a case study on depression

Mental Health Case Study: Understanding Depression through a Real-life Example

Through the lens of a gripping real-life case study, we delve into the depths of depression, unraveling its complexities and shedding light on the power of understanding mental health through individual experiences. Mental health case studies serve as invaluable tools in our quest to comprehend the intricate workings of the human mind and the various conditions that can affect it. By examining real-life examples, we gain profound insights into the lived experiences of individuals grappling with mental health challenges, allowing us to develop more effective strategies for diagnosis, treatment, and support.

The Importance of Case Studies in Understanding Mental Health

Case studies play a crucial role in the field of mental health research and practice. They provide a unique window into the personal narratives of individuals facing mental health challenges, offering a level of detail and context that is often missing from broader statistical analyses. By focusing on specific cases, researchers and clinicians can gain a deeper understanding of the complex interplay between biological, psychological, and social factors that contribute to mental health conditions.

One of the primary benefits of using real-life examples in mental health case studies is the ability to humanize the experience of mental illness. These narratives help to break down stigma and misconceptions surrounding mental health conditions, fostering empathy and understanding among both professionals and the general public. By sharing the stories of individuals who have faced and overcome mental health challenges, case studies can also provide hope and inspiration to those currently struggling with similar issues.

Depression, in particular, is a common mental health condition that affects millions of people worldwide. Disability Function Report Example Answers for Depression and Bipolar: A Comprehensive Guide offers valuable insights into how depression can impact daily functioning and the importance of accurate reporting in disability assessments. By examining depression through the lens of a case study, we can gain a more nuanced understanding of its manifestations, challenges, and potential treatment approaches.

Understanding Depression

Before delving into our case study, it’s essential to establish a clear understanding of depression and its impact on individuals and society. Depression is a complex mental health disorder characterized by persistent feelings of sadness, hopelessness, and loss of interest in activities. It can affect a person’s thoughts, emotions, behaviors, and overall well-being.

Some common symptoms of depression include:

– Persistent sad, anxious, or “empty” mood – Feelings of hopelessness or pessimism – Irritability – Loss of interest or pleasure in hobbies and activities – Decreased energy or fatigue – Difficulty concentrating, remembering, or making decisions – Sleep disturbances (insomnia or oversleeping) – Appetite and weight changes – Physical aches or pains without clear physical causes – Thoughts of death or suicide

The prevalence of depression worldwide is staggering. According to the World Health Organization, more than 264 million people of all ages suffer from depression globally. It is a leading cause of disability and contributes significantly to the overall global burden of disease. The impact of depression extends far beyond the individual, affecting families, communities, and economies.

Depression can have profound consequences on an individual’s quality of life, relationships, and ability to function in daily activities. It can lead to decreased productivity at work or school, strained personal relationships, and increased risk of other health problems. The economic burden of depression is also substantial, with costs associated with healthcare, lost productivity, and disability.

The Significance of Case Studies in Mental Health Research

Case studies serve as powerful tools in mental health research, offering unique insights that complement broader statistical analyses and controlled experiments. They allow researchers and clinicians to explore the nuances of individual experiences, providing a rich tapestry of information that can inform our understanding of mental health conditions and guide the development of more effective treatment strategies.

One of the key advantages of case studies is their ability to capture the complexity of mental health conditions. Unlike standardized questionnaires or diagnostic criteria, case studies can reveal the intricate interplay between biological, psychological, and social factors that contribute to an individual’s mental health. This holistic approach is particularly valuable in understanding conditions like depression, which often have multifaceted causes and manifestations.

Case studies also play a crucial role in the development of treatment strategies. By examining the detailed accounts of individuals who have undergone various interventions, researchers and clinicians can identify patterns of effectiveness and potential barriers to treatment. This information can then be used to refine existing approaches or develop new, more targeted interventions.

Moreover, case studies contribute to the advancement of mental health research by generating hypotheses and identifying areas for further investigation. They can highlight unique aspects of a condition or treatment that may not be apparent in larger-scale studies, prompting researchers to explore new avenues of inquiry.

