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Bipolar maelstrom: Diagnostic uncertainties and treatment challenges

Mr. AG, a 61yearold married gentleman was referred to an outpatient clinic in a psychiatric hospital more than 10 years ago for treatment of bipolar I disorder, obsessive– compulsive disorder, and generalized anxiety disorder. Bipolar disorder began with an episode of mania and psychotic features in his lateteens for which he was hospitalized. He was diagnosed with generalized anxiety disorder and occasional panic attacks when he was 35 years old followed by a diagnosis of obsessive– compulsive disorder 15 years later. He had been hospitalized for both manic and depressive episodes more than 20 times prior to his referral to our clinic, however, there was a 16year period during which was free of mood episodes and did not require a psychiatric admission. During the first 5 years of our involvement in his care, he spent only 5 months in hospital during as many hospitalizations, however, during the subsequent 5 years, there were frequent and prolonged psychiatric hospitalizations. The illness course was marked by discrete episodes of hypo/mania and depression with full interepisodic recovery during the first half of his involvement with us. Symptoms of the psychiatric comorbidities including obsessive– compulsive disorder and generalized anxiety disorder were largely confined to the mood episodes and would resolve or attenuate upon remission of hypo/manic or depressive episodes. However, over the subsequent 5 years, there was a marked change in the illness course due to the progressive shortening and eventually disappearance of euthymic intervals. Although the intensity and nature of symptoms have varied and the consequent emotional distress has fluctuated, he has continued to struggle with a variety of symptoms such as sadness, uncontrollable crying, hypervigilance, psychomotor agitation, unrelenting anxiety, pressured speech, panic attacks, insomnia, racing thoughts, intrusive distressing memories, poor concentration, poor memory, obsessive thoughts, and suicidal thoughts. His only suicide attempt occurred a couple of years ago with a prescription drug overdose. There is no history of alcohol abuse or illicit drug use. He has been investigated extensively to rule out any medical conditions that could have contributed to worsening of symptoms over the past 5 years. He has continued to adhere to the recommended drug regimen and attends his appointments regularly. He has a loving and supportive relationship with his wife who often accompanies him to his appointments and provides useful collateral information. Prior to the recent change in the illness course, he had experienced sustained improvement in his mood on the combination of lithium, lamotrigine, and olanzapine. Over the past 5 years, he has been tried on various psychotropic drugs including valproic acid, carbamazepine, lurasidone, aripiprazole, brexpiprazole, and clozapine often in combination with other psychotropic drugs. He was retried on previously effective medications (lithium, lamotrigine, and olanzapine), however, these medications were either poorly tolerated or ineffective. A short trial of bupropion during one of his hospitalization led to a lifethreatening episode of delirious mania requiring use of electroconvulsive therapy (ECT), but the ECT was ineffective. He is currently being treated with quetiapine 500 mg, olanzapine 20 mg, haloperidol 15 mg, oxazepam 15 mg, clonazepam 2 mg, topiramate 275 mg, and lorazepam 0.5 mg daily prn. Quetiapine was prescribed for depression but he developed restlessness of legs and required the addition of clonazepam. Olanzapine was added to manage mixed episodes and haloperidol was used to control agitation. The latter drug was prescribed for agitation after he failed to respond to a higher dose of olanzapine. Finally, oxazepam was prescribed to treat anxiety during the day. This drug regimen reflects our focus on managing crosscutting symptoms namely insomnia