This case conference provides an opportunity for clinicians to share experiences from their practices. This case is a 47-year-old woman who is suffering from substance abuse and depression.

Case Conference Moderator: Michael M. Scimeca, MD, Mount Sinai Medical School, New York, NY

This patient is a 47-year-old, unemployed, overweight, Caucasian woman who presented to the Seattle VA Women’s Addiction Treatment Center for ongoing outpatient treatment for her alcohol dependence. She had recently been hospitalized for depression and suicidality combined with ongoing alcohol intoxication and symptoms of withdrawal. This was her second hospitalization for the month of June 2002.

She has a severe problem with alcohol and has had a history of hallucinations, DTs and seizures in the past as a result of alcohol withdrawal. During her hospital stay, she was also diagnosed with bipolar disorder type II. She is currently depressed and was started on lithium. During her first outpatient visit, she complained of low mood, poor concentration and variable sleep. She reported poor memory for things like events, dates and job-related duties. She also complained of water retention and an inability to lose weight on a 1,000 calorie per day diet and with daily exercising.

She has a psychiatric history of low moods that she thinks has been present for her entire life. She first noticed intermittent suicide ideation beginning at the age of 14. She had her first serious depression at the age of 31 after the death of her father and shortly after the birth of her son. She has had three prior psychiatric hospitalizations for depression and alcohol problems. She has had two prior suicide attempts. She has been on multiple medication trials, and she felt that all of them had helped her briefly, but eventually, her depression would return. She’d stop her medications and she would begin drinking again. Prior medications included desipramine, Prozac, Serzone, Effexor, Wellbutrin and Neurontin.

She admitted that she continued to drink intermittently during her treatment with the medications. In the past 2 years, she has had several episodes of mood elevation that lasted up to 5 days. Her most recent episode was just prior to the June admissions. She thinks that when she starts drinking, she has episodes of mood elevation. During these episodes, she experiences increased energy, increased goal-directed activities, increased spending, pressured speech and decreased need for sleep. She then will crash with serious depression, low energy, no motivation and increased need for sleep.

She has had a long history of drug and alcohol problems. They began at the age of 14 when she started using stimulants, including amphetamines and cocaine. She continued to use these for many years. In her twenties, she started drinking heavily and used some marijuana. In her late thirties, she had a 2-month binge on Vicodin and found that it was stimulating. In her late thirties, she decided that she was going to stop using drugs and was able to do so with the exception of alcohol, which she continued to binge on, especially when she had low moods. When she was in her late thirties and early forties, she was able to obtain 4½ years of complete abstinence from drugs and alcohol. During this period of time, she felt that she was depression-free. Unfortunately, she relapsed about 4 years ago on alcohol, which was precipitated by the end of a relationship.

Other history includes her being adopted as an infant into a nice family. There is no family history available. She also was traumatized by a date rape at the age of 15, but denied any past or present symptoms consistent with post-traumatic stress disorder. For the past 2 years, she has had worsening symptoms of panic, which has gotten so bad that she finally was diagnosed with panic disorder, and this led to her quitting her job.

When she has her symptoms, they are sudden onset of tremor, hyperventilation, fear of going crazy, fear of future attacks and the need to escape. The symptoms are intermittent and are definitely worse when she’s drinking more.

Psychosocial history includes the fact that a nice family adopted her. She stated that there was no abuse. She had no siblings. She is a high school graduate and was able to successfully complete 4 years in the Army as a clerk and had an honorable discharge. She is currently divorced, but lives with her ex-husband and 17-year-old son. Her ex-husband is financially and emotionally supportive to her. She quit her job 1 year ago due to worsening symptoms of panic. She had worked as a dental hygienist for 10 years prior to that. She applied for disability when she stopped working, but was turned down, and is now considering vocational rehabilitation. She was very financially stressed until she was able to obtain a refinancing loan recently on the home that she has owned for 10 years.