Examining a Real-life Case Study of Depression

To illustrate the power of case studies in understanding depression, let’s examine the story of Sarah, a 32-year-old marketing executive who sought help for persistent feelings of sadness and loss of interest in her once-beloved activities. Sarah’s case provides a compelling example of how depression can manifest in high-functioning individuals and the challenges they face in seeking and receiving appropriate treatment.

Background: Sarah had always been an ambitious and driven individual, excelling in her career and maintaining an active social life. However, over the past year, she began to experience a gradual decline in her mood and energy levels. Initially, she attributed these changes to work stress and the demands of her busy lifestyle. As time went on, Sarah found herself increasingly isolated, withdrawing from friends and family, and struggling to find joy in activities she once loved.

Presentation of Symptoms: When Sarah finally sought help from a mental health professional, she presented with the following symptoms:

– Persistent feelings of sadness and emptiness – Loss of interest in hobbies and social activities – Difficulty concentrating at work – Insomnia and daytime fatigue – Unexplained physical aches and pains – Feelings of worthlessness and guilt – Occasional thoughts of death, though no active suicidal ideation

Initial Diagnosis: Based on Sarah’s symptoms and their duration, her therapist diagnosed her with Major Depressive Disorder (MDD). This diagnosis was supported by the presence of multiple core symptoms of depression that had persisted for more than two weeks and significantly impacted her daily functioning.

The Treatment Journey

Sarah’s case study provides an opportunity to explore the various treatment options available for depression and examine their effectiveness in a real-world context. Supporting a Caseworker’s Client Who Struggles with Depression offers valuable insights into the role of support systems in managing depression, which can complement professional treatment approaches.

Overview of Treatment Options: There are several evidence-based treatments available for depression, including:

1. Psychotherapy: Various forms of talk therapy, such as Cognitive Behavioral Therapy (CBT) and Interpersonal Therapy (IPT), can help individuals identify and change negative thought patterns and behaviors associated with depression.

2. Medication: Antidepressants, such as Selective Serotonin Reuptake Inhibitors (SSRIs), can help regulate brain chemistry and alleviate symptoms of depression.

3. Combination Therapy: Many individuals benefit from a combination of psychotherapy and medication.

4. Lifestyle Changes: Exercise, improved sleep habits, and stress reduction techniques can complement other treatments.

5. Alternative Therapies: Some individuals find relief through approaches like mindfulness meditation, acupuncture, or light therapy.

Treatment Plan for Sarah: After careful consideration of Sarah’s symptoms, preferences, and lifestyle, her treatment team developed a comprehensive plan that included:

1. Weekly Cognitive Behavioral Therapy sessions to address negative thought patterns and develop coping strategies.

2. Prescription of an SSRI antidepressant to help alleviate her symptoms.

3. Recommendations for lifestyle changes, including regular exercise and improved sleep hygiene.

4. Gradual reintroduction of social activities and hobbies to combat isolation.

Effectiveness of the Treatment Approach: Sarah’s response to treatment was monitored closely over the following months. Initially, she experienced some side effects from the medication, including mild nausea and headaches, which subsided after a few weeks. As she continued with therapy and medication, Sarah began to notice gradual improvements in her mood and energy levels.

The CBT sessions proved particularly helpful in challenging Sarah’s negative self-perceptions and developing more balanced thinking patterns. She learned to recognize and reframe her automatic negative thoughts, which had been contributing to her feelings of worthlessness and guilt.

The combination of medication and therapy allowed Sarah to regain the motivation to engage in physical exercise and social activities. As she reintegrated these positive habits into her life, she experienced further improvements in her mood and overall well-being.

The Outcome and Lessons Learned

Sarah’s journey through depression and treatment offers valuable insights into the complexities of mental health and the effectiveness of various interventions. Understanding the Link Between Sapolsky and Depression provides additional context on the biological underpinnings of depression, which can complement the insights gained from individual case studies.

Progress and Challenges: Over the course of six months, Sarah made significant progress in managing her depression. Her mood stabilized, and she regained interest in her work and social life. She reported feeling more energetic and optimistic about the future. However, her journey was not without challenges. Sarah experienced setbacks during particularly stressful periods at work and struggled with the stigma associated with taking medication for mental health.

