Bipolar disorder: Mixed episodes concomitant with gambling addiction

To the Editor

‘Mixed episodes’ is a diagnostic subcategory within the spectrum of bipolar affective disorders. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) refers to it as a specifier ‘with mixed features’ (MxFS). Mixed episodes are characterized by the concomitant occurrence of depression and mania symptoms during the same mood episode (Malhi, 2013). Mixed episodes associated with gambling addiction are more likely to develop in individuals with features of hyperthymia (Cerullo et al., 2012; Kuiper et al., 2013).

This case report shows how bipolar disorder may have an atypical course with mixed episodes that may cause significant diagnostic difficulties.

A 35-year-old patient was admitted to the psychiatric ward for the treatment of gambling addiction. During assessment, the patient reported a history of depressive episodes treated with the following antidepressants: sertraline 100 mg/day, venlafaxine 150 mg/day and citalopram 20 mg/day. However, the treatment was ineffective and full remission of mood disorder was not achieved. During these depressive episodes, increased anxiety and elevated mood were present and the patient engaged in active gambling. On the day of admission, the patient reported the feeling of a strong gambling urge that he found difficult to resist. Addiction to gambling was revealed from playing risky gambling machines, having heavy gambling debts, lying, criminal activity in order to obtain money and the avoidance of paying debts. Additionally, the patient complained of decreased mood with suicidal thoughts, increased psychomotor drive and sleep disturbances. A thorough psychiatric assessment of the patient revealed that during puberty the patient had become hyperactive and had problems maintaining concentration. In adulthood, the patient developed depressive and coexisting manic symptoms during the same mood episodes. In addition, the patient’s grandfather had had a manic episode in the past. Bipolar disorder was diagnosed, currently mixed episodes. The patient was commenced on lamotrigine 150 mg/day and aripiprazole 15 mg/day. After 8 weeks of treatment, psychomotor drive and mood were stabilized, concentration span was increased and sleep disturbances disappeared. However, obsessive thoughts about gambling activities were still observed, so the patient was commenced on cognitive-behavioural therapy. After another 8 weeks of treatment, obsessive thoughts and compulsive activities connected with gambling were less severe and the patient’s mood stabilized.

This case report reveals the necessity for the verification of a mood disorder diagnosis. A medical history that includes a thorough investigation of a patient’s past behaviours is extremely important in order to make the right diagnosis and for proper drug treatment. The use of lamotrigine and aripiprazole in combination for the treatment of mixed episode of bipolar disorder was effective in this case.