case study 29 the depressed man who thought he was out of options

Case study # 29: The depressed man who thought he was out of options.

The Case: The depressed man who thought he was out of options The Question: Are some episodes of depression untreatable? The Dilemma: What do you do when even ECT and MAOIs do not work?

69-year-old man • Chief complaint: unremitting, chronic depression

Psychiatric History • Recurrent, unipolar major depressive episodes for the past 40 years, with good response to treatment and good inter-episode recovery until fi ve years ago • Onset then of one long, waxing and waning major depressive episode ever since • Five years ago, relapsed on venlafaxine 225 mg after having had a good response to it • Two years ago had nine electroconvulsive therapy (ECT) treatments with a partial response • In the past few years since relapse on venlafaxine has tried (adequate trials, no severe side effects) essentially every known antidepressant and augmentation combination known or reported in the literature, from many capable psychiatrists and numerous consultations from local, regional, and national psychiatrists, and distinguished medical centers – 5 SSRIs – Duloxetine – Mitazapine – 2 TCAs – Augmentation with 5 different atypical antipsychotics – Augmentation with – Lithium – Thyroid – Buspirone

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