Previous history

Our patient, a 16-year-old girl of Middle East origin, arrived in Sweden with her family as a refugee in 2016. The family had lived under traumatic circumstances and had been forced to flee due to the political situation in their country of origin. On arrival in Sweden, our patient was under treatment with lithium, levothyroxine, and haloperidol, and was enrolled in our out-patient care unit for pediatric bipolar and psychotic disorders. Her parents showed a medical document saying she was diagnosed with BD and OCD by a psychiatrist in a major city in the Middle East. However, the parents and our patient had difficulties in accounting for her psychiatric history and showed little knowledge about the disorders and why she was taking the prescribed medicines.

She had no family history of psychiatric diseases. Her psychomotor development in childhood was reported normal. She had been physically active, successfully participated in martial arts, and was described as helpful, responsible, and having friends, but with no academic schooling. The first psychiatric symptom observed in our patient, according to her parents, was an episode of altered mood at 14 years of age. During this episode she was unable to get up from bed for 1 month, stopped eating and drinking, and needed help to visit the bathroom. She was prescribed psychopharmacological treatment and recovered after approximately 3 more weeks. This episode was followed by a more active episode with disruptive behavior, including self-harm by cutting her ankles. There were no reports of suicide attempts.

Out-patient care

During her first months in Sweden, our patient’s main psychiatric problems were irritability, aggressiveness toward herself and her sister, mood shifts, and sleep difficulties. Her mood stabilized somewhat after an increased dose of lithium, even though she was under pressure from the process of seeking asylum and waiting for decisions from the authorities. She had great difficulties in recalling any previous episodes of mania or depression, but could describe periods of obsessive thoughts, mainly of sexual and religious character, since childhood. She felt shameful about these thoughts and about previous reckless behavior.

Additional treatment with quetiapine was initiated at a low dose of 25 mg daily. After a conflict with her parents, our patient stopped taking her medications, including lithium, for a few days. Shortly after this episode of altered compliance, she was exposed to several additional psychosocial stress factors. These included interviews at the migration office and deportation of an elder brother and his 4-year-old son, at the same time as she started school. Our patient presented severe anxiety, disturbing sinful thoughts, and depressive and suicidal ideations. She was subsequently admitted for emergency care at the Department of Child & Adolescent Psychiatry in Malmö, 7 months after arriving in Sweden.

In-patient care, course of acute illness

During the intake interview, our patient expressed a strong sense of guilt and distress because of her obsessive thoughts, with fear that she might harm herself or others, show inappropriate sexual behavior, or offend religious objects and thereby dishonor her religion. At the ward, compulsive behavior was noted, including excessive hand washing, showering procedures, and a need to line up different items on her bed with great accuracy. She did not wish to continue treatment with lithium, in part because she experienced adverse effects such as tremor and because of the need for repeated blood sampling. Her serum lithium level was 1.3 mmol/L (0.5 to 1.2 mmol/L) 2 days after admission. Our patient’s negative attitude, possible side effects, and the clinical picture dominated by depressive mood and OCD symptomatology, led to the decision to phase out lithium. Over the following 2 weeks, lithium was removed from her treatment and simultaneously quetiapine was up-titrated to 600 mg daily.

Our patient underwent magnetic resonance imaging (MRI) of her brain that showed no abnormalities. Routine laboratory tests indicated mild under-treatment of her hypothyroidism and there were no suspicions of illicit drug use. The Children’s Yale-Brown Obsessive Compulsive Scale (CY-BOCS) showed a total score of 18 points, indicating moderate OCD severity.

During the third and fourth week of in-patient care, our patient experienced a certain degree of mood stabilization and less anxiety. However, during the fifth week, her mood switched to a manic state with mixed and psychotic features. Further care was given according to the Swedish Compulsory Mental Care Act. Our patient showed a complex symptomatology, with rapid switches from euphoria with elevated energy to episodes of dysphoria with depressed mood, feelings of worthlessness, and fatigue. Overlapping manic and depressive symptoms such as psychomotor agitation, irritability, and distractibility were present, as well as paranoid delusions such as fear of being poisoned. Her pattern of sleep was severely impaired with a decreased need for sleep. In her room, she tore away some of the base-boards, on one occasion using them as a weapon against the staff. At times she was also aggressive toward fellow patients, leading to recurrent periods of seclusion. At other times she planned a wedding to take place between herself and members of the staff. Occasionally, she sang and laughed inappropriately or excessively, at other moments she kicked and punched the walls. For a few days, she refused oral medication. In this severe state, forced injections with haloperidol, zuclopenthixol acetate, and diazepam respectively were needed on various occasions to prevent self-harm and injury to others.

Despite reinstatement of lithium and further elevation of quetiapine to 800 mg daily, our patient did not improve during the following 2 weeks. Blood samples showed serum lithium concentrations of 0.7 to 0.9 mmol/L. At the beginning of the eighth week, haloperidol, which had previously shown a stabilizing effect in our patient, was reinstated and increased to 4 mg daily, while quetiapine was successively lowered to 150 mg daily. However, our patient’s behavior was continuously labile, with episodes of hyperactivity, agitation, and delusions.

Clinical discussions ensued regarding further psychotropic drug trials versus ECT; ECT was initiated with a first administration during the ninth week of hospitalization. ECT was administered every second or third day for 4 weeks with a total of 11 treatments. Unilateral ECT according to d’Élia [16] was used with a dose of 96.0 to 156.8 millicoulombs (mC) and a pulse-width of 0.3 to 0.35 milliseconds (ms). The average seizure length was 23 seconds (range 16 to 37 seconds). Propofol was used as an anesthetic agent in ten sessions and thiopental was used in one session. Our patient showed a prompt and marked positive response to treatment, with a dramatic decrease in her severity of illness, as described by using the Ziegler Young Mania Rating Scale (YMRS) and Clinical Global Impression (CGI) scores (Fig. 1a and b). She experienced no evident negative side effects. Fourteen weeks after admission, our patient could be discharged to stay with her family. Her base medication at discharge was lithium, with a serum concentration of 0.7 mmol/L, haloperidol 4 mg daily, and quetiapine 150 mg daily, with a plan of further tapering of antipsychotics.

Fig. 1 Severity of illness after start of electroconvulsive therapy, as described in Clinical Global Impression (a) and Ziegler Young Mania Rating Scale score (b) CGI Clinical Global Impression, YMRS Ziegler Young Mania Rating Scale Full size image

Follow-up period

After discharge, our patient was reviewed by our specialized out-patient care unit and monitored by home visits twice a week. The lithium concentration was controlled once a week and kept at 0.9 to 1.1 mmol/L. Psychosocial interventions including psychoeducation about BD and OCD were conducted. Psychotic and OCD symptoms were meliorated and new mood episodes have not yet been observed during the current 3-month follow-up period. Our patient has restarted school and is actively taking part in some physical activities. The family is still waiting for final decisions about permanent residency in Sweden.

After discharge, we established contact (by telephone and email) with our patient’s physician in the family’s previous country. We were informed that our patient had been treated for approximately 2 years in their out-patient clinic, and that her OCD symptoms most probably were related to her BD, as decreased obsessions and compulsions had been noted when her mood was normalized. Our foreign colleague emphasized that there had often been a high level of expressed emotions within the family.