Ms. A was a 64-year-old married woman with a past psychiatric history of bipolar mood disorder that met ICD-10 diagnostic criteria. The disease began about 33 years ago with puerperal psychosis. Ms. A had, in all, nine hospital admissions in the next 23 years. At the first six admissions, she came in with psychotic depression and received treatment with major tranquilizers and antidepressants. On four occasions, ECT was administered.
Ms. A’s first four hospital admissions led to a complete recovery; after the last two, Ms. A was discharged with some residual depressive symptoms. She was followed up in the community between admissions. She was admitted again on two occasions after being seen for treatment of manic and hypomanic symptoms, respectively. She was then treated with haloperidol and hypnotic medications. After follow-up in the community, she was admitted again. She exhibited features of psychotic depression and was therefore administered lithium and imipramine. Since then, she had had minor relapses managed with adjustment of her dose of imipramine.
When Ms. A was next admitted, she was profoundly depressed and mute, with akinesia associated with negativism and psychomotor retardation. Upon physical examination, she was found to have bilateral pitting edema. She had a history of chronic cardiac failure; otherwise, her past medical history was unremarkable. The results of an ECG and a chest X-ray were normal. There was no evidence of constipation or dehydration (as indicated by her urea, creatinine, and packed cell volume values). Obesity was present. In view of Ms. A’s age, lack of response, and potential physical complication, mainly related to side effects, imipramine was switched to citalopram, 20 mg/day, and the citalopram dose was increased to 40 mg/day after 4 weeks.
When Ms. A started to improve to a degree that allowed her to walk around with a walker, shortness of breath upon minimal exertion was noted. A repeat physical examination and another ECG revealed no new features. Ms. A was referred to a medical unit, where she was admitted with a diagnosis of multiple pulmonary emboli, which was confirmed with a ventilation perfusion scan. She was prescribed an anticoagulant and eventually made a good physical and mental recovery.