Pretest self-assessment question (answer at the end of the case)
Which are correct regarding vascular depression?
A. There is evidence that cerebrovascular disease creates vulnerability to depression, as well as cognitive impairment and neurologic signs
B. Clinical presentation suggests a medial frontal lobe syndrome with psychomotor retardation, apathy, and marked disability
C. Cerebrovascular lesions on neuroimaging results in poor outcomes, including persistence of depression with unstable remission and increased risk for dementia
D. Depression–executive dysfunction syndrome (DED) is similar but may have multifactorial causes, that is, vascular disease, aging-related changes, degenerative brain disease, combined in a cumulative or synergistic effect
E. All of the above
Patient evaluation on intake
Patient #1
– 79-year-old woman whose chief complaint was of “feeling awful”
Patient #2
– 85-year-old man who had no chief complaint
Psychiatric history
Each patient presents with family members
– Patient #1 has a history of recurrent mild MDEs throughout her life
This latest MDE is more severe and more incapacitating than previous episodes
– Patient #2 has no history of mental illness
Survived cancer and was robust and active until a recent pneumonia
Despite recovery, seems depressed and inactive
Neither patient has any clear psychiatric comorbidity
– Except that Patient #1 appears to have a phobia with an intense fear reaction that occurs only if her elderly husband leaves the house for too long
Neither has any psychiatric inpatient admissions, nor suicide attempts
Initially, Patient #2 was somewhat confused and/or thought disordered
Outside of this, both patients admitted being depressed, down, fatigued, unable to concentrate, unable to sleep well. Both deny guilt, worthlessness feelings, or any suicidal thoughts.
These patients are not related and not married to each other, but both families presented concerned that their once robust, energetic family members were now down, out, and despondent. In fact, the families chief complaint is that these patients “just sit on the couch all day”
Question
Of the following depression treatment choices, what would you do?
Start an SSRI
Start an SNRI
Start an NDRI
Start an NaSSA (mirtazapine [Remeron])
Initiate or refer to psychotherapy
Case outcome
Both patients are tried sequentially on therapeutically dosed SSRI, SNRI, NDRI, and NaSSA monotherapies
Both were augmented with stimulants, atypical antipsychotics, and BZs
Patient #1 now receives maintenance ECT
Patient #2 is off all psychotropics as there was no benefit noticed during any medication trial
Both declined psychotherapy
Both had relief from sadness, insomnia, fatigue, anorexia within the first few months
Both now still sit on their couches (in their separate houses) most of the day, with little motivation or concern for time and other interests
Both are somewhat docile and dependent and have little interest in other pursuits
When asked if they like and enjoy their lifestyles and their daily routine, the answer is “yes” with little relationship to the active lives they used to lead
They are not upset by these losses
They have short-term memory problems, which have become more pronounced with time
Their treatment course was complicated
– Patient #1: by oversedation and a fall while taking BZs
– Patient #2: by onset of mild TD that has mostly remitted
– Regardless of agents used, such as antidepressants, sedatives, stimulants, and antipsychotics, both patients’ apathy did not worsen or lighten, suggesting that their apathy was not iatrogenic nor side-effect driven. In fact, one of the patients who is off all medications remains the same
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
