disorder?
41yo married Chinese female flight
attendant, stable hep B, hosp’d for mania 3
years ago
doesn’t recall what she was treated with, off
meds since.
No h/o substance abuse. No kids.
Now presents with one month of increased
anxiety, insomnia, depression
Appears tearful, distractible, loquacious,
ruminative, doesn’t want to see a psychiatrist
Useful adjuncts for maintaining sleep-wake cycles
N.B. High rates of co-morbid substance abuse in
patients with bipolar disorder.
Benzodiazepines: clonazepam (Klonopin), lorazepam (Ativan),
temazepam (Restoril)
non-benzodiazepines: zolpidem (Ambien), zaleplon (Sonata)
41yo MWF housewife, 2 children (5+2), no
prior psych hx,
for the past year, progressively more depressed and
irritable, low energy, increased sleep, snapping and
yelling at kids (guilty about this)
further hx: one summer trip in her 20’s to Europe,
elevated mood, sleeping 4-5 hours night, multiple
romantic partners (“I had the time of my life”)
41yo MWF housewife, 2 children (5+2), no
prior psych hx (previous patient)
citalopram 20mg daily  agitated, more irritable: “my
mind is going a mile a minute”
lithium 900mg at bedtime  signficantly improved, not
irritable, sleeping normalized, but still low energy
Augmented with paxil 20mg euthymic, still somewhat
stressed with two children, part-time job, but manageable
68yo MWM
dx’d with bipolar disorder long ago, stable on lithium
600mg twice a day, LL = 1.0
rountine creatinine = 1.6
Discuss your management of this patient
Don’t stop lithium acutely (<30d) because of risk
of mania inducation
55yo single WM, unemployed
lives in SRO, is on disability for unknown reasons
sleeps 12-14 hours per day, minimal activity, rather
minimal thought processes
has been on haloperidol 10mg q day, cogentin 1mg
daily for at least 10 years
past 6 months, insomnia, agitation, problems with
landlord (?paranoia?)
?what monitoring should occur?
(check labs, check utox, check
stressors/collaterals/compliance, increase haldol)
Pearls for Mood Disorders:
If you hear something like mania or hypomania, then it is
Don’t miss mixed depressive episodes
Think of bipolar disorder if 2-3 AD’s have been tried and they
haven’t worked, or they worked transiently and then “pooped out”
Watch for hypomania after you start antidepressants
Think of concept of target symptoms
Individuals with bipolar disorder spend most of time depressed,
may have difficulty recalling hypomanias
When patient is asymptomatic, cont with acute treatments if
possible (keeping in mind diagnosis)
Number 3 cause of death in young adults, number 11 over
25,000 deaths per year in the U.S.
Almost of third of people who kill themselves visit a
physician in the week before they die (More than a half visit
a physician in the month before they die).
Most cases do not report suicidal ideation, most are not
Most cases associated with major psychiatric disorder.
Doctors twice as likely to kill themselves as the general
44 year-old, divorced, white man
Seen in ED after crashing his car into a telephone pole.
Physical examination and routine blood work are
unremarkable. On further interview, he acknowledges
“Maybe I didn’t want to live any more.”
CASE (Shea)
Chronological Assessment of Suicide Events
3) Past events
2) Recent events (two months)
1) Presenting events: what, means, lethality (real or
perceived), risk/rescue, intention, when, wills,
letter,drugs/etoh, etc. "walk me through step by step"
(behavioral incident)
4) Immediate events
Evaluate risk factors:
Presenting event (fall from height, single passenger
MVA, drug OD)
Prior h/o suicide attempts
Male, living alone
Major psychiatric/medical disorder
Substance abuse/intoxication
Assess hopelessness/depression
Still thinking of suicide?
Interview techniques
1) behavioral incident -- scene by scene
2) gentle assumption -- assume pt has done it "gentle":
rapport, nonverbal communication. "what other ways
have you thought of killing yourself"
3) symptom assumption -- for minimization, suggest
high number,
4) denial of the specific --interview strategy for a list, list
specific sx -- allow pt to affirm or deny
44 year-old, divorced, white man
Seen in ED after crashing his car into a telephone pole.
Physical examination and routine blood work are
unremarkable, except for a BAC of 0.10%. On further
interview, he acknowledges that he has been thinking
about committing suicide, but currently denies any
current intent or plan to kill himself.
Can you discharge him from the ED?
Before Discharging a patient, Check:
1) Firearms and lethal medications have been
secured or removed
2) A supportive person is available
3) A follow-up appointment with a mental health
professional has been scheduled
4) The patient has the name and number of a
clinician who can be called in an emergency
Suicide References/Resources
The Practical Art of Suicide Assessment : by
Shawn Christopher Shea, Wiley 2002.
Night Falls Fast: Understanding Suicide by Kay
Redfield Jamison, Vintage Books 2000.
American Foundation for Suicide Prevention
American Association of Suicidology
Resources for Bipolar Disorder
National Organizations:
Depression and Bipolar Support Alliance
National Alliance for the Mentally Ill (NAMI)
National Institute of Mental Health Publications
Resources for Bipolar Disorder
Miklowitz, D. (2002). The Bipolar Disorder Survival Guide: What you
and your family need to know. New York: Guilford Press.
Mondimore, F. M. (1999). Bipolar disorder: A guide for patients and
families. Baltimore: Johns Hopkins University Press.
Jamison, K. R. (1995). An Unquiet Mind. New York: Knopf.
Solomon, A. (2001). The Noonday Demon: An Atlas of Depression.
New York: Touchstone.
Styron, W. (1992). Darkness visible: A Memoir of Madness. New
York: Vintage Books.
The End: Questions and Comments

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