Patient evaluation on intake

32-year-old woman with a chief complaint of unremitting depression for several years, who was transferred from another provider who had just retired

Psychiatric history

The patient had onset of MDD in her 20s, which was likely predated by comorbid GAD

Presents moderately depressed but is partially responding to medication now

Depressive symptoms have fluctuated from mild to severe but have never remitted

Sober from prior AUD for three years

Despite these symptoms, has been gainfully employed at times and has been able to return to school for college credits on a part-time basis

Exhibits classic symptoms of MDD but the depression is also vegetative in that she is not predominantly sad, but more anhedonic with blunted affect, and poor energy and concentration

Admits to passive suicidal thoughts but has never acted on them

Required no psychiatric hospitalizations in her lifetime

• – A review of psychiatric systems revealed no other formal anxiety disorder, psychosis, mania, eating disorder

• – Has undergone eclectic, supportive psychotherapy in the past but her mental state at this presentation made reciprocal talk therapy almost impossible given her psychomotor slowing and lethargy

• – There is no evidence of marked personality disorder

• – Inherited from a previous psychiatrist, the patient currently takes an SNRI (duloxetine [Cymbalta]) and a stimulant (methylphenidate [Concerta])

• – The stimulant is for depression augmentation and she only experiences dry mouth as a side effect

• – States she is about 30% better on this regimen

• – Previously, the patient failed to respond to

  • Two or three SSRIs prescribed in the primary care setting prior to being seen in psychiatry. She is unaware of the dose strength utilized but states she spent several months on each

  • Adequately dosed NaSSA, mirtazapine (Remeron) 45 mg/d

  • Patient had previous trials of a TCA but these appear to be low doses used for treating insomnia and pain only

• – Continues to be seen weekly by a supportive psychotherapist with whom she has a good rapport

Social and personal history

Divorced and has two children

Is high school educated, working part-time and taking courses part-time

Has supportive parents and siblings who help her with childcare

Does not drink alcohol, smoke cigarettes, or take illegal drugs

Medical history

Iron deficiency anemia treated with iron supplements

Successful bariatric surgery, lost 70 lbs., and weighs 130 lbs.

Is normotensive

History of lower back pain

Family history

SUD in parents and many relatives, largely AUD

MDD in mother

No history of schizophrenia or bipolar disorder in the family

Current psychiatric medications

Duloxetine (Cymbalta) 60 mg/d (SNRI)

Methylphenidate-ER (Concerta) 36 mg/d (stimulant)

Current medical medications

Iron supplements 1500 mg/d

Ibuprofen (Motrin) 600–1800 mg/d

Question

Based on this patient’s history and the available evidence base, do you consider augmentation with stimulants to be a reasonable approach?

Yes

No

What makes, or would make you comfortable using a stimulant augmentation?

Stimulants are not approved but are covered in many psychopharmacology texts as legitimate augmentations, and in many peer-reviewed journal review articles, and there are a few trials available in the literature supporting the practice

Larger controlled trials seem to indicate that, if not a full antidepressant, stimulants have anti-fatigue and procognitive effects useful in treating MDD

Stimulants often offset side effects induced by SSRI and SNRI, such as sedation, fatigue, executive dysfunction, and weight gain

Stimulants often treat residual depressive symptoms not managed by SSRI, such as fatigue and poor concentration

What makes, or would make you uncomfortable with stimulant augmentation?

A history of addiction

A history of cardiac or hypertensive issues

A history of tic or movement disorders

A history of anxiety