Patient evaluation on intake

42-year-old woman with a chief complaint of depression

Psychiatric history

The patient had onset of depression in late teens. These episodes were often limited and likely adjustment disorder episodes

Depression became more prominent and pervasive and she developed a chronic low-level depression consistent with dysthymia

Since her late 20s, she has also had full MDD episodes lasting two to 24 weeks in duration, which were at times incapacitating

Appears at times to have full inter-episode recovery from her depressive symptoms

Many of the stress-induced depression exacerbations suggest a paranoid personality style noted in her interpersonal interactions

She also mentions having PMS (premenstrual syndrome) and feels that her symptoms often are worse during her menstrual cycle

History includes no previous psychiatric hospitalizations, nor any suicide attempts

A review of psychiatric systems revealed no anxiety disorder, schizophrenia, mania, or substance misuse history

However, she admitted to experiencing hallucinations (predominantly when depressed) where the wood grain paneling in her house (that resembles eyes and faces) would talk to her

Her only previous treatment was with fluoxetine (Prozac) up to 40 mg/d, which she reports was intermittently and only partially effective and was discontinued the previous year

Engagement in sporadic eclectic and supportive psychotherapy is noted

Social and personal history

Grew up with separated parents

Had difficulties with grades throughout school

Ultimately achieved an associate’s degree

Works as an artist and seamstress periodically

Is married but is estranged at times

Medical history

Stress urinary incontinence

Migraines

Trigeminal neuralgia

She currently takes trospium, hydrocodone as needed, carbamazepine for these conditions

Family history

Anxiety disorder in mother

AUD in father

Current psychiatric medications

An SNRI, duloxetine (Cymbalta) 120 mg/d, was started and titrated in lieu of fluoxetine (Prozac) by her primary care provider and she states it is for incontinence

Question

Based on what you know about this patient’s history and current symptoms, would you consider her to fall within the TRD spectrum?

Yes

No

Would you continue the SNRI duloxetine monotherapy?

Yes, but increase the dose above the approved 120 mg/d

Yes, but add an augmentation or combination therapy

No, taper off and try a new monotherapy

No, taper off and try a new CIT where two antidepressants are started simultaneously

Attending physician’s mental notes: initial evaluation

Nothing unexpected on mental status examination

Because she has had numerous recurrences, this makes her illness appear to be somewhat unstable; she has not shown any overt signs of bipolarity but does have clear mood lability due to hormonal changes with menses, and also due to social stressors, which are suggestive of mild-moderate personality disorder, as well as somatic illness. She also has unique quasi-psychotic features of auditory and visual illusions verses hallucinations, which may be suggestive of dissociative features or schizotypal traits, not just psychotic depression

The best diagnosis for this patient may be MDD, recurrent unipolar disorder at this time

During ongoing care, will need to better assess for personality disorder, premenstrual dysphoric disorder (PMDD), and psychotic disorder

Continuing duloxetine (Cymbalta) above the 120 mg/d Food and Drug Administration (FDA) limit seems ill-advised as she has had little response to the full dose and has failed a therapeutic selective serotonin reuptake inhibitor (SSRI), fluoxetine (Prozac), in the past. The SSRI and SNRI mechanisms have failed to treat her to remission

Given her lability and treatment-resistant status, the patient was offered a choice of an atypical antipsychotic to augment her current SNRI