Patient evaluation on intake

55-year-old woman with a chief complaint of unremitting depression for 30+ years

Psychiatric history

Onset of depression in her 20s

Questionable recurrent depressive episodes versus a single, chronic unremitting episode. Patient cannot recollect a two-month symptom-free period or any clear inter-episode recovery

MDD symptoms have never been mild enough to allow gainful employment, likely ruling out persistent depressive disorder plus MDD, which is often called “double depression”

Meets melancholic MDD specifiers with severe anhedonia (patient was housebound and essentially bedridden), worse symptoms in the morning, marked psychomotor retardation (a simple depression symptom screening took 15 minutes to complete due to thought slowing), and weight loss (patient’s weight was 90 lbs)

History includes at least two psychiatric hospitalizations. She has had no suicide attempts

Review of psychiatric systems revealed no formal anxiety disorder, psychosis, mania, eating disorder, SUD

She has received eclectic, supportive psychotherapy in the past, but her mental state at this presentation made reciprocal talk therapy almost impossible

There is no evidence of clear personality disorder

Failed to respond to adequately dosed

• – Fluoxetine (Prozac) 60 mg/d and sertraline (Zoloft) 200 mg/d SSRI monotherapies

• – Venlafaxine-XR (Effexor-XR) 225 mg/d SNRI therapy

• – Bupropion-SR (Wellbutrin-SR) 400 mg/d NDRI therapy

• – Mirtazapine (Remeron) 45 mg/d NaSSA therapy

• – TCA trials in distant past

• – Course of ECT (electroconvulsive therapy)

Social and personal history

Married and has a son

High school educated and has not been gainfully employed outside raising children

Grew up with outside relatives as both parents died when she was younger

Does not drink alcohol, smoke cigarettes, or use addictive drugs

Medical history

Coronary artery disease (CAD)

Irritable bowel syndrome (IBS)

GERD

Hyperlipidemia

Family history

Eating disorder (likely anorexia nervosa [AN]) in a sibling

Current psychiatric medications

Citalopram (Celexa) 60 mg/d (SSRI)

Olanzapine (Zyprexa) 30 mg/d (atypical antipsychotic)

Dextroamphetamine (Dextrostat)10 mg/d (stimulant)

Topiramate (Topamax) 100 mg/d (antiepileptic, anti-migraine, weight-loss agent)

Current medical medications

Lansoprazole (Prevacid) 15 mg/d

Diphenoxylate plus atropine (Lomotil) four tablets/d

Cholestyramine (Questran) two packets/d

Question

Based on what you know about this patient’s history and current symptoms, would you consider her to be suffering from TRD or do you think she would be refractory (will never respond) to treatment altogether?

What conventional antidepressant-type treatments might you suggest?

Lithium augmentation

Thyroid augmentation

Taper off medications and use an MAOI

Try ECT again

Try ketamine infusion therapy

Try transcranial magnetic stimulation (TMS)

Try vagus nerve stimulation (VNS)

Try deep brain stimulation (DBS)

Try magnetic seizure therapy (MST)

Attending physician’s mental notes: initial evaluation

The patient has melancholic MDD that is chronic and surprisingly has no other psychiatric comorbidities, which is relatively uncommon in this patient population

Patient has marked psychomotor slowing: a symptom of melancholia or subtle psychotic depression? Could this be considered “psychiatric parkinsonism”?

As she has had more than two years of unremitting symptoms without any full inter-episode recovery, this makes her depression chronic

She should also be considered resistant as she has failed antidepressants from several different classes (TCA, SSRI, NDRI, SNRI, ECT) and augmentation strategies (olanzapine, dextroamphetamine, topiramate)

She is treatment resistant so far, but she has not had some of the leading empirical augmentation strategies (lithium, thyroid) or an MAOI trial

She also has utilized supportive psychotherapy well, but not formal CBT, IPT, or PDP

Her regimen at her first outpatient visit is complicated and minimally effective. The prescriber could streamline her medications and discontinue ineffective medications as the current medications seem to be fairly well maximized

She could be sent for neurostimulation treatment (VNS, DBS, TMS) given her medication failures and high treatment resistance, but ECT has already failed