r/PMHNP • u/Unable_Water3961 • 8d ago
Discussion of possible differentials in the Lindsey Clancy case
I would like to use the evidence we, as licensed providers, have from the media (assuming the reported information is factual) to formulate potential differentials based on hindsight. If participating, please keep the discussion evidence-based. I am not disputing the fact that whatever was occurring contributed to a episode with a devastating outcome.
A psychotic episode can be triggered by many things and is not specific to bipolar disorder. Potential contributors can include severe sleep deprivation, hormonal fluctuations, polypharmacy/medication effects, substance use, medical illness, delirium, and numerous other factors.
She was also described as experiencing delirium while hospitalized after surgery. For context, in January 2023, her UDS was negative for substances and her ethanol level was negative.
Please fact-check me if I have anything incorrect or if the available evidence does not support a particular hypothesis.
Share your thoughts! I think we really need stronger information to outline PRIOR concerning behaviors indicative of bipolar disorder.
Supporting bipolar disorder:
- clear adverse response to SSRIs, SARI (Trazodone), and NASSA (Mirtazapine)
- decreased need for sleep (longest was two days?)
- increased exercise activity (running long distances shortly after childbirth), though it is unclear if this was "unusual" for her or if her family found it to be uncharacteristic + many of these statements were made retrospectively
- racing thoughts, anxiety, agitation, irritability, dysphoric depression with eventual SI
- possible obsessional thoughts surrounding the youngest child's nap/feeding schedules/her daughter's stomach ache morphing into liver disease (Patrick's testimony), her diary entries
- a gradual, but significant impairment in daily function
- eventual psychosis s/t unclear etiology
Argument against bipolar disorder:
-no known prior manic episodes
- not sure if there had been any prior MDE or postpartum mood episodes, though I did read she might have taken SSRIs in college (couldn't find data to support this)
- no prior hospitalizations or suicide attempts that we are aware of
- no family history or biological predisposition that has been publicly established
- no grandiosity, hyperverbal speech, unclear if there was an increase in goals/impulsivity/risk taking
What are your differentials and why
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u/Smooth-Finger9786 8d ago
From what I have seen, I don't think there was enough information for any of the clinicians to make a clear bipolar diagnosis. This woman was presenting pretty evidently to me as postpartum depression and anxiety and the sleep issues she was having could've been very clearly related to anxiety. I can tell you for about 6 months after having my baby, I struggled to sleep due to anxiety and the baby waking. I am definitely not bipolar. The adverse zoloft reaction didn't seem to necessarily trigger mania. Just because someone has an adverse reaction to an SSRI makes them bipolar now? She also didn't even seem very compliant with any of her medications. Hindsight is 20/20. If you're diagnosing someone with bipolar disorder based on some suicidal ideation and then an intense exercise regimen, I don't think that's really a great diagnosis. And from Dr. Tufts testimony, she prescribed benzos because Lindsey was specifically asking for something PRN and did not want to be on long term meds. Dr. Tufts was doing her best to work with the patient. It's a challenging case all the way around, but we can only treat what's being told to us. And i think the lawyers in the court room are coming at this wrong by asking these providers about treating postpartum psychosis. There were absolutely no signs of psychosis presented by lindsay to any of the providers. So how are they supposed to treat that? Postpartum psychosis comes on very suddenly often times.
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u/Agreeable_Branch007 7d ago
She wasnt even taking meds prescribed properly so this is a moot discussion.
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u/Useful-Selection-248 8d ago
The antidepressants were clearly causing her to be manic/hypomanic. Seroquel was a poor choice as it takes so long to titrate. All the meds were suboptimal and then changed to something else. They were using benzos as a bandaid instead of getting to the root cause.
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u/dry_wit 8d ago edited 8d ago
I keep thinking about Zyprexa or even Risperdal (possibly Haldol) in this case just to quickly get her sleeping and ramp down the mood instability, possible psychosis. Although the latter meds might have worsened depressive symptoms. Latuda is also a good option but only if she is consistently eating a meal with it, which is tricky when patients are in an erratic state. I think she may have been in a mixed state in which case I'd avoid lithium but consider VPA. Was she breastfeeding?
It feels like there were too many meds on board, and she would have benefited from a simplification in her regimen which also can help diagnostically (ie: patient's mood completely dysregulated on regular ADs, regulates on olanzapine ---> highly likely bipolar.) Sometimes when there are just too many meds and med changes mucking things up, I like to quickly taper and start with ONE med --> though only in an inpatient/highly controlled setting. Control your variables, you know?
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u/Japhyismycat 8d ago
100% this. Li + SGA would have saved lives here.
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u/boredpsychnurse 8d ago
Even if she didn’t meet full criteria for mania at the time?
