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Abstract
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Bipolar disorder affects approximately 50 million individuals worldwide1 and is associated with a significant burden of disability, with a high rate of delayed or misdiagnosis and low rates of appropriate treatment.2,3 Among those diagnosed with bipolar disorder, the risk of attempting suicide is 31.1%,4 and attempts are most likely during mixed episodes.5 Up to 55% of individuals with posttraumatic stress disorder (PTSD) are also diagnosed with bipolar disorder. These individuals experience overall greater symptomatic burden and diminished quality of life compared to those diagnosed with either disorder alone.6
We report the case of a patient with bipolar I disorder and PTSD who experienced an unfavorable outcome following abrupt discontinuation of mood stabilizers and the introduction of an unopposed selective serotonin reuptake inhibitor (SSRI). Use of an SSRI is an appropriate treatment for PTSD alone but relatively contraindicated as monotherapy in individuals with bipolar disorder,7 as serotonergic antidepressants are implicated in manic switch and poorer course of illness in a significant proportion of these patients.8 The case demonstrates the risks of abrupt medication changes in complex psychiatric patients such as may occur during a change in providers without sufficient handoff or review of the patient's diagnostic and treatment history...
Case Report
A 52-year-old White man with bipolar I disorder and PTSD presented to the emergency department in a mixed mood episode with extensive injuries inflicted by police canines after attempting suicide by police. The patient's first depressive episode occurred at age 8 years. He first presented to outpatient psychiatric care at age 14 years after he was abducted and held by a pedophile for a period of months, an experience that resulted in a diagnosis of PTSD. In subsequent years, the patient and his providers largely attributed his psychiatric symptoms to PTSD, and he was treated with multiple SSRIs and prazosin, with minimal therapeutic effect.
After graduating high school, the patient joined the Navy SEALs, during which time he disengaged from psychiatric care and attempted to suppress his symptoms, despite frequent depressive and dissociative episodes and repeated traumatic experiences in the line of duty. He was ultimately diagnosed with bipolar I disorder in the context of a manic episode with psychotic features...
Language: en |