Case debrief

This patient presented in a highly treatment-resistant state

She was suffering from comorbid depression and anxiety

There was a likelihood that she also suffered from active Lyme disease, but this was ultimately treated and ruled out as a primary cause of her depressive symptoms

This patient’s treatment course was interrupted in several ways

• – Non-compliance with medications

• – Inability to tolerate mild side effects

• – Strife with family members and other providers regarding her diagnosis

  • These punctuated her partial response periods with depressive relapses

  • She never gained remission

• – She was noncompliant at pivotal points, which caused relapses, and many attempts were made to create a psychotropic regimen that would be effective with less fatigue-related side effects

The patient underwent ECT and again was deemed a 50% responder, but over the next few years suffered relapses into MDD

She engaged in three-times-a-week PDP and a year-long course of DBT, which appears to have helped her to sustain a response more successfully for more substantial periods, but has never achieved a sustained symptom remission

She finally underwent a course of TMS, which remains a maintenance treatment

• – This neuromodulation approach was free of side effects for her

• – She has not achieved remission but likely has reached the best sustained response so far with regard to her TRD

Take-home points

Patients with TRD are more apt to attain only partial symptom relief and to relapse frequently into MDEs

Frequent medication regimen adjustments are warranted to attempt to gain remission and to hopefully delay relapses

Sometimes treatment regimens are interrupted by outside forces (family, friends, outside providers) and have to be navigated acutely

Side-effect management in chronic depression often becomes more important than obtaining symptom reduction

• – If a patient will not stay on a medication at therapeutic doses, they cannot obtain good outcomes

• – In psychopharmacologic practice, it often is not about choosing the right medication but the art of keeping the patient on a good medication

Comprehensive and intensive psychotherapy may also be utilized to better treat patients with TRD

Infectious organic CNS insults, like Lyme disease, should be considered in TRD cases

• – In this case, Lyme disease may have been a fully plausible explanation, especially if there was a more acute onset of MDD symptoms over the last few years since exposure and if there were positive laboratory findings

• – Lyme disease might also have been more likely if her current MDE came with a “different flavor” or different, novel symptomatology compared to her previous MDEs

• – However, this episode presented with symptoms similar to her previous MDEs

• – This patient’s chronic depression since childhood made Lyme disease a less likely etiology, but worthy of a workup regardless

Performance in practice: confessions of a psychopharmacologist

What could have been done better here?

• – Psychiatrists are often not up-to-date on medical illness comorbidities

• – Clinicians have become better regarding metabolic disorder detection and management, but likely not in infectious illnesses such as Lyme disease

• – Some areas of the country have much higher infection rates and prevalence of Lyme disease

• – Clinicians in these endemic areas should be up-to-date on Lyme disease as it can mimic depression, anxiety, and dementia to a certain degree

  • Lyme disease patients tend to have many somatic symptoms

  • This type of presentation also occurs in the depressed–anxious patient population

• – As this patient was partially treated by an atypical antipsychotic, could atypicals with less sedation be utilized to improve adherence?

  • Aripiprazole was used instead of olanzapine (Zyprexa) at one point, but to no avail

  • Perhaps ziprasidone (Geodon) could have been tried

  • Lurasidone (Latuda) was not available at the time, but this could be an option as a possibly less-sedating medication

  • Alternatively, atypical antipsychotic-induced fatigue could have been challenged by using a stimulant such as methylphenidate (Ritalin) or a wakefulness-promoting agent such as modafinil (Provigil)

  • These combinations could provide a “win–win” situation in that fatigue may have lessened, improving her medication compliance, and could have acted as an augmentation strategy to improve her MDD

  • Controversially, consider if adding a DA-enhancing stimulant makes clinical sense when the patient was taking a D2 receptor blocking atypical antipsychotic

Possible action items for improvement in practice

• – Review the epidemiology of Lyme disease in your geographic area

• – Review its etiology, diagnosis, and treatment standards