Sarah, a 34-year-old teacher, has experienced chronic, remitting episodes of depression for 10 years. Her current episode involves low self-esteem, sleep problems, lack of enjoyment, suicidal thoughts, weight gain, despair, isolation, worthlessness and concentration difficulties. Previous treatments with SSRIs provided initial relief but symptoms returned. Amitriptyline was prescribed but exacerbated manic symptoms, leading to a diagnosis of bipolar disorder. Hospitalization and lithium stabilized her condition. The case highlights how bipolar disorder can initially present as depression and the importance of a thorough psychiatric history for correct diagnosis.

1. Patient Profile: Sarah
Onset of illness:
 Aged 34 rapid
 Single Course: chronic
 Teacher
remittent
Duration: 10
years

2. Each episode Sarah has
 feeling tearful with low self-esteem
 Has trouble sleeping at night but sleep many hours at day
time
 Has nothing in her life which brings her enjoyment
 Has suicidal ideas
 Gained weight
 Feeling despair
 Isolation from friends and family
 sense of worthlessness
 Concentration difficulty
 Symptoms are worsening over episodes

3. Sarah said
• When I am down, I want to be alone
• I shut out everyone and hide
• I cry for no reason
• I don't know why I am scared
• I can not see anything good in my future
• My head is filled with dark thoughts
• I no longer want to be here
• I often think about ways to end this misery life
• I have to fight the thoughts in my head
• I feel like I cannot breath
• The depression has given me the worst days in my life especially the
mornings , I hate my morning because of my depression and I hate
myself.
• It was true that while I was sunk in gloom at morning, I could laugh, be
animated in the evenings, entertaining friends with mimicry and hiding
my true state of mind.

4. Previous treatment trials
• She responded rapidly to different SSRIs on start
of treatment and within few days but soon she
lost the response and she stopped drugs out of
her despair.
• She tried to adapt herself for her symptoms .
• Each episode lasted on average 5-7 months and
they had seasonal preference and disappeared
suddenly.
• She had a lot of episodes and never free for more
than few weeks.

5. Case study: diagnosis and treatment
Sarah diagnosed Prescribed
with major amitryptiline
depression 100 mg

6. 6-week follow-up
Sarah is still
experiencing
As usual she felt some
depressive
improvement at first weeks
symptoms although
Then worsened again
appears agitated
and restless
Sarah has had several Sarah reports that she
heated arguments with is still only getting
her mother 2-4 h sleep per night

7. Psychiatrist’s Increased dose
Decision 150 mg

8. One week later , Sarah
• Spent hours and hours on her computer
• Did not sleep at all for days
• She heard music in the distance all the time
• She left her work
• She started to self medicate herself with
amphetamine and cannabis
• She wrapped wet towels around her head afraid
her brain was going to over heat from thinking so
much

9. Two weeks later
• She thought she is more intelligent than Albert Einstein
• She thought she was going to walk through invisible time gap
• She thought she discovered the theory of everything
• She thought the ancient Egyptians knew she had discovered the
theory of everything and they wanted her back in their time
• Her sex drive went through the roof and she called some of her
colleagues at work for marriage at late night.
• She wrote to all journals and magazines in the country and TV
stations
• She wrote to the prime minister and the US president
• She wrote to Pope in Vatican
• She thought she is going to get Nobel prize
• She thought she is a God

10. Congratulations
Sarah does not appear depressed now

11. Inpatient, one week later
Sarah More
hospitalised thorough Diagnosis changed
with acute psychiatric to bipolar disorder
manic episode history taken

12. Premorbid : Sarah
She is described by her family and friends that she is a nice
person and known between her friends with her Brilliant
abilities, versatility, wealth of ideas, artistic capability,
sociability and supportive attitude for weak people
high energy, remarkable capacity for productive work,
On the other side , they described her also by some negatives
as she is risk taker, impulsive, lack of reliability, steadiness and
perseverance in work, a tendency to building castles in the air,
impatience, and a tendency to be easily annoyed.
Hyperthymic
temperament

13. Final diagnosis
She was a soft But now after
Severe manic
bipolar case strong ADD
drug breakdown

14. Take home message
• Patients with Bipolar disorders are missed , under-
diagnosed and under-estimated
Bipolar
disorder Correct
frequently Misdiagnosis diagnosis can be
begins with a delayed by up to
as MDD
depressive 10 years
episode
Lewinsohn et al 1995; Hirschfeld et al 2003

15. Case study: treatment
Dose Slow
Admission
titrated resolution
switched
to of symptoms
to lithium
1.1 mEq/L
Cognitive
Change in
dulling
treatment?
and tremors

16. Case study: treatment
Dose of Atypical
lithium ant
reduced psychotic
added?

17. Few weeks later
Calm , cooperative, euthymic
She could concentrate again
her insomnia vanished
she lost weight
she went back to work