Further investigation

Is there anything else you would especially like to know about this patient?

What about details concerning the diagnosis of PMDD and of her hallucinations, and about the treatments given and the responses to those treatments for her depression?

During the past year on her SNRI, she states she is about 30% better and has a less labile affect, but still has most of her MDD symptoms, but to a “lesser degree”

She has had PMS for many years. Screening for PMDD is positive, but confounded by the fact that she is depressed often, if not routinely, outside of her luteal phase. It appears she is regularly depressed, but during the luteal phase, she becomes more depressed. This is a premenstrual exacerbation (PME) of an existing unipolar MDD. PMEs occur when depressed patients suffer an exacerbation of MDD symptoms during the luteal phase. She has failed to respond to one of the FDA-approved medications for PMDD (fluoxetine [Sarafem]). The other FDA approval is for sertraline (Zoloft)

During the past year she has also complained of continuing migraines and urinary problems, which are bona fide medical conditions but may also be considered psychosomatic in that her depression likely makes them worse and more complicated to treat

Question

Based on what you know about this patient’s history, current symptoms, and treatment responses, are you convinced she has TRD with PMEs?

Yes

No

Would you combine her SNRI with an atypical antipsychotic as suggested?

Yes, but keep the atypical antipsychotic at a low dose for depression treatment

Yes, increase the atypical antipsychotic to a moderate to high dose to treat her affective lability and psychosis

No, I’d use a different medication approach altogether

Attending physician’s mental notes: initial evaluation (continued)

The patient is clearly depressed and obviously is worse in her luteal phase. Adding another agent with more serotonergic potential (serotonin [5-HT] receptor modulating agents with 5-HT2A, 5-HT2C, 5-HT1A mechanisms) seems reasonable, as long as informed consent about side effects is given

Ways to treat her PMEs could be to add buspirone (BuSpar) for its 5-HT1A receptor partial agonism activity. Augment with trazodone (Desyrel, Oleptro) for its 5-HT2A receptor antagonism activity. Change to vilazodone (Viibryd) as it is an SSRI with pre- and postsynaptic 5-HT1A partial agonist properties. Some of the atypical antipsychotics possess some of these serotonergic mechanisms and could be utilized as well

The mood lability never consists of sustained hypomania, thus bipolarity is ruled out. She clearly has mood lability whether due to PMEs or social stressors. Alternatively, the DSM-V now allows the specifier of having mixed features even when MDD is the principal diagnosis. In this case, the patient meets full MDD criteria and if she were to have an additional three classic symptoms of (hypo)mania simultaneously, then she would meet this specifier

The paranoid personality traits become more evident over time and predispose her to stressful interactions

She does have frank hallucinations when she looks at the grain of her wood paneling in her house. She interacts verbally with them. This occurs predominantly when she is stressed and depressed. They can be mood congruent or incongruent. Culturally she feels it is acceptable as she is interacting with relatives who have passed away