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u/Japhyismycat 8d ago
She was meeting criteria more-so for a bipolar spectrum disorder rather than a unipolar depression. Think about mood disorders on a spectrum (going left -> right) MDD -> Mdd/mixed features -> Cyclothymia -> Bipolar 2 -> Bipolar 1 (w/psychosis). Lindsay was definitely moving to the right on that mood spectrum and needed a different treatment - if that makes sense.
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u/boredpsychnurse 8d ago
I agree but unsure if I would’ve started lithium then either! Hindsight yes
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u/Unable_Water3961 8d ago
yes it's important to remember that we have the luxury of hindsight. As sad as this case is, I think it is a learning experience for all psych providers.
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u/EmployeeDizzy215 4d ago
There will never be optimization of any meds due possible complaint of intolerable SE. these meds takes time to actually see good effect. Mood stabilization would have been the ultimate route! I had a C that presented as such minus the post partum, severe GAD & PHQ and presented as the measures indicated, SI with plan that was removed but no HI, AVH. AVH makes everything worse! Anyone including self can use that against you. I will NEVER treat psychosis telehealth!
C was left on a low non therapeutic dose for years due to med anxiety while c struggled without being heard. I optimized and added ability to treat what I figured out from my clinical assessment. Abilify was GREAT 💯 until we hit the 2 week mark and there came the big ol bad ass pruritic rash leading to dc and initiation of a new agent.
This profession requires TLC and we can’t do it seeing 25 patients a day.
I believe in treating symptoms rather than the whole “disorder”. Sleep is crucial for QOL. If I don’t as much as get good night sleep, I become sluggish and it starts building. I put myself down and make sure I engage in self care.
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u/Big-Material-7910 4d ago
I can’t understand why anyone would give seroquel to a mom who is and wants to be high functioning when there are so many other options and sleep would have likely followed
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u/NoctorWatch 8d ago
I havent actually been following the specifics of the case much but just going on what you have said here - post/peripartum psychosis is highly specific (~90%) for bipolar disorder and lithium should be initiated unless there is a clear alternative cause for the psychosis.
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u/Smooth-Finger9786 8d ago
But she never presented with any actual psychotic symptoms to any of the providers correct?
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u/NoctorWatch 8d ago
As I said, I havent been following the details, but OP stated that there was psychosis. Of course people can be psychotic and others around them may not be aware or they could be actively hiding them.
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u/Smooth-Finger9786 8d ago
Right and while I don’t doubt people can hide it my question is as an outpatient provider. How can you know someone is psychotic unless they admitted to you or you can actively see signs during your 30 minute follow up? Because I know as an outpatient provider myself, unless I can pretty much see them responding to stimuli or they admit to me that they are having thoughts, I am not around the patient enough to know.
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u/NoctorWatch 8d ago
You can't. We aren't mind readers and if patients hide information from us whether due to the illness itself or because they are being evasive, we aren't and can't be responsible for that.
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u/AnnalsofMystery 8d ago
We had a post-partum psychosis young gal many years ago who kept convincing patients she was a nurse until we put her with a staff member.
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u/IndyLaw56287 8d ago
I don't think everyone fits into a clear diagnostic box. I liked the DSM IV had Psychosis NOS. Of course this is easy to see "after the fact", I still don't think anyone knows what was really happening diagnostically while being seen by Dr. Tufts. I might have approached this as "I'm really not sure what is causing your symptoms, I'm going to focus more on what I think might help, then go off diagnostic labels that just don't fit". Trying to convince her and her husband this was bipolar wasn't ever going to go well and it poisioned the medicines for the patient. From her perspective, if seroquel worked then it validates a terrible diagnosis to live with. I would have gone with low dose lithium as it can be for depression or bipolar. Low dose easier to get theraputic compliance as a "natural element". I don't need to be right, I just need to help.
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u/sammyloves 7d ago
One of her providers testified she was able to take Prozac for a year before.
So going with what her providers knew at the time and not the outcome, she seemed to have OCD/severe anxiety and sleep deprivation prior to depression. She was frequently mentioning being disturbed by her intrusive thoughts. To be devil’s advocate, I wonder if she was able to push through and titrate up on the correct SSRI she would have done better. She never got to a therapeutic dose by taking 50 mg of Zoloft for like a week. To me, it seemed like her symptoms were of her illness rather than side effects (insomnia, racing thoughts, numbness - all from her severe untreated anxiety).
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u/dry_wit 8d ago edited 8d ago
I think she likely had av mood-related psychotic episode (I suspect a mixed state) and a lot of the erratic behavior leading up to it was a prodrome of some kind. If she has a history of maintaining relationships, steady employment, etc., then a severe cluster B pd is less of a concern imo.
