A 69 year-old male seeks treatment for severe depression. He had experienced one depressive episode 30 years earlier, leading to psychiatric hospitalization, and improvement after one month of treatment with imipramine. He remained well for three decades without any psychotropic medication treatment. He was a successful journalist, writing a number of books; he was passionate, liberal, and opinionated, often having some interpersonal conflicts with those who had different political views. He had a wide circle of friends, and an equally wide circle of enemies. He had three adult children, was divorced, remarried, and happy in his relationship. He had partially retired five years earlier, but was still writing, traveling, and enjoying his activities. He was normally high in energy, slept about 6 hours nightly, had many activities, high libido, and was very creative.
In March, he began to feel inexplicably sad, with low energy and decreased interest in his usual activities. His libido remained high and active, though, and when he would have a good day, he would describe pleasurable sexual activity with this wife. He was also very agitated and anxious and worried about the sudden return of depression. He was more angry than usual.
Family history was positive for severe depression in some relatives but no one sought help and no official diagnoses or treatments existed. The patient had no drug allergies and no drug/alcohol abuse. His medical history was normal except for mild hyperlipidemia.
He visited his primary care doctor who prescribed sertraline 25 mg/d. He immediately felt better for a few days, but then more depressed again. Sertraline was increased to 50 mg/d. He improved for a few days, then felt worse again. Sertraline was increased to 100 mg/d. He then felt high in his mood, with markedly increased energy, very high libido, and a complete inability to sleep. He called a friend and complained about this mood state: it was uncomfortably energetic and he was worried about not sleeping at all. After two days, these symptoms went away and he went back into his depressive state. He reported these symptoms to his doctor, who stated that since they lasted two days, not four days, they did not represent a hypomanic episode. In any case, they had gone away and the patient remained very depressed, so his primary care doctor increased sertraline to 150 mg/d and consulted a psychiatrist.
The patient had investigated the topic on the internet, had read about antidepressant-induced mania/hypomania as representing possible bipolar illness, and told the psychiatrist that he was willing to take lithium for his current depression. The psychiatrist told the patient that the diagnosis was major depressive disorder and that lithium wasn't necessary.
Over the next three months, the psychiatrist increased sertraline to 200 mg/d, added bupropion plus lorazepam, and gave brief trials of quetiapine 25 mg for sleep, venlafaxine in place of sertraline (added to bupropion), and trazodone for sleep. The patient had no further brief hypomanic-like episodes, but his depression did not improve, he became more and more agitated and angry. He was taken to the emergency room a few times by his wife due to concerns about some expression of suicidal ideation, but he would always deny imminent intent or plan, and would refuse voluntary hospitalization. He was not hospitalized. One morning he jumped off a building to his death.