One of the most significant challenges Sarah faced was learning to prioritize her mental health in a high-pressure work environment. She had to develop new boundaries and communication strategies to manage her workload effectively without compromising her well-being.

Key Lessons Learned: Sarah’s case study highlights several important lessons about depression and its treatment:

1. Early intervention is crucial: Sarah’s initial reluctance to seek help led to a prolongation of her symptoms. Recognizing and addressing mental health concerns early can prevent the condition from worsening.

2. Treatment is often multifaceted: The combination of medication, therapy, and lifestyle changes proved most effective for Sarah, underscoring the importance of a comprehensive treatment approach.

3. Recovery is a process: Sarah’s improvement was gradual and non-linear, with setbacks along the way. This emphasizes the need for patience and persistence in mental health treatment.

4. Social support is vital: Reintegrating social activities and maintaining connections with friends and family played a crucial role in Sarah’s recovery.

5. Workplace mental health awareness is essential: Sarah’s experience highlights the need for greater understanding and support for mental health issues in professional settings.

6. Stigma remains a significant barrier: Despite her progress, Sarah struggled with feelings of shame and fear of judgment related to her depression diagnosis and treatment.

Sarah’s case study provides a vivid illustration of the complexities of depression and the power of comprehensive, individualized treatment approaches. By examining her journey, we gain valuable insights into the lived experience of depression, the challenges of seeking and maintaining treatment, and the potential for recovery.

The significance of case studies in understanding and treating mental health conditions cannot be overstated. They offer a level of detail and nuance that complements broader research methodologies, providing clinicians and researchers with invaluable insights into the diverse manifestations of mental health disorders and the effectiveness of various interventions.

As we continue to explore mental health through case studies, it’s important to recognize the diversity of experiences within conditions like depression. Personal Bipolar Psychosis Stories: Understanding Bipolar Disorder Through Real Experiences offers insights into another complex mental health condition, illustrating the range of experiences individuals may face.

Furthermore, it’s crucial to consider how mental health issues are portrayed in popular culture, as these representations can shape public perceptions. Understanding Mental Disorders in Winnie the Pooh: Exploring the Depiction of Depression provides an interesting perspective on how mental health themes can be embedded in seemingly lighthearted stories.

The field of mental health research and treatment continues to evolve, driven by the insights gained from individual experiences and comprehensive studies. By combining the rich, detailed narratives provided by case studies with broader research methodologies, we can develop more effective, personalized approaches to mental health care. As we move forward, it is essential to continue exploring and sharing these stories, fostering greater understanding, empathy, and support for those facing mental health challenges.

References:

1. World Health Organization. (2021). Depression. Retrieved from https://www.who.int/news-room/fact-sheets/detail/depression

2. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

3. Beck, A. T., & Alford, B. A. (2009). Depression: Causes and treatment. University of Pennsylvania Press.

4. Cuijpers, P., Quero, S., Dowrick, C., & Arroll, B. (2019). Psychological treatment of depression in primary care: Recent developments. Current Psychiatry Reports, 21(12), 129.

5. Malhi, G. S., & Mann, J. J. (2018). Depression. The Lancet, 392(10161), 2299-2312.

6. Otte, C., Gold, S. M., Penninx, B. W., Pariante, C. M., Etkin, A., Fava, M., … & Schatzberg, A. F. (2016). Major depressive disorder. Nature Reviews Disease Primers, 2(1), 1-20.

7. Sapolsky, R. M. (2004). Why zebras don’t get ulcers: The acclaimed guide to stress, stress-related diseases, and coping. Holt paperbacks.

8. Yin, R. K. (2017). Case study research and applications: Design and methods. Sage publications.

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Antidepressants: A Research Update and a Case Example

What experiences do people have if they take antidepressants.

Posted December 20, 2018

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This post briefly reviews what researchers have been finding about the effectiveness and also the downsides of antidepressant medications — Zoloft, Prozac, and the like. The post then adds a fascinating case example, a self-description submitted to me by a reader who has experienced both the ups and the downs of antidepressant drugs. First, though, a word about my personal bias : Antidepressant pills definitely do help some people. At the same time, I regard them as vastly over-prescribed for mild to moderate depression and also for anxiety . Other treatment strategies for these situations can be equally or more effective, and without the downsides. In my TEDx talk on lifting depression , for instance, I demonstrate an antidepressant visualization exercise that I have used effectively in my clinical practice for decades. See also the techniques here .