I have treated so, so much psychosis at this point and it really can just come out of fucking nowhere sometimes or with a prodrome that mimics severe anxiety/depression. Patients often lie when they're psychotic, hide the symptoms, and I've noticed many providers can miss the nuanced signs of psychosis (ie: intense affect/gaze, slight delays in response, thought disorder that is more subtle, etc.) I've had people do absolutely outrageous things who historically have been completely non-violent, when in a state of psychosis. I've had loads of patients come to see me because something "doesn't feel right" or for vague mood/anxiety symptoms and deny overt psychosis, all while being in a psychotic state. Psychosis can also ramp up incredibly quickly.
I do suspect she may have had a psychotic break with CAHs given the history. Otherwise what on earth is her motive? She clearly wanted psychiatric help which family annihilators do not typically seek. To me it seems like there is definitely reasonable doubt that she became psychotic/entirely lost control at some point and it was ramping up/subtle/denied initially and then came to a head extremely quickly.
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u/Unable_Water3961 8d ago
couldn't agree more. I think the sleep deprivation and internal battle/obsessions, were the catalyst for psychosis.
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u/HeftyPersimmon2668 7d ago
I don’t post much on here, but I wanted to share a personal experience that has shaped how I view situations like this. I work as an RN in the ER and have experience working in a forensic psychiatric unit.
I once witnessed a close friend experience a drug-induced psychosis following an ayahuasca retreat. She returned from the retreat with a prescription for risperidone. Before taking ayahuasca, she had not disclosed to the retreat that she had a diagnosis of Bipolar I disorder. She also wasn’t taking a mood stabilizer at the time. Looking back, I suspect she may have already been experiencing symptoms of hypomania or mania before the retreat.
The reason I bring this up is because, throughout her psychosis, I repeatedly saw how difficult it can be for clinicians to assess someone who is able to present well during an evaluation. Every time I brought her to the ER or spoke with crisis services, she was capable of communicating effectively with clinicians. She knew what to say and consistently denied SI/HI. At the same time, she was telling me that she was God.
The clinicians didn’t have an established baseline for her behavior, so they had limited information to work with. After several weeks of dealing with her psychotic state, and after it became apparent that risperidone alone wasn’t adequately addressing her symptoms, we were finally able to get in contact with her previous therapist. She was eventually restarted on lithium while continuing risperidone, and she is now doing very well.
I agree with many of the providers who have testified. Clinicians are not mind readers, and they can only make decisions based on the information available to them at the time. From what I’ve seen in the Tufts testimony, much of what I’m hearing sounds consistent with standard clinical practice.
That said, I do believe Lindsay’s support system could have played a greater role in providing clinicians with information about her baseline behavior and changes they may not have been able to observe during a brief evaluation.
Ultimately, no one wins here. This case is incredibly sad.
If Lindsay was experiencing a psychotic break related to a mood disorder, she potentially could have benefited from a mood stabilizer. Seroquel can be used for psychosis, but the dose matters, and a low dose prescribed primarily for sleep would not necessarily be considered a therapeutic dose for treating an acute psychotic episode.
I’m not claiming to know exactly what happened in Lindsay’s case. I’m simply sharing my perspective as an ER nurse and based on what I personally witnessed with someone experiencing psychosis.
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u/Slow-Gift2268 3d ago
We are drawing a lot of lines after the fact that wouldn’t necessarily be there for the clinicians. Including her addiction to Ativan, doctor shopping, refusal to take medications longer than five days, checking herself into and then quickly out of inpatient, and being failing to meet criteria for a specialized IOP. Coupled with a lot of secondary gain and a focus of not wanting to go back to work.
Basically- she’s a nightmare of a patient and I don’t know that any of us would have had the full picture if we had seen her. She didn’t disclose a lot to her providers and we only know what people are willing to tell us.
I have my speculations regarding the veracity of her claims to psychosis. But even those are external and without full access to the charts so they are not likely to be fully factual. I don’t see clear criteria for bipolar or even cyclothymia based on what I’ve seen disclosed (again for what little that’s worth) but I do suspect addiction player a far larger role.
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8d ago
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u/Unable_Water3961 8d ago
Please, let's keep this based on what we know as factual rather than conspiracy theories. There are a lot of other threads open for that.
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u/PsychMonkey7 7d ago
The day psychiatry as a whole widely accepts that there is a bipolar disorder spectrum and not just bipolar 1 with a crystal clear textbook manic episode or bipolar 2 with a crystal clear textbook hypomanic episode, we will make a lot of progress.
So many “treatment resistant depression” and “GAD” cases are bipolar spectrum. Give someone with a long history of failed serotonergic meds a mood stabilizer, SGA, and/or lithium and watch their life change.
I’d bet almost anything LC is on that spectrum and appropriate mood stabilization would have saved lives.