Pretest self-assessment question (answer at the end of the case)
While OCD may develop postpartum in some cases, which is not true of postpartum OCD?
A. It is less common than postpartum blues
B. It is less common than postpartum depression
C. It occurs in up to 5% of postpartum women
D. Obsessions are most frequently related to contamination fears
Patient evaluation on intake
56-year-old woman with a chief complaint of “not doing well for many years”
Has suffered anxiety and depression for over 30 years
Psychiatric history
Was without major psychiatric symptoms until her late twenties
Lost a child in utero and a few weeks after this there was an outbreak of pinworms in her household
Since this time she has never recovered
Has been depressed, and has obsessive thoughts about contamination
Is essentially dependent on husband and family, does not drive, cannot work as a result
– Reasonable sleep but only with medication
– Low interest
– Low energy
– Poor concentration and worsening short-term memory
– Ideational guilt but not to a psychotic level
– Poor appetite
– Denies suicidal thinking
Does not meet criteria for PTSD, PD (although she has frequent acute episodes of agitation), or GAD
– Obsessions of excessive contamination are frequently encountered
– Compulsively, she used to wash hands hundreds of times a day
A course of exposure and response prevention (ERP) therapy helped to decrease this many years ago
Interestingly, this compulsion was largely replaced by her actions of living in her car in her garage for extended periods of time
She often will leave the house in the morning and spend the whole day in her car in the garage reading books as the car is not contaminated nearly as much as the rest of the house
Denies other OCD symptoms
It is clear that much of daily routine and life revolves around the symptoms of OCD, which are deemed more disabling
While screening for mania, she and her husband do acknowledge bipolar-like symptoms with sustained hypomania and possible mania in the distant past
– These are ill defined and without any clear consequences
– There is subtle mood elevation at times
– More often, these appear to be sustained agitation episodes
There is no evidence of eating disorder or substance abuse
Social and personal history
Graduated high school and was gainfully employed as a clerk/secretary thereafter, but stopped work after she was married and started a family
Now is married with grown children
Drinks coffee in the morning, does not smoke or take drugs
Medical history
Hyperlipidemia
HTN
No drug allergies, no vision problems, no skin problems
Family history
SAD, avoidant personality, MDD in the patient’s mother
Medication history
Has tried a myriad of TCA, SSRI, SNRI, and BZ throughout the years
Augmented with low-dose atypical antipsychotics in the past
Psychotherapy history
Eclectic, supportive psychotherapy intermittently attended over last 30 years
Some behavioral therapy but unclear if a full ERP behavioral therapy protocol was completed
Little to no sustained response to these psychotherapeutic interventions, as she continues with fluctuating symptoms that never fully remit
Patient evaluation on initial visit
Acute onset of apparent MDD symptoms associated with trauma of loss of an unborn child
Symptoms of MDD have remitted at times
OCD has not ever fully remitted
Has fair insight, at best, into the OCD symptoms and better insight into the distress caused by the depressive symptoms
Possible history of hypomania
Despite symptoms, she has no suicidal ideation and no recent history of psychiatric inpatient admissions
– 30 years ago, admitted twice for inpatient hospitalizations for suicidal thoughts, which in retrospect may have been postpartum induced
Reports no current side effects but does have pre-existing metabolic illness
Current medications
Question
In your clinical experience, would you consider her current medication regimen a therapeutically dosed one?
Yes
No
Attending physician’s mental notes: initial evaluation
This patient seems to have recovered from her index episode of postpartum MDD, but often relapses
There is some corroborative evidence to suggest hypomania episodes
Has comorbid OCD that has never fully remitted
Seems content to be at home and not working but clearly is distressed by some symptoms
Presents with a supportive spouse, which will help prognosis and treatment adherence
Has been on many psychotropics over the last 30 years
– It is unclear if these have been therapeutically dosed, but regardless, is likely fairly treatment resistant
Current regimen’s SSRI is too low a dose to be effective in treating OCD
The combination of the SSRI and this particular atypical antipsychotic would be considered adequate for treating MDD
Question
Which of the following would be your next step?
Increase the fluoxetine (Prozac) to the full FDA dose toward 80 mg/d for OCD
Increase the quetiapine (Seroquel) to a higher, possibly more effective dose, toward 600 mg/d
Increase both agents simultaneously
Augment the current two medications with a third agent to improve response
Attending physician’s mental notes: initial evaluation (continued)
This patient seems to be on a standard approach for treating MDD
– Good dose/duration of therapeutic SSRI
– A therapeutic dose of her quetiapine (Seroquel) is being utilized now
The original quetiapine (Seroquel) immediate release is not approved as adjunctive treatment for unipolar MDD
The immediate-release preparation is approved for treating bipolar depression as a monotherapy at doses 300–600 mg/d
Suspect either preparation could be helpful in her case
The atypical antipsychotics are often used clinically to treat resistant OCD, but the current SSRI is likely at too low a dose to be helpful
Care may be complicated in that she has elevated cholesterol and blood pressure and the atypical antipsychotics are associated with escalation of metabolic disorder
Quetiapine (Seroquel) seems to have a dose-related escalation in metabolic disorder
– These adverse effects may increase remarkably at doses greater than 150 mg/d, according to MDD studies utilizing the XR preparation
Developing better insight into her contamination fears and a referral for a bona fide CBT/ERP course may be warranted
Further investigation
Is there anything else you would especially like to know about this patient?
What about details concerning her current HTN and hyperlipidemia?
What about details regarding her longitudinal disability and family support?
– Her illness struck while she decided to be a homemaker and raise children
– Did not leave work due to her psychiatric symptoms
– Was able to raise children without difficulty
– Spouse is currently very supportive but reports that the patient only really functions well within the immediate family
– Over time they have not challenged her idiosyncratic OCD symptoms, but do feel she suffers more when concomitantly depressed and agitated
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