CASE RECORDS of the MASSACHUSETTS GENERAL HOSPITAL. Case 30 2016. A 63 Year Old Woman with Bipolar Disorder, Cancer, and Worsening Depression.
Dr. Daniel J. Daunis (Psychiatry) A 63 year old woman with bipolar disorder, worsening depression, and multiple other medical conditions, including lung cancer and breast cancer, was admitted to the inpatient psychiatry service of this hospital for electroconvulsive therapy (ECT) The patient had a long standing history of bipolar disorder, including depressive episodes, which were characterized by low motivation, low energy, a feeling of hopelessness, agoraphobia, and suicidal ideation without suicide attempts, and brief episodes, each lasting for 2 to 3 weeks, of hypomania and mania with irritable or elevated mood, labile affect, pressured speech, and a decreased need for sleep. Twelve years before this admission, she had received a diagnosis of stage IIA estrogen receptor positive and progesterone receptor positive, HER2/neu negative invasive ductal carcinoma of the left breast, with lymphatic vessel invasion and isolated tumor cells in 2 of 2 lymph nodes. The patient underwent lumpectomy and adjuvant wholebreast radiation therapy. Follow up therapy included four cycles of doxorubicin and cyclophosphamide chemotherapy and a 5 year course of tamoxifen. She had also been hospitalized three times for mania with psychotic features, including paranoia and visual hallucinations; her most recent hospitalization for mania occurred during her treatment for breast cancer, 11 years before this admission for ECT. She also had attention deficit hyperactivity disorder (ADHD) Over the years, she had been treated with lithium, stimulants, atypical antipsychotic agents, and multiple classes of antidepressants. Six years before this admission, the patient discontinued primary care follow up, and shortly thereafter she discontinued psychiatric care. Two years before this admission, a diagnosis of stage II non small cell carcinoma of the right lung was made. At the time of the diagnosis, she was referred to a psychiatrist at the cancer center of this hospital. Her medications were adjusted, and her depression abated. She underwent a right upper lobectomy and received adjuvant chemotherapy. From the Departments of Psychiatry (K.E.I. O.F. Radiation Oncology (A.G.T. Radiology (P.E.F. and Pathology (T.M.G. and the Division of Medical Oncology (J.P. Massachusetts General Hospital, and the Departments of Psychiatry (K.E.I. O.F. Medicine (J.P. Radiation Oncology (A.G.T. Radiology (P.E.F. and Pathology (T.M.G. Harvard Medical School both in Boston.
The New England journal of medicine