Augmentation therapy in treatment-resistant depression – a case report
Dr. Sushil Kumar Sompur V*
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Abstract:
Major Depressive Disorder (MDD) is a highly debilitating condition, and utilizes more healthcare costs than many other chronic debilitating disorders. Among patients with depression, MDD seems to be the most debilitating. We report a case of a 75-year-old female patient who has experienced multiple episodes of MDD. The recurrent nature of her depressive episodes that amounted to fifteen MDD episodes over a period of forty years was perplexing. She also had Electro Convulsive Therapy (ECT) for three out of the total of fifteen episodes of MDD. Although beneficial at the time of treatment, the recurrences, as in case with non-ECT treatment, occurred within two to four years of a previous episode of MDD. This case illustrates that MDD may occur as a stable phenotype over many episodes. It is important to recognize psychotic symptoms in order to prescribe the best possible treatment with the available psychopharmacological medications and augmentative therapies.
Keywords – Major Depressive Disorder (MDD), recurrence, antidepressant, augmentation
Introduction:
Depression is a state of low mood and aversion to activities that can affect a person’s thoughts, behavior, feelings, and sense of well being (1). Health cannot be achieved without mental health as is evident by the World Health Organization (WHO) definition for health. Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity (2). Thus, the fact is that mental health is not the mere absence of infirmity according to the WHO definition of depression (2). Depression has significant socioaˆ?economic costs. The costs of depression in the EU were estimated at ˆ92 billion in 2010, affecting more than 30 million people (3). Although stable over the last two decades, the economic burden of depression dramatically increased in the proportion of depression sufferers who received treatment more recently (4). This may be a good health trend but the burden of the disease MDD has increased enormously (5).
Major Depressive Disorder is a severe condition characterized by the simultaneous presence of depressive thoughts and/or lack of interest in activities (anhedonia) along with 4 of the other symptoms (6). The other symptoms are guilty feelings, loss of energy or lethargy, poor concentration, poor or excessive appetite resulting in weight gain or weight loss, psychomotor retardation or a sense of having slowed down, disturbed sleep, or suicidal ideations (6).
Case Presentation:
This is a case of a 75 year old female patient who had been suffering from depression for nearly the past 40 years. She was living by herself in an apartment, currently widowed and had 4 children who were in close contact with her. One of her children, a daughter, was living close by and was visiting with her mother on a regular basis and used to take care of her medical and at times to her domestic needs. The case report is based on the verbal communication or clinical interview of the patient as well as corroborative clinical evidence from available medical records.
The patient had her first major depressive episode in 1974 after the birth of her first baby. She described very vividly what happened during the course of her pregnancy and thereafter when she gave birth. She described domestic abuse during and after marriage, continuing through her pregnancy and also thereafter. She had been somewhat opposed to the arranged marriage even before she was married and was starting to have depressive symptoms at that time. Depression worsened to the point where she started to not care of the baby after childbirth and also started to have poor sleep and appetite; she felt like not being a good mother to her baby and had suicidal ideations. This was when she was taken to a doctor for the first time. She also had problems with backache after childbirth. She first was prescribed a tricyclic antidepressant and she continued to be on the same for about a year. She subsequently felt better. However, when she came off of the medications as her husband wanted to have another baby with her, she started to have symptoms of depression again. She also described continued harassment and domestic abuse on the part of her husband and their family all through this time which lasted for about twenty years.
During her second episode of depression she started to have bouts of suicidal ideations and even attempted overdosing on pills which made her abort her pregnancy. She reportedly was started on the same treatment again, however, this time around she was given Electro Convulsive Therapy (ECT) treatment as it was; at the time; one of the best treatments available according to her doctor. Although she felt better afterwards, she continued to have relapses, about thirteen that she could recount. Among the relapses she described depressive episodes during postpartum periods for her next three pregnancies as well.
She subsequently had a more episodes, relapsing every two to four years with a new episode of depression. Although she was tried on many antidepressants, including but not limited to tri-cyclic antidepressants, monoamine antidepressants, tetra-cyclic antidepressants, serotonin specific reuptake inhibitors, serotonin nor-epinephrine reuptake inhibitors, nor-epinephrine dopamine reuptake inhibitors, serotonin antagonist and reuptake inhibitors and serotonin modulator medications. However, she was never initiated on any kind of medication that was used as an adjuvant or augmentative therapeutic modality. She also was consulting a local ayurvedic physician who had given her medications from their pharmacopoeia. However she did not see any consistent effect in terms of complete recovery from any of these medications as well. The patient had also tried two more series of ECT before her current presentation with depression for about the fifteenth time that she could recall. She had not been suicidal during any of her past episodes and she was not suicidal during her current presentation.