Her past medical history includes problems with TMJ and obesity. In addition, she had a hysterectomy about 10 years ago. Discharge medications from the hospital included Wellbutrin 100 mg three times daily; lithium carbonate, which was increased during her stay to 300 mg in the morning and 600 mg at bedtime; naltrexone 25 mg daily; Antabuse 250 mg daily; and trazodone 50 to 100 mg as needed for sleep.

Her liver function tests, creatinine, blood urea nitrogen and the rest of her electrolytes were normal. Her complete blood count was normal. Her lithium level was somewhat low at 0.4. Her TSH was normal at 2.61. Her T₃ was 123, which is normal. Her T₄ was low at 0.88, with a normal range being 0.93 to 1.7. She had an

EKG that showed normal sinus rhythm with no ST changes.

Mental status exam showed an alert, well-groomed woman who made good eye contact and had no psychomotor abnormalities. Her mood was described as depressed. Her affect was restricted. She had no suicidal or homicidal ideation. Her thinking was linear although somewhat circumstantial, but she had no psychotic features. She continued to complain about memory difficulties and lapses, but her Folstein Mini-Mental Status Exam had a score of 30 out of 30, which is completely normal.

Regarding Axis I issues, we know she has a substance abuse diagnosis, and she was diagnosed with bipolar and panic disorder. Is there some eating issue going on with her? Is that Axis I or Axis III?

Regarding Axis II, what do we know about her personality? Does she have a personality disorder? What’s the overlap of the personality issues with her substance abuse as well as her affective diagnosis? In a woman, it’s of interest to know where she is in her life cycle in terms of endocrine status and how that affects mood and weight.

Is weight an Axis III or Axis I? What is the specific recent stressor? She had an exacerbation of her panic disorder, and she has financial problems and unemployment problems. She was high functioning in the past, but not recently. She started using stimulants at age 14, and she used them until her late thirties. What has that been about for her? Was she using it for mood? Did she have some ADD? Was she using it to manage her weight? Does she use it as part of her sexual life?

Her first suicidal ideation was at age 14, about the time that she started using stimulants. She didn’t have much of a history with opioids. People do get stimulated by opioids and do get sleepy in the withdrawal phase of it. Alcohol is her main drug of choice. Did she have any sobriety around the birth of her son? Was she sober during the pregnancy? Many women are able to maintain some form of sobriety during pregnancy. How long was she able to maintain that after he was born? She had her first major depression at that time. Her dad happened to die right when her son was born, so those are two big psychosocial as well as biologic stressors.

What is the role of alcohol in her sexual life? Does she need that to help her in that sphere of her life? Is it possible for alcohol to precipitate a panic disorder? Will she continue to have that after she’s sober? The panic can just be a symptom of depression.

Chemically-dependent women have a high incidence of eating disorders, so the history is important. Has she always been overweight? Was she abusing stimulants for this when she was a teenager? How much overweight is she? Is her weight issue a function of her endocrine status or her mood? Does she have a separate eating issue that might qualify as an Axis I diagnosis? What is the relationship of weight to mood for her?

Lithium does precipitate weight gain in many patients, and trazodone is known for causing edema, so these might be two drugs that are not going to be desirable to this woman.

Other Axis I questions include the following: Did she have a learning disorder? Was she a well-behaved child? She did well in the Army and in her job.

She does have some affective instability and impulsivity, recurrent suicidal behavior and possibly unstable relationships. This points toward possibly a borderline diagnosis.

Regarding thyroid function, the labs were taken after lithium was initiated, so it is not known whether she’s ever had any signs of thyroid lab abnormalities before being on lithium. Being on lithium will obfuscate the understanding of pre-existing thyroid status. Compliance may be a question with her lithium, because she had a low level. Lithium blocks TSH-induced release of T₃ and T₄ so that early on, there is a decrease in T₃ and T₄ with a compensatory increase in TSH.

Then, there is an eventual return to normal levels and functional euthyroidism. In problem situations, patients can get goiter and hypothyroidism on lithium. Women over 40 and women with pre-existing thyroid disturbances are at greatest risk.

