DOUBLE STIGMA IN PSYCHIATRY: MANAGING PSYCHOTIC BIPOLAR DEPRESSION IN AN LGBTQ+ PATIENT - A CASE REPORT

Abstract

Introduction: Bipolar affective disorder with a severe depressive episode and psychotic features is a high-risk clinical state characterised by marked suicidality, prolonged morbidity and frequent readmission. When it occurs in a sexual- or gender-minority individual, the patient may carry two concurrently devalued identities — a minority sexual identity and a serious mental illness — creating a "double stigma" that can amplify interpersonal invalidation, impede help-seeking and destabilise the illness course. Clinical descriptions of this intersection remain scarce in Indonesia and the wider Southeast Asian region.

Case Illustration: A 22-year-old man in a same-sex relationship, with a two-year history of bipolar disorder, presented with panic-like anxiety, pervasive hopelessness, urges to self-cut, insomnia and mood-congruent command auditory hallucinations urging him to go to the beach to end his life, following an interpersonal conflict and repeated accusations from his partner and peers that he was "pretending to be ill". The Beck Depression Inventory score was 33. He was diagnosed with bipolar affective disorder, current episode severe depression with psychotic symptoms (ICD-10 F31.5), and treated with lithium carbonate, a second-generation antipsychotic (olanzapine, subsequently quetiapine), alprazolam, supportive psychotherapy and family psychoeducation; persecutory ideation, vomiting, bloody diarrhoea and positional vertigo complicated the first admission. He was discharged on 2 September, self-escalated his medication doses, exhausted his supply prematurely, and relapsed with self-injury using broken glass after a further conflict with his partner. On 20 September he was readmitted with command hallucinations to drown himself or jump from a balcony, having picked up a glass shard at home, together with a seven-day intermittent fever, recurrent vomiting, epigastric pain and four episodes of haematochezia. Investigations showed mild leucocytosis (11.33 × 10³/µL), low-titre Widal agglutinins (1/80), a non-reactive provider-initiated HIV test, normal renal and hepatic indices, and a chest radiograph reported as cardiomegaly; digital rectal examination revealed a firm, fixed 0.5 × 0.5 cm mass at the 7 o'clock position. He was co-managed with internal medicine, continued on lithium carbonate 800 mg/day and olanzapine 15 mg/day with as-needed lorazepam, and scheduled for colonoscopy.

Discussion: The case illustrates how distal and proximal minority stressors, partner-level invalidation of psychiatric illness, early maternal loss and chronic familial invalidation can converge on a biologically vulnerable substrate to precipitate psychotic depressive relapse, non-suicidal self-injury used for affect regulation, and early readmission. It further highlights modifiable clinical gaps: frequent antipsychotic switching, absent serum lithium, thyroid and electrocardiographic monitoring despite dose escalation and gastrointestinal fluid loss, benzodiazepine self-escalation and withdrawal, dispensing of large medication quantities to a high-risk patient, over-interpretation of a single Widal titre and a borderline glucose value, the use of tranexamic acid for minor lower gastrointestinal bleeding, and the risk of diagnostic overshadowing. Ethically conducted HIV testing, attention to the acute seroconversion window, confidentiality regarding sexual orientation, structured safety planning and partner-inclusive, affirmative psychoeducation emerge as key components of care.

Conclusion: Managing psychotic bipolar depression in an LGBTQ+ patient requires an integrated biopsychosocial approach that treats the mood episode with guideline-concordant, adequately monitored pharmacotherapy, systematically excludes and manages somatic comorbidity, and explicitly addresses intersectional stigma through affirmative, confidential and partner-inclusive psychoeducation and suicide-prevention measures.