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Excerpt
Mr. A, a 22-year-old single white man, presented for consultation after an overdose. He gave a history of depressed mood with diurnal variation, irritability, anhedonia, anergia, 10-pound weight loss, sleep disturbance, poor concentration, multiple somatic complaints, thoughts of worthlessness and hopelessness, and psychomotor retardation with periods of agitation. There had been two other recent serious suicide attempts, a single-car motor vehicle accident, and attempted electrocution by immersing a radio in water, each of which resulted in brief hospitalization. There was no history of mania or psychotic symptoms. An ADHD screening was positive for 13 of 14 DSM-III-R symptoms.
Mr. A had had three psychiatric assessments in childhood, with diagnoses of "developmental delay," "soft neurological signs," and "attention deficit." Stimulants had been considered, but had not previously been introduced. His intelligence fell in the low average to average range on multiple assessments (Wechsler Intelligence Scale for Children-Revised), with scatter seen in low scores on the coding and digit-span subtests. He had seen two other psychiatrists as an adult, receiving diagnoses of "adjustment reaction," "severe anxiety state," and "major depression." He had previously been treated with buspirone, without improvement. At the time of consultation, Mr. A was taking sertraline, 50 mg/day.
Mr. A's father had had ADHD, and his mother had a history of recurrent major depression responsive to imipramine and doxepin.
DSM-III-R axis I diagnoses of major depression, recurrent (296.33) and attention-deficit/hyperactivity disorder (314.01) were made. No diagnosis was given on axis II or III.
Sertraline was discontinued. Moclobemide, chosen for its efficacy in MDD and potential to ameliorate ADHD, was initiated at 450 mg/day in divided doses. Adverse effects of nausea, headache, and nightmares were noted, but responded to dose reduction. With gradual increases of 150 mg/week, dosages of 600 mg/day (divided) were eventually reached without reemergence of adverse effects. After 8 weeks of treatment, suicidal ideation returned, precipitating hospitalization. Mr. A's mood symptoms responded well, but he remained restless, irritable, fidgety, and had difficulty concentrating. Methylphenidate was introduced and titrated to 10 mg orally four times a day with improvement in concentration, attention span, irritability, and restlessness. Mild appetite suppression and initial insomnia were noted, but were well-tolerated. Blood pressures were carefully monitored in hospital, with no hypertension or elevation of baseline blood pressure.
At a 30-month follow-up, Mr. A is stable in family-care placement and actively participates in psychosocial rehabilitation programs. He is maintained on moclobemide, 300 mg two times a day, and methylphenidate, sustained release, 20 mg in the morning, and short-acting methylphenidate, 10 mg at 1500 hours. His depressive symptoms have resolved, although he experienced a 1-month period of blue mood and fatigue without vegetative features and which did not require changes in medication or other treatment. He continues to meet the DSM-III-R and DSM-IV criteria for ADHD, although the severity rating has improved from severe to mild, both in number of items that are present and in the severity of each of these items.
