A Curious Case of Depression: Mr. Z, Age 61, Has a History of Bipolar I Disorder and Presents with Worsening Depression, Fatigue, Thrombocytopenia, and a Rash. What Is Exacerbating His Symptoms?

Article excerpt

Mr. Z, age 61, is referred by his primary care clinician to the hospital's medical service with increasing depressive symptoms and non-pruritic rash. He has a history of bipolar I disorder for >30 years. When the primary care physician evaluated Mr. Z, his vitals were normal, but blood work revealed mild anemia and thrombocytopenia of 34 x [10.sup.3]/[mu]L, which prompted referral to the hospital. During admission, the psychiatric consultation service is called to evaluate Mr. Z's depressive symptoms.

Mr. Z reports having chronic sleep problems and feeling cold and tired, shivering at times, but has no pain. He says he's worried because he feels severely depressed, worthless, and hopeless, but denies suicidal ideation and psychosis. Mr. Z says he started experiencing increasingly depressed mood, anhedonia, insomnia, fatigue, poor appetite, and concentration 2 months ago. At that time his outpatient psychiatrist started Mr. Z on risperidone, 6 mg/d, and divalproex, 1,500 mg at bedtime because of emerging mood symptoms, after he was off medication for 7 months. Mr. Z attributed his worsened mood symptoms to being overwhelmed by several psychosocial stressors, including going through a complicated divorce, financial problems, and homelessness after being evicted from his apartment.

A review of Mr. Z's psychiatric history reveals several remote hospitalizations--the last was 7 years ago--for escalated manic symptoms after he stopped taking his medication. He denies past suicide attempts. Mr. Z says he is compliant with his current medication regimen--risperidone, 6 mg/d, and divalproex, 1,500 mg at bedtime. He denies illicit drug use and says he drinks "a couple of beers, mostly on weekends." Family history is positive for depression and bipolar II disorder.

His medical history is significant for hypothyroidism after goiter removal 6 years ago, for which he takes levothyroxine, 150 mcg/d, and a sports injury-related splenectomy in childhood. He reports no allergies. Vital signs at the time of admission are temperature, 99.1 [degrees] F; pulse, 98 beats per minute; respiration, 16 breaths per minute; blood pressure, 123/73 mm/Hg; and oxygen saturation, 97%.

During the interview, Mr. Z presents with tired facies and exhibits psychomotor retardation. He has to force himself to stay engaged in the evaluation and maintain eye contact. His speech is clear, regular, and soft. Mr. Z says he is "very depressed"; his affect is constricted, almost flat, stable, and consistent with depressed mood. His thought process is linear and somewhat concrete and his thought content is notable for hopelessness, although Mr. Z continues to deny suicidal or homicidal ideations. No hallucinations or apparent delusions are noted. Insight and judgment are fair. Mr. Z understands his current mental state; however, he displays some lack of knowledge regarding his current hospitalization. Cognition is intact

Table 1

Differential diagnosis in patients presenting with mood changes

Cerebrovascular disease

Degenerative disorders (Parkinson's disease, Huntington's disease, Wilson's disease)

Demyelinating disorders (multiple sclerosis, amyotrophic lateral sclerosis, lipid storage disease)

Endocrine disorders (Addison's disease, Cushing's disease, hyperthyroidism, hypothyroidism, hyperparathyroidism, pituitary dysfunction)

Epilepsy

Infectious diseases

Immune diseases

Metabolic encephalopathy

Neoplasm

Nutritional deficits (thiamine, niacin, vitamin B12)

Primary psychiatric disorders (mood disorders, dementia, sleep disorders)

Substance use

Toxins/medications

Traumatic brain injury

Source: Reference 1

What is the possible explanation for Mr, Z's clinical presentation?

a) reaction to stressors such as his divorce, financial problems, and homelessness

b) an endocrine disorder

c) pharmacologic effect

d) infection

e) all of the above

The authors'observations

The differential diagnosis in patients presenting with mood changes is extensive (Table 1) (1) and in Mr. …