Pretest self-assessment question (answer at the end of the case)
In which of the following clinical situations is ECT felt to be robustly effective?
A. MDD with psychotic features
B. MDD
C. OCD
D. Schizophrenia
E. A and B
F. A, B, and C
G. All of the above
H. None of the above
Patient evaluation on intake
18-year-old man states he has been “depressed all year”
He has been reasonably successful in high school, enjoys athletics, has a girlfriend, and should be happy
He is not, he is despondent to the point of being suicidal
Psychiatric history
Reports increasing MDD symptoms over the last several months
– Cannot sleep without medication
– Is fatigued and cannot concentrate at school, and is allowed to attend for half days as a result
– Reports marked guilt as he is letting others down
– He is convinced he will never get better
– Admits daily suicidal thinking that so far he has not acted on, but states it is “a struggle every day”
– Experiences intrusive “images” where he sees himself hurting himself or others that he deems separate from his suicidal thinking, which he states are “clearly his own thoughts”
These images started shortly after the depression began
These MDD symptoms started after a break up with a girlfriend, but never remitted, even as his social life improved
He has long-standing feelings that people do not like him and has low self-esteem despite being a well-rounded and accomplished teenager, as he was picked on for being overweight as a child
– He is not overweight now
There is no evidence of sustained manic episodes, anxiety disorder, eating disorder, or SUD, confirmed by corroborative history and diagnostic rating scales
– Interestingly, his previous provider had diagnosed him with bipolar disorder and ADHD
– He transitioned to this provider on a stimulant, a mood stabilizer, and an antidepressant
Social and personal history
Due to graduate high school on time this year but has had academic accommodations given his MDD
Parents are married and supportive
Has no siblings
Does not abuse substances, nicotine, or caffeine
Medical history
There are no medical issues
Family history
There is no family history of bipolar disorder or schizophrenia
Uncles may have AUD
Aunts may have MDD
Medication history
Psychotherapy history
Patient evaluation on initial visit
Patient suffers from a single, severe, and possibly psychotic MDD
He sees images that look like “videos playing” vividly in front of him
He has a blunted affect, concrete thoughts, and mild thought slowing
– This could be from MDD
– Also need to consider these as negative symptoms, that his obsessive images are frank hallucinations, and that this is a schizophrenia prodrome
Has been compliant with medication management and psychotherapy
Suicidal thinking is readily apparent, serious, and problematic
There is no evidence of bipolarity
Current medications
Question
Do you think his obsessive images are from MDD or OCD?
OCD as they are intrusive images that appear in the distance, instead of being generated internally, and he does not interact with them
OCD as they often depict a loss of control and violence toward himself or others, which he does not identify with and they horrify him
MDD as these images started after the MDD and increased as his MDD escalated
MDD as these images were never present when euthymic
Neither; these are paranoid in nature and may be early schizophrenia or schizoaffective disorder
Neither as they are likely induced by his stimulant
Not sure as all of these are plausible
Attending physician’s mental notes: initial evaluation
This patient has a risky, severe MDD given his symptoms and suicidal thinking
The images appear to be intrusive, obsessive images, or depressive ruminations rather than psychotic ones
Negative and cognitive symptoms appear consistent with vegetative MDD
His medication regimen is interesting and cannot be explained easily
– There are no defined (hypo)mania spells, based on careful interview with patient and family
– Rating scales suggest no current mania, nor mixed features
– The inattention and poor concentration symptoms seem consistent with inattentive ADHD
Patient feels he has always been this way but is worse over last one to two years
Parents and school records suggest no problems academically or behaviorally in elementary school that would be consistent with ADHD
Stimulant has not helped and may have made him worse
If he has bipolar disorder, he should be stabilized on the divalproex (Depakote) but might be destabilized on the antidepressant and stimulant, which could be problematic
The inattention and cognitive dysfunction currently are likely due to depression, agitation, and not ADHD
Question
Which of the following would be your next step?
Discontinue the mood stabilizer, divalproex (Depakote)
Discontinue the stimulant, d/l-mixed amphetamine salts (Adderall), and increase the SSRI antidepressant
Discontinue all but the SSRI, augment it with an atypical antipsychotic, admit to an inpatient psychiatric unit
Attending physician’s mental notes: initial evaluation (continued)
The medication combinations the patient presents with are not effective. They may even be worsening the patient’s original MDD symptoms
The patient is horribly depressed but resilient enough to maintain some schooling and some friendships
He is suicidal, but has many psychosocial supports and an extensive safety plan that has successfully avoided inpatient hospitalization
He either has psychotic MDD or MDD with comorbid OCD
Further investigation
Is there anything else you would especially like to know about this patient?
Could the obsessional/psychotic images be organic?
– There is no history of head injury
– There is no evidence of migraine or seizure activity
– He is forthcoming about random experimentation regarding illicit drugs but does not seem to have had any acute use to explain these symptoms
– Blood laboratory tests, EEG, and MRI were negative
What about details regarding his personality style and coping skills?
– The patient has been socially engaging
– Seems a bit dependent on his family and perhaps enmeshed
It is unclear if this is his usual personality pattern or
If owing to MDD causing a regression into more severe personality traits or
If owing to the sick role he has accommodated due to his severe MDD
– Does not appear to have affective dyscontrol, mood swings outside those triggered by his depressive state
– Often is rejection sensitive with some avoidant traits due to being picked on as a youngster
– Does not seem to meet clear criteria for a personality disorder diagnosis, but has certain dependent/avoidant traits that are troublesome
Case outcome: first interim follow-up visits one to two weeks later
All medications except for the SSRI escitalopram (Lexapro) are discontinued
The SSRI is increased to 20 mg/d because
A SARI, trazodone (Desyrel) 50–100 mg at bedtime, is given to treat insomnia
– Insomnia is an acute risk factor for suicide
– Aggressive treatment here may lower risk of suicide and avoid an inpatient stay
– He immediately sleeps better and his suicidal ideation is reduced
– This off-label use of an SARI may also provide MDD augmentation treatment
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