What does the latest research suggest about whether you should take antidepressant medications?

For a particularly comprehensive review of the established medical risks of antidepressants , this article from Harvard Medical School is especially informative. You can find many similar articles with a web search of antidepressant risks.

In addition, a recent comprehensive review article of 522 trials and more than 116,000 patients — a meta-analysis combining the findings of all the available studies — reported on findings regarding 21 antidepressant drugs. This review was described as the most comprehensive analysis of the evidence ever undertaken. The Lancet Psychiatry , which reported the study, also then published a further analysis by the study’s authors. Here are their conclusions:

• Antidepressants can be, on average, an effective treatment for adults with moderate-to-severe major depression in the acute phase of illness.
• Effective as defined in this study means that there was a 50 percent or more reduction of depressive symptoms over an eight-week period. “Effective” did not imply complete remission (removal) of the depression.
• Some patients experienced great benefit from the medication ; others gained little or no benefit. In general, the more severe the depression, the more benefits from the antidepressant.
• The average response to a placebo (a sugar pill disguised as medication) was 35 percent. The average response to antidepressants ranged between 42 percent (reboxetine) and 53 percent (amitriptyline).
• For between 47 and 58 percent of subjects, depending on the specific drug, the medication was not effective. That is, they did not experience at least a 50 percent reduction in their depression symptoms.

Note that the depressed clients who did receive relief from taking an antidepressant medication definitely felt better — and yet not necessarily fully healed. Again, "effective" is defined as a 50 percent improvement in symptoms. This definition raises a number of questions:

• What about the remaining effects of depression, if only 50 percent of the symptoms have been relieved by the medication?
• Are antidepressant drugs appropriate to prescribe for milder depression? Or are non-medication therapy techniques just as or more effective? The research deals with only moderate to severe depression. Yet most prescriptions for antidepressants are given for milder to moderate depressive reactions.
• Earlier studies have concluded that the combination of both drugs and psychotherapy has the highest response rate. Both show about equal effectiveness on their own, except that psychotherapy has longer-lasting positive impacts, because it teaches skills and understandings that have long-term benefits. And what about the European research which has found that after people have taken an antidepressant, they become more likely to have subsequent depressive episodes?
• Because of the addictive potential of anti-anxiety drugs, like Xanax and Librium (xxx), antidepressants with sedating side-effect profiles now are prescribed to keep anxiety at bay. What are the effectiveness rates of antidepressants for treating anxiety?
• What about the negative side effects of antidepressants? The Lancet Psychiatry summary article says nothing about these, the most significant of which is drug dependency. Drug dependency means that once people have taken an antidepressant over a significant time period, their body begins to depend on it. The result is that when they try to discontinue taking the medication, their body has a rebound reaction of depression. That depression does not mean that they needed the antidepressant all along. It just means that the drug has caused their body to no longer produce the chemistry of well-being on its own.

A Medications Case Example: Despair, Delight, Disaster, and More

Many thanks to LC, for sharing her antidepressant experiences.

LC: It all started one late afternoon. I was in my car with my toddler-aged son, driving home through typical late afternoon traffic.

Suddenly I smelled the distinct scent of burning. Ahead of me, just five cars away, a plume of neon orange fire was climbing higher and higher. It was so out of place and so sudden that I didn't feel panicked or scared, I just stared for a few seconds, mouth wide open, my brain calibrating a fire on the highway.

Then I saw the people starting to run. And the panic set in. People all around me were jumping out of their cars and running down the highway, away from the gas truck that was literally on fire in front of us. The truck was still mostly intact, and it dawned on me all at once that a larger explosion might be imminent.

I jumped out of the car, pried open the car-seat straps, and then, flinging my son over my shoulder, ran to get as far away from the gasoline truck as possible. There was a BOOM sound, but I didn't look back. I just kept running and saying, "It's OK. We just need to move away from the fire," both to my son, and to myself.

The sirens started. Police and fire-trucks and ambulances somehow made their way through the maze of stopped