From the Editor
Misdiagnosing bipolar depression as major depressive disorder
During my residency, I was never urged to distinguish if a depression is unipolar or bipolar because the treatment was the same!
CASE Grief and confusion
Mr. P, age 47, is arrested for entering the apartment of a woman he does not know and tossing her belongings out the window. When he is assessed to determine if he can participate in his legal defense, examiners find an attentive, courteous man who is baffled by his own behavior.
Mr. P says that he had been “stressed out” after the recent death of his grandmother, with whom he was close. He says he entered the apartment because voices told him to do so. He has no recent history of substance abuse or psychiatric hospitalizations, but he had a similar episode of “confusion” years before, when another close family member died.
Mr. P is found not fit to stand trial and the charges are dropped. He accepts haloperidol, 10 mg/d, and benztropine, 2 mg/d, and is transferred to a hospital for psychiatric treatment.
On interview, Mr. P is well groomed, soft-spoken, and shy, without formal thought disorder. Physical exam and routine lab tests are within normal limits. He says that 18 months before his arrest, he and his frail grandmother moved to a large city in hopes that he would find a wife. Both depended on the grandmother’s Social Security benefits while he cared for her.
In the 2 months after she died, he reports that he felt sad and alone and slept poorly, but made efforts to find a job and keep his apartment. When his efforts failed and he lost the apartment, he stayed with various friends for a few days at a time, then spent several days in the subway before ending up on the streets.
His arrest on the current charge occurred 4 days after he began walking the streets.
How would you treat Mr. P?
a) continue haloperidol to treat psychotic symptoms
b) discontinue haloperidol and observe him
c) add an antidepressant to haloperidol
HISTORY Imagining nonsense
Mr. P cannot explain why he started “trashing” the woman’s apartment, but says he entered it because he thought it was his apartment. With embarrassment and regret, he admits he has been depressed and confused, “imagining things”—“foolish things,” he admits—such as being in a different “time zone.”
Contradicting his earlier statements, Mr. P now admits that he had “a few beers” and denies that he experienced auditory hallucinations, saying he only talks to himself. He now says that within 2 days after his arrest, he was “all over it.” Mr. P denies current symptoms, including hallucinations, but, when pressed, waffles, then admits to a strange belief: that some people, including him, can move from one “time zone” to another.
Mr. P says he was treated for psychiatric problems 4 years earlier when his parents were killed in a car crash. By his recollection, his reaction to their death was similar to his reaction to his grandmother’s death: He became upset and wandered the streets for a few days, “moving between time zones” and talking to himself but not experiencing hallucinations. After he was taken to a hospital and “given an injection,” he calmed down and was released. Within a few days he recovered and returned to supporting himself and caring for his grandmother. Mr. P says the idea of travelling between “time zones” is embarrassing and nonsensical but adds that he was affected in this way because he “bickered” with his mother.
Mr. P’s grandmother raised him until he was age 15, although he frequently visited his parents, who lived nearby and worked during the day. Mr. P initially denies substance abuse, then admits to smoking marijuana every day for about a year before admission. He also admits to cocaine abuse in his 20s. He denies a history of suicide attempts.
The author’s observations
Mr. P reported only 2 episodes of “confusion” (or psychosis) and strange behavior in his life, both precipitated by the loss of a loved one, and at least 1 while under the influence of alcohol and Cannabis. He gave an inconsistent and ambiguous history of auditory hallucinations associated with episodes of confusion. He believes that time travel is possible, an idea that he acknowledged is nonsense. This alone was not enough to warrant long-term antipsychotic treatment. The most likely diagnosis seemed to be brief psychotic episode induced by Cannabis and the stressors of homelessness and his grandmother’s death.
EVALUATION Changing stories
No longer taking haloperidol, Mr. P continues to deny hallucinations and depressed mood, but keeps to himself. Nine days after admission he becomes tearful after he informs his aunt of his grandmother’s death in a telephone call, then approaches a nurse and complains of sadness and auditory hallucinations.