Patient evaluation on intake

Patient #1

• – 79-year-old woman whose chief complaint was of “feeling awful”

Patient #2

• – 85-year-old man who had no chief complaint

Psychiatric history

Each patient presents with family members

• – Patient #1 has a history of recurrent mild MDEs throughout her life

  • This latest MDE is more severe and more incapacitating than previous episodes

• – Patient #2 has no history of mental illness

  • Survived cancer and was robust and active until a recent pneumonia

  • Despite recovery, seems depressed and inactive

Neither patient has any clear psychiatric comorbidity

• – Except that Patient #1 appears to have a phobia with an intense fear reaction that occurs only if her elderly husband leaves the house for too long

Neither has any psychiatric inpatient admissions, nor suicide attempts

Initially, Patient #2 was somewhat confused and/or thought disordered

• – A delirium workup ensued and was negative

• – Initial treatment with an antipsychotic cleared his symptoms

Outside of this, both patients admitted being depressed, down, fatigued, unable to concentrate, unable to sleep well. Both deny guilt, worthlessness feelings, or any suicidal thoughts.

These patients are not related and not married to each other, but both families presented concerned that their once robust, energetic family members were now down, out, and despondent. In fact, the families chief complaint is that these patients “just sit on the couch all day”

Question

Of the following depression treatment choices, what would you do?

Start an SSRI

Start an SNRI

Start an NDRI

Start an NaSSA (mirtazapine [Remeron])

Initiate or refer to psychotherapy

Case outcome

Both patients are tried sequentially on therapeutically dosed SSRI, SNRI, NDRI, and NaSSA monotherapies

Both were augmented with stimulants, atypical antipsychotics, and BZs

Patient #1 now receives maintenance ECT

Patient #2 is off all psychotropics as there was no benefit noticed during any medication trial

Both declined psychotherapy

Both had relief from sadness, insomnia, fatigue, anorexia within the first few months

Both now still sit on their couches (in their separate houses) most of the day, with little motivation or concern for time and other interests

Both are somewhat docile and dependent and have little interest in other pursuits

When asked if they like and enjoy their lifestyles and their daily routine, the answer is “yes” with little relationship to the active lives they used to lead

They are not upset by these losses

They have short-term memory problems, which have become more pronounced with time

Their treatment course was complicated

• – Patient #1: by oversedation and a fall while taking BZs

• – Patient #2: by onset of mild TD that has mostly remitted

• – Regardless of agents used, such as antidepressants, sedatives, stimulants, and antipsychotics, both patients’ apathy did not worsen or lighten, suggesting that their apathy was not iatrogenic nor side-effect driven. In fact, one of the patients who is off all medications remains the same