The challenge
Marco’s case looked straightforward on paper.
A 37-year-old combat veteran referred for sleep disturbances, fatigue, and requests to restart Adderall. His PHQ-9 showed mild depression (8/27). His Mood Disorder Questionnaire screened positive for bipolar—10 of 13 items endorsed with confirmed co-occurrence. He’d been on “about 16 pills a day” post-military but had been medication-free for 7 years.
Standard care would have been efficient: bipolar diagnosis, mood stabilizer, antidepressant for depression, Adderall refill as requested.
This would have been catastrophically wrong.
What standard care would have done
Standard care would have treated the positive MDQ as diagnostic, initiated a mood stabilizer for presumed bipolar disorder, prescribed an antidepressant for the mild depression, and refilled the Adderall he requested. Perhaps a sleep study would have been ordered—siloed from mental health care.
He would have been put back on multiple medications after 7 years of successful medication-free stability.
What Assess surfaced
Comprehensive assessment revealed why every assumption was wrong:
- MDQ artifact: substance-induced historical symptoms, not current bipolar. All 10 endorsed MDQ items occurred more than 7 years ago during active alcoholism immediately post-military. When asked about current elevated mood or decreased sleep need, Marco denied any recent symptoms. The positive screen was capturing historical substance-induced mania, not bipolar disorder.
- TBI-related cognitive symptoms, not ADHD. Marco requested Adderall for concentration problems. But his “ADHD” symptoms were actually sequelae of traumatic brain injury from repeated blast exposures during combat—”danger close” air strikes called in almost daily. Stimulants are not indicated for TBI-related cognitive dysfunction.
- Severe airway obstruction as primary driver. A dental scan revealed his airway measured 67mm versus the normal minimum of 300mm. “Just getting oxygen in general is a little bit difficult for me.” His sleep apnea wasn’t just a comorbidity—it was the upstream cause of his fatigue, concentration problems, and mood symptoms.
- Seven years medication-free as treatment success. Marco had successfully tapered from “about 16 pills a day” to zero through yoga, meditation, running, and plant medicine. His self-directed approach had worked. Pathologizing it would have been malpractice.
- PTSD in sustained remission via plant medicine. When asked how he worked through extensive combat and sexual trauma, Marco stated simply: “Plant-based medicine.” His psilocybin use wasn’t a substance problem—it was likely why his PTSD was in remission.
What changed
Diagnosis: NOT Bipolar Disorder (ruled out). NOT ADHD (TBI etiology). Major Depressive Disorder, single episode, mild—reactive to unemployment. Alcohol Use Disorder in early remission. PTSD in sustained remission. Severe obstructive sleep apnea.
Treatment: Instead of polypharmacy, we recommended:
- Sleep study with CPAP implementation as primary intervention
- Silexan (lavender supplement)—honoring his plant-based preference
- CBT psychotherapy every other week
- Decline of Adderall given TBI etiology and sleep apnea confound
- Validation of psilocybin use as contributing to PTSD remission
- SDOH support for employment transition
- No new psychiatric medications
”I concentrated on how far I've come and that I really don't wanna do that and life is actually pretty good.
Marco, 37PHQ-9: 8 | MDQ: Positive (ruled out as artifact) | 7 years medication-free
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These findings came from real assessments at Texas Center for Lifestyle Medicine. We have detailed documentation on 50+ patient evaluations, with more being added from ongoing clinical work.
