Deborah J. Hales, M.D., Mark Hyman Rapaport, M.D., FOCUS Editors                                                    focus.psychiatryonline.org
Thomas Kramer, M.D., Carlyle Chan, M.D., Associate Editors for Clinical eFOCUS

Clinical eFOCUS is a continuation of the FOCUS program of lifelong learning. Learn more about patient management of treatment resistant depression through this activity; the patient vignette exercise provides an opportunity for you to share your opinion and see how others approach the same case. Given your knowledge of MDD and the points made in the vignette, which treatment approach would you choose? Next month, expert commentary by John Rush, M.D. will review the result and discuss the merit of the options presented. Indicate your choice using the voting buttons. There are no wrong choices. To read more about treatment resistant depression
[Acute and Longer-Term Outcomes in Depressed Outpatients Requiring One or Several Treatment Steps: A STAR*D Report]
[Continuation electroconvulsive therapy vs pharmacotherapy]

A History of Recurrent Depressions
by
Carl Chan M.D.

A colleague asks you to consult on a patient who is a 50 year old single white female health professional who originally presented with a history of recurrent depressions dating back to adolescence. She believes her mother has had depressive episodes and two of her sisters have been treated with antidepressants. She has had prior treatments going back 15 years with various SSRIs (fluoxetine, paroxetine, sertraline, and citalopram). The best response was to fluoxetine at doses up to 60 mg per day. However, this improvement could not be sustained. She has also had trials of buproprion, trazodone, and venlafaxine. All have either been ineffective or were stopped because of side effects. At various times she has had severe suicidal ideation, but refuses to consider this an option.

Although there were no current or recent manic symptoms, her previous psychiatrist felt that there may have been some past symptoms suggestive of Bipolar II Disorder and sequentially added and discontinued olanzapine, ziprasidone and quetiapine because of side effects. Methylphenidate and modafinil were also tried in sequence as part of a polypharmacy approach with only temporary improvement. She was eventually titrated on lamotrigine to 275 mg per day with little improvement. The patient was concurrently on escitalopram 10 mg daily and eszopiclone 3 mg nightly for sleep. There does appear to be a seasonal component to the depression as the depression typically worsens in winter and lightens, but never fully disappears in summer. She dutifully sits before a light box (10,000 lux) each morning but doesn't feel it helps. She has always been reluctant to try ECT.

Lamotrigine was tapered down and she was tried on desipramine and was up to 70 mg/day before discontinuing secondary to constipation and chest pains (cardiac problems were ruled out). A return to fluoxetine up to 90 mg/day with lithium augmentation of 600 mg/day brought only momentary relief. Neurological symptoms (ataxia) emerged concurrent with evidence of cerebellar atrophy. She was tapered off all meds with no improvement in neurological symptoms and with continued depression. Selegiline transdermal patch was tried for 6 weeks at doses up to 12 mg per day with no improvement and worsening insomnia.

No manic symptoms have been observed over the past 18 months. How likely is the Bipolar II diagnosis to influence treatment? That is, what is the next pharmacotherapy treatment option you would recommend?