Further investigation

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

What medical details about this patient are you concerned about?

At the first visit, her weight was very low. Is she medically stable? Could she tolerate ECT or other neurostimulation treatments?

Her medications seem contradictory in that she is on a weight gaining olanzapine (Zyprexa), but weight-losing topiramate (Topamax) and dextroamphetamine (Dextrostat)

She has hyperlipidemia and CAD for which she is being treated. (Of note is that these were medications upon admission to author’s service in 2000 and many of the warnings and guidelines about the atypical antipsychotic inducing metabolic disorders were not available until 2003–2004.)

She has a family history of eating disorders and collateral information about her typical eating habits and body habitus should be collected

• – Preliminarily, she does not appear to suffer from AN

Obtaining a nutrition or dietary consultation might be warranted as she is mostly immobile, bedridden, and her caloric intake is low

• – This may also help to determine if the patient is in a “failure to thrive” situation where an inpatient admission might be warranted

Obtaining routine blood laboratory analyses and a discussion with her PCP is warranted, to determine medical stability for future treatment with psychotropics, neurostimulation techniques, and also to rule out medical causes of her depression

Question

Based on what you know about this patient’s history, current symptoms, and treatment responses, do you think that a bona fide, formal trial of established psychotherapy is warranted?

Yes, a referral for PDP is warranted

Yes, a referral for CBT is warranted

No, this patient has had many years of supportive, eclectic style psychotherapy and further psychotherapy intervention is unlikely to be effective

No, specific psychotherapies are no better than eclectic psychotherapies in treating MDD

No, this patient’s cognitive impairment and psychomotor slowing would likely make psychotherapy ineffective

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

The patient is clearly depressed and seems to have had no clear benefit to monotherapy antidepressant treatments nor to her current aggressive augmentation regimen

The patient may be psychotic given her marked cognitive impairment, but the current high-dose olanzapine (Zyprexa) use and past ECT trial likely rules out depressive psychosis, leaving her profound thought slowing and vegetative symptoms likely due to severe MDD without psychosis but with melancholic features

She has a history of thorough antidepressant trial follow-through where full, therapeutic dosing has been utilized. Her husband is supportive and a good historian about her medical interventions

Pharmacy records confirm her medication trials

• – Note that in the absence of a good historian or available medical records from previous providers, most pharmacies can print out medications dispensed, going back several years. This is often an easy way to tabulate how treatment resistant a patient is while confirming their medication trial history

The patient really needs to be evaluated medically before more aggressive treatment is prescribed