XX is a medical resident aged between 30 and 40 years old. She presented a cyclothymic temperament with traits belonging to borderline personality disorder. When she was a child, she experienced a traumatic event of loss as she witnessed the sudden death of a parent. XX then developed feelings of emptiness; fear of abandonment from other attachment figures; emotional swings with quick change to sadness, anger, and anxiety; or impulsive behaviours that led to a first suicide attempt by drug ingestion at the age of 14.
In the following years, the subject continued to experience mood swings. These were mainly depressive in nature with a subsequent compromission of her interpersonal skills though not of her intellectual performance. The patient maintained a very strong academic performance in school. In her last year of medicine, around the age of 25, under pressure for exams and the required final thesis, the subject developed a depressive episode according to DSM-5, characterized by low mood, loss of enjoyment in most activities, anxiety, hypoergy, difficulty with concentration, and insomnia which led to a great increase in alcohol use together with benzodiazepines. She turned to a psychiatrist and started various antidepressants (including citalopram, venlafaxine, and duloxetine). However, the clinical benefits of these antidepressants were poor, and she continued to have mood swings alternating between moments of sadness and pervasive anxiety and moments of increased work performance, self-confidence, increased involvement in hobbies as writing poetry and reading, more energy, and decreased need for sleep. Alcohol abuse remained stable through the alternation between the various mental states.
Two years later, during her first year of residency program, she presented a worsening of the psychopathology framework developing a mood episode with mixed features according to DSM-5. During that period, she started a binge use of anesthetics (midazolam, propofol), and she reached a total deterioration of general personal functioning. This was followed by hospitalization for about two weeks and discharge with a diagnosis of Bipolar Disorder (BD) and Alcohol Use Disorder (AUD) and a pharmacological treatment with valproic acid (immediately suspended by the patient herself), anxiolytic stabilizers (gabapentin), atypical antipsychotics (quetiapine), and benzodiazepines (lorazepam), again however with poor clinical benefit. During the next two years, she continued to experience mixed-depressive symptoms, despite the therapeutic attempts, which led to several hospitalizations and, at the age of 28, to another suicide attempt by means of lithium salt ingestion with intoxication that led to temporary cardiac arrest. In the following years, she continued to show mood instability that she managed by herself, combined with a daily use of alcohol that allowed her to recover her ability to work and thus return to her residency program. Nevertheless, she presented a poor adaptation on the social and leisure plan with no social circle and a lack of confidence in social situations.
In 2018, following a new worsening of the psychopathological elements with a daily alcoholic consumption of about two to three beers a day, she attempted suicide again by means of a massive ingestion of her psychiatric treatment. She was again hospitalized and started a new therapeutic program based on buprenorphine (now at 8 mg/day), various mood stabilizers then discontinued, benzodiazepines: clonazepam (later discontinued) and currently delorazepam (now 4 mg/day), tricyclic antidepressants (amitriptyline 75 mg/day), and antidepressant SARI (trazodone, 75 mg/day). Since then, the patient has shown a slight improvement in her mood and was admitted for some weeks to a therapeutic community for alcoholics from which she reported that she emerged detoxified. In 2019, she continued her residency with relative stability and good performance. In March 2020, with the outbreak of the COVID-19 pandemic, she was assigned to a COVID-19 emergency unit.
At that point, due to various risk factors and vulnerabilities for an alcohol abuse and psychiatric relapse, the patient asked for support to deal with new stressful situations present in the workplace. As a result, the subject's case was assigned to the multidisciplinary group of the Occupational Medicine Unit (see Figure 1).
Blood count tests showed no signs of recent alcohol abuse though the subject's liver was slightly compromised. The subject denied any kind of alcohol and recent drug use except for smoking. She reported feelings of anxiety and frustration because of exclusion from procedures of her level of expertise due to her psychiatric history. Evaluation revealed that the subject suffered from a very low mood with general flattening, detachment, and difficulty concentrating. The patient did however deny suicidal ideation. At the time of the evaluation, she presented a working function within acceptable limits but still had difficulty in organizing daily life and suffered from poor social relations. She had no friends at work or outside and no emotional relationships. Our group confirmed the diagnosis of BD (according to DSM-5) with previous AUD and some features of borderline personality.
XX was offered a personal plan of monitoring of alcoholemia and periodic blood tests together with psychiatric evaluations and the possibility of new pharmacological treatment. The occupational psychiatrist (with a specialty both in psychiatry and psychotherapy) managed psychological and psychiatric interventions.
XX presented borderline personality traits with bipolar depression symptoms and posttraumatic stress elements due to the nature of the work environment brought about by the COVID-19 pandemic. She presented a flattened life likely due to prolonged use of alcohol and benzodiazepines. Consistent with the complex clinical elements of XX, previous addictive behaviours, suicidal ideation, drug resistance, and her professional role, the need to prescribe and manage off-label medications was evident. In accordance with these considerations, in agreement with XX and with the occupational physician, the occupational psychiatrist requested a consultation with the service provided for persons with pathological addictions (Servizi Dipendenze: SerD) and an addictology psychiatrist. The final maintaining treatment was the following: buprenorphine, lithium, methylphenidate, and delorazepam together with weekly sessions of third generation of Cognitive Behavioural Therapy (CBT) with integration of Mindfulness and Acceptance and Commitment Therapy (see Table 1). The occupational team, with the consent of XX, informed her supervisor about the surveillance program and the psychiatric treatment choice and, with his assistance, drew up a new flexible working plan, more appropriate to XX's level of experience but with assistance and monitoring of her hazards.
During the following year, XX followed the Occupational Unit's indicated treatments and was able to maintain her stability and finish her residency program.