Regarding Axis III, was her fertility affected by her alcohol? Is she perimenopausal? Is she taking hormones? What was her sexual appetite like during these possibly hypomanic episodes?

Regarding treatment, is she ready for AA? Some people are averse to it. Sometimes, patients can go through moderation management or rational recovery before they go to AA. Private groups are very helpful for people who feel uncomfortable in AA. A women’s group would be good for her.

Individual treatment can be started right away, just so the person has a relationship with one person. Mood stabilizers other than lithium may be considered. Additionally, women need lower doses of naltrexone. Women get sick on 50 mg of naltrexone. Consider valproic acid as a mood stabilizer.

Delay treatment for panic disorder. Think about cognitive treatment and SSRIs to treat it, and then reevaluate it later. She has insomnia, which may resolve when she stops drinking. Also, trazodone causes water retention, so something else may be considered. Get medical consultation when there is a confusing thyroid question.

Is a TRH stimulation test indicated? For weight, use food logs, nutritional assessment and possibly Overeaters Anonymous. She needs both financial and vocational psychosocial support.

What’s her residential situation? Is she living in the house that she owns? Does she like living with her ex-husband? Should she get disability?

What about her self-concept and the nature of her relationships, especially with her son?

She has a history of bipolar II illness in addition to the depression. This history is episodes of elevated mood, elevated energy, elevated goal-directed activities, spending, pressured speech and decreased need for sleep. After that, there is a crash with depression and low energy. She says she’s been depressed her whole life. She also says that she felt pretty good while she was sober.

She had her first major depressive episode at 31, and there were some stresses attached to that. It is important to pay attention to the developmental history in this type of patient. What are the features of the early history to look for as evidence of dysthymia or related problems? Dysthymia itself can be hard to diagnose because, if a patient is really dysthymic, then he or she has always felt this way and doesn’t know any other way. The history that we get from her has to raise the index of suspicion that a lot of this is toxicity. The history is a clue to how to treat her now. What were the conditions during that sober period when she was apparently doing well? Can the treatment plan somehow recreate those conditions?

What about her medication history? She has a history of having brief trials. They worked for a little while and then they didn’t work. It is helpful to try to get details, because it may provide a clue about which medicine to try next. If they were all adequate trials and none of them really worked, then you want to think about something new and different that she hasn’t taken already.

It takes a long time to get a history from one of these patients. Ask questions a little more open-endedly, and listen to what the patient says before launching into the DSM checklist. Pay attention to the developmental history. Ask about elementary school and how he or she got along with the teachers. This provides information about ADHD and about either separation anxiety or social anxiety. The child with separation anxiety will say he or she was frightened about leaving home and being away from his or her parents. The child with social anxiety will say that he or she sat in class terrified that the teacher would call on him or her.

Often, these patients will have social phobic symptoms as teenagers and adults. They start taking drugs, and they feel a little bit more relaxed and can socialize. Then, they get hooked. Social anxiety has a lot of overlap with atypical depression and chronic depression.

To determine learning disabilities or problems, ask whether they had trouble learning how to read or write or with math? School failure is one of the big predictors of which children will go on to have drug and alcohol problems.

With atypical depression, what looks like hypomania could be mood reactivity. She could be getting really enthused and energized when something goes well, and then when something goes badly, she crashes. It’s hard to get a reliable diagnosis of hypomania. Unless the patient has really clearly marked manic symptoms or marked impairment in judgment, it can be very hard to sort out whether it is hypomania or other things.

Atypical depression is also in the differential diagnosis as is borderline character. Lithium could be problematic for a patient like her. Consider giving this patient thyroid replacement, because thyroid replacement is a good adjuvant treatment for antidepressants. Most patients on lithium end up on thyroid replacement. There is evidence that even in bipolar patients whose thyroid function tests are normal, adding thyroid is often a good adjuvant. It might help with the weight problem. Very few of the drugs psychiatrists work with don’t have weight problems associated with them.