CASE STUDY 2

Robert is a divorced, 58-year-old Vietnam veteran. Chronically underemployed, he does not have healthcare insurance and resisted reentering care with the Veterans Administration system. After his most recent scrape with the law, he was mandated to seek court-ordered psychiatric treatment. Initially resistant to his new therapist, he ultimately warmed and confided his story. In recent months, Robert reports that he has relapsed on painkillers and marijuana. As he ages, he is finding it more difficult to make contact with drug sources and, as a result, he frequently experiences opiate withdrawal. After returning from the Army, Robert spent three years incarcerated as an accomplice to a robbery. He has had further contact with law enforcement and fears that a third felony will result in a life sentence. Despite this risk, his temper is uncontrollable; he is easily provoked and demonstrates frequent episodes of road rage.

Robert was raised in central Idaho. His mother died when he was 10; he never knew his father and was raised by his maternal grandparents. Always antiauthoritarian, Robert did poorly in school and was drafted in 1967. He did well in basic training and became an Army Ranger. He was commended for heroism twice and has surprisingly fond memories of his wartime service. In Vietnam, he experimented with drugs and briefly became heroin addicted. Upon returning stateside in 1969, Robert stopped injecting opiates but began using oral codeine. For several years after his return he worked in an automobile repair garage, during which time he married and fathered two children.

Robert entered the mental health system in the early 1980s and was initially treated for substance use disorder, anti-social personality disorder and posttraumatic stress disorder (PTSD). He attended group therapy, but his symptoms intensified and he was unable to continue in his marriage or parent his children. He became increasingly alienated from mainstream society and blamed the tepid welcome he received following his wartime service for his ensuing problems. In the early 1990s, he was diagnosed with bipolar disorder type II and the antidepressant medications that he was earlier given were replaced by mood-stabilizing medications.

In 2004, Robert was assigned to a new psychiatrist. Though he had been in the system for some time, the doctor insisted on taking a fresh history. She learned that Robert exhibited behavioral problem from early on. He left school in 10th grade. At 13, he started smoking cigarettes and using alcohol. Soon thereafter, he was cited for underage driving. He totaled two cars and a farm vehicle before he was 17 years old.

Robert’s mother and family had no identifiable psychiatric problems and Robert could offer little history about his biological father other than alcohol abuse and petty crime. Notably, Robert’s adult son was diagnosed with a learning disability when he was in grade school. Like his father, he has been inconsistently employed and has had recurrent contacts with the criminal justice system.

Cognizant that treatment for depression and bipolar disorder had been unsuccessful, the new physician looked for alternative explanations. Utilizing the Adult Self-Report Rating Scale (ASRS), Robert endorsed many symptoms of ADHD. Treatment with Atomoxetine was initiated with good results. Within weeks, Robert reported that his mood was more stable, he was far less impulsive and he seemed to have fewer interpersonal conflicts. Even with these gains, two months later his mood was still depressed and escitalopram (Lexapro) was added to the Strattera. At his next visit, on both medications, Robert reported that he was feeling and functioning better than he had in years.