Current medications

Escitalopram (Lexapro) 10 mg/d (SSRI)

d/l-amphetamine salts (Adderall) 15 mg/d (stimulant)

Divalproex sodium-ER (Depakote-ER) 750 mg/d (mood stabilizer)

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