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PS5.1-2,PS6.1 | Mood Disorders — PBL Case

CLINICAL SETTING

A primary health centre in a semi-urban district. You are the duty medical officer. The case unfolds over three visits spanning six weeks. Each visit reveals new clinical information that changes the management trajectory.

Trigger 1: The First Consultation

Mr Arjun S., a 34-year-old secondary school physics teacher, is brought to the PHC by his wife, Meena, on a Thursday afternoon. Meena tells you that for the past five weeks Arjun has been 'not himself.' She describes him as withdrawn, sleeping 10–11 hours a night but still waking up exhausted, eating very little, and having stopped attending social events he used to enjoy. He resigned as the school's cricket team coach last week, saying 'I am not good enough.' When you see Arjun alone, he speaks slowly and makes poor eye contact. He says, 'I feel empty, like a dead battery. Even teaching — I used to love it — feels like a chore.' He denies any thoughts of suicide. He has no past psychiatric history, takes no regular medications, and denies alcohol use. Physical examination is unremarkable. Routine thyroid function, blood glucose, and haemogram are all within normal limits.

DISCUSSION POINTS

  • Using ICD-11 or DSM-5 criteria, construct a formal diagnosis for Arjun. What is the minimum symptom count and duration required? Which core symptom(s) does Arjun definitely have, and which associated symptoms can you identify from Meena's and Arjun's accounts?
  • How would you classify the severity of Arjun's depression (mild/moderate/severe)? What additional questions must you ask to complete your assessment — specifically about suicidality, past mood episodes, and psychosocial stressors?
  • What is your immediate management plan? Which pharmacological agent would you choose as first-line, at what dose, and why? What psychoeducation would you provide to Arjun and Meena before they leave today?
  • How would you structure follow-up for Arjun over the next 4–8 weeks? What specific outcomes would you be monitoring at each visit?
Click to reveal Trigger 2: Six Weeks Later — The Unexpected Turn (discuss previous trigger first!)

Trigger 2: Six Weeks Later — The Unexpected Turn

Meena brings Arjun back to the PHC six weeks after the first visit. You had started him on sertraline 50 mg/day. Meena is visibly alarmed. She says that for the past 9 days Arjun has been 'completely different — but not in a good way.' He has been sleeping only 2–3 hours per night, getting out of bed at 3 a.m. to work on 'a revolutionary physics curriculum that will transform Indian education.' He has contacted several publishers without Arjun mentioning it to Meena. He speaks very rapidly and jumps from one topic to another. Yesterday he told Meena he had decided to quit his job and use their savings to fund a private school. When you see Arjun, he greets you loudly, shakes your hand vigorously, and says, 'Doctor, I have never felt better. I have discovered my true potential.' His speech is pressured, he is distractible, and his affect is expansive. He is irritable when you try to redirect him. He has been sertraline-adherent throughout. Physical examination is unremarkable.

DISCUSSION POINTS

  • What diagnosis does Arjun's current presentation represent? Apply ICD-11/DSM-5 criteria — what is the minimum duration for this episode, and does Arjun meet it? How does this change your understanding of his original diagnosis?
  • What is the significance of the fact that this episode emerged while Arjun was on sertraline? What pharmacological principle does this illustrate, and what is the immediate implication for his medication?
  • What are the immediate safety concerns for Arjun and his family at this point? What primary-care actions must you take RIGHT NOW, before specialist transfer?
  • Under the Mental Healthcare Act 2017, under what circumstances could Arjun be treated involuntarily if he refuses referral? What steps must be documented?
Click to reveal Trigger 3: The Specialist's Report and the Long Road Ahead (discuss previous trigger first!)

Trigger 3: The Specialist's Report and the Long Road Ahead

Arjun was admitted to the district psychiatry unit for 10 days. He is now discharged and returns to you for primary care follow-up. The discharge summary reads: 'Diagnosis: Bipolar Disorder Type I, current episode manic with psychotic features (grandiose delusions). Sertraline discontinued. Started on lithium carbonate 400 mg three times daily and quetiapine 100 mg at night. Serum lithium level at discharge: 0.75 mEq/L. Renal function and thyroid function at discharge: within normal limits. Follow-up: primary care physician to monitor serum lithium, renal function (serum creatinine), and thyroid function (TSH) every 3 months. Return to psychiatrist in 6 weeks.' Arjun is now calm, slightly sedated, and grateful for the care he received. He tells you he does not fully understand why he cannot take his 'old antidepressant' back if he 'feels low again,' and Meena asks you what signs would mean they need to seek emergency care.

DISCUSSION POINTS

  • What is the therapeutic serum lithium range, and what level indicates toxicity? What symptoms of lithium toxicity would you counsel Arjun and Meena to watch for? What monitoring schedule and investigations will you implement at the PHC level?
  • Arjun asks why sertraline was stopped. How would you explain, in language appropriate for a patient, the risk of antidepressant monotherapy in bipolar disorder?
  • What are the red-flag signs — both depressive and manic — that should prompt Arjun's family to seek urgent care rather than waiting for the next scheduled appointment? How does the MHCA 2017 protect Arjun's right to have his Advance Directive respected, and what should you counsel him to consider now, while he is well?
  • Reflecting on the entire case: what was the initial diagnostic uncertainty, and how did it resolve? What does this case teach about the risk of antidepressant-induced switching in undiagnosed bipolar disorder at the primary care level?

Learning Issues

Research these questions and bring your findings to the discussion.

  1. [PS5.1] What are the ICD-11/DSM-5 criteria for a major depressive episode, and what constitutes evidence-based first-line pharmacological management at the primary-care level, including duration of treatment after remission?
  2. [PS5.2] What red-flag signs in a patient with depression mandate urgent psychiatric referral, and how does a past history of mania (indicating bipolar disorder) fundamentally change the safe management of a depressive presentation?
  3. [PS6.1] What are the ICD-11/DSM-5 criteria for a manic episode (versus hypomania), what is the primary-care role in acute mania management (including safety and bridging pharmacotherapy), and what are the principles and monitoring requirements of long-term lithium therapy for bipolar disorder?