She met the diagnostic criteria for Major Depressive Disorder, severe without psychotic features (6). She had a Patient Health Questionnaire-9 (PHQ-9) (See APPENDIX) score of 12 despite being on medication at the current time (7). She was already on Sertraline at 150 mg PO daily qAM along with a multivitamin supplement. She also currently had developed hypertension as a co-morbid condition and was taking Atenolol 20 mg PO daily. We increased her Sertraline to 200 mg PO daily qAM and since she was tolerating the medication well we started her on Aripiprazole 2.5 mg PO daily qHS as an augmentative strategy. The response to treatment, with a higher dose of antidepressant along with a small dose of antipsychotic as an augmentative strategy, was dramatic and her PHQ score at the next visit which was two weeks later was two.
Discussion:
Augmentative strategies in treatment resistant depression even in geriatric age groups are worth a trial after optimization of treatment with a known anti-depressant. The patient in our case history presented with similar symptoms as during her previous visits with a psychiatrist and this was not unusual for her. Not being suicidal was also a good reason for using an augmentative strategy to be on the safer side. There are multiple studies to show that augmentation with a small dose of an antipsychotic for treatment resistant Major Depressive Disorder works and works well enough to the point where the patient has complete remission from her symptoms. Also the treatment choice in the case discussed in this paper is not unusual as it reflects the lack of an established, clearly superior, pharmacological intervention treatment regimen in this case.
International guidelines are also of use in determining the best course of treatment and it is evident from many studies that the strategy used in our case meets these standard guidelines. Furthermore, when considering antipsychotics, the question of the least harm is answered in the usage of Aripiprazole for the treatment and augmentation strategy, as it has been proven to have minimal side effects at low dosages.
This case illustrates that unremitting Major Depressive Disorder can be a stable phenotype in the absence of suicidal ideation over many episodes and that it is important to recognize the efficacy of using an augmentative strategy like a low-dose antipsychotic while at the same time optimizing the dose of the medication in order to prescribe the best possible treatment of this kind of depression. In the present case, a fast and safe response in the acute phase of illness, over many episodes in a time span of two weeks is significant. What remains to be seen is whether this treatment strategy is effective in relapse prevention and more so with treatment adherence.
Acknowledgements:
Patient has given written and oral consent to the publication of this case report. The authors are grateful for her participation.
APPENDIX
Nine-symptom Checklist
Name ______________________ Date _________
Over thelast 2 weeks, how often have you been bothered by any of the following problems?
Not at all
Several days
More than half the days
Nearly every day
1. Little interest or pleasure in doing things
0
1
2
3
2. Feeling down, depressed, or hopeless
0
1
2
3
3. Trouble falling or staying asleep, or sleeping too much
0
1
2
3
4. Feeling tired or having little energy
0
1
2
3
5. Poor appetite or overeating
0
1
2
3
6. Feeling bad about yourself—or that you are a failure or have let yourself or your family down
0
1
2
3
7. Trouble concentrating on things, such as reading the newspaper or watching television
0
1
2
3
8. Moving or speaking so slowly that other people could have noticed? Or the opposite—being so fidgety or restless that you have been moving around a lot more than usual
0
1
2
3
9. Thoughts that you would be better off dead or of hurting yourself in some way
0
1
2
3
(For office coding: Total Score ____ = ____ + ____ + ____)
If you checked offanyproblems, howdifficulthave these problems made it for you to do your work, take care of things at home, or get along with other people?
Not difficult at all
Somewhat difficult
Very difficult
Extremely difficult
a-?
a-?
a-?
a-?
References:
American Psychiatric Association.Criteria for major depressive episode.http:www.dsm5.org.
Constitution of the World Health Organization, WHO, 2006, pp 1-18.
Olesen J, Gustavsson A, Svensson M, et al: The economic cost of brain disorders in Europe. Eur J Neurology 2012; 19: 155-162.
OECD: Sick on the job? Myths and Realities about Mental Health and Work, 2012, pp 1 – 3
Mental well-being: For a smart, inclusive and sustainable Europe. European Commission report 2011, pp 4 – 22
Grohol, J. (2013). DSM-5 Changes: Depression & Depressive Disorders.Psych Central. Retrieved on March 26, 2014, from http://pro.psychcentral.com/2013/dsm-5-changes-depression-depressive-disorders/004259.html
Spitzer RL, Kroenke K, Williams JB: Patient Health Questionnaire Primary Care Study Group. Validation and utility of a self-report version of the PRIME-MD: the PHQ primary care study. JAMA 1999; 282:1737-44.
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