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What To Treat First?

Question:

A person who has a very screwed up childhood presents himself for treatment without talking about the childhood and because of doomsday thoughts and ideations is pronounced bi-polar. This person in the last three years has never taken an antipsychotic medication and has been under stress that a psychotic person would never be able to handle. A deep depression lingers after the “supposed manic incident” Which should now be treated, the long ago incident or the pronounced depression being felt now?

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Answer:

In general, it is important to treat a patient’s symptoms as they are occuring at the time of presentation for treatment. This is particularly true when dealing with depression of any sort, as depression can be a lethal disease (a substantial minority of persons with depression commit suicide). I encourage this person to seek immediate treatment for their depression with a competent and licensed psychiatrist. It will be important to tell this psychiatrist about the past bipolar diagnosis and the question of whether this diagnosis was accurate, the childhood situation, the current lingering depression, the stressors that have been endured, etc. so that the psychiatrist understands the full picture and can plot an appropriate course of treatment. Diagnoses are difficult things to get right – particularly when there is a question of any interplay between mood and psychotic symptoms. What at first blush might seem to be a depression can easily later been better seen as a bipolar or schizoaffective disorder as further symptoms emerge. Often a provisional diagnosis is made when a patient is first seen and a course of treatment is designed to help quell the symptoms occurring at that time. The diagnostic picture is then refined over time as the patient and the treatment team interact. It just isn’t clear what the appropriate diagnosis should be for the person you describe. “Textbook” Bipolar disorder follows a cyclical course, but in my experience there are some individuals who primarily experience a unipolar or straight depression but have a history of manic like symptoms. These individuals are sometimes conceptualized and treated as having a bipolar process. The determination of the optimal diagnosis to describe what is happening for the person you describe should be left to an experienced, licensed psychiatrist. I hope that this is helpful, Dr. Dombeck

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