Patient evaluation on intake

48-year-old woman states she has been “depressed and anxious since childhood”

She is extremely worried she will become incapacitated and institutionalized

Psychiatric history

Does not remember any sustained euthymia since her teenage years

Feels as though she has fluctuated between chronic lower-level dysthymia symptoms and has had many MDEs consistent with double depression

Now has full syndrome of MDD symptoms

• – Admits having passive and chronic suicidal thoughts but has much ideational guilt that she feels she is a bad mother and was an unreliable employee

• – Feels quite fatigued with an inability to focus or concentrate

• – Appetite is low and sleep is interrupted often

Additionally, she has uncontrollable worry, racing thoughts, muscle tension, irritability, nightmares, feelings of dread and detachment

• – Some of these latter symptoms she attributes to being neglected, but not abused, as a child

She admits to having BN in college

She denies SUD symptoms

Psychotherapy history

Attends eclectic, supportive psychotherapy often and has recently started with a new therapist

Has no history of undergoing organized psychoanalysis, or completing a course of CBT or IPT

Social and personal history

Graduated from college and worked as a teacher until MDD worsened two to three years ago

Has two children but was divorced several years ago

Has brothers who are supportive

Smokes cigarettes and drinks a moderate amount of coffee

Medical history

Denies current medical problems except she is considering being treated for a possible Lyme disease diagnosis as many family members have suffered from this after unknown exposures, although she has not been tested yet

Family history

Mother suffered from treatment-resistant bipolar disorder and was institutionalized often

• – The patient reports much fear and currently reliving episodes related to her mother’s symptomatology

• – Her mother was often absent in her life because of psychiatric institutionalization

She has two other siblings with bipolar illness

AUD is present in many family members

Medication history

Currently she is taking

• – Alprazolam (Xanax) 3 mg/d (BZ)

• – Mirtazapine (Remeron) 30 mg/d (NaSSA)

• – Divalproex sodium (Depakote) 1000 mg/d (mood stabilizer)

In her current MDE occurring over the last two years, she has failed to respond to

• – Therapeutic trials of an SSRI, citalopram (Celexa) plus various BZs

• – An atypical antipsychotic (risperidone [Risperdal]) 2 mg/d, and a mood stabilizer (lamotrigine [Lamictal] 200 mg/d) augmentation

• – A combination SSRI plus an NDRI (bupropion-SR [Wellbutrin-SR] 300 mg/d)

Patient evaluation on initial visit

Chronic MDD symptoms with associated, or possibly comorbid GAD or PTSD for many years

MDD progressively more resistant to treatment with each MDE, lasting longer

Possible exposure to tick bites and Lyme disease, but patient does not recollect a bite or a rash

She and her family are particularly concerned as other family members have suffered with Lyme disease

Appears to be compliant with medication management and has attended psychotherapy

Does have passive suicidal ideation, is quite despondent, but is amenable to outpatient treatment and contracts for safety

Reports no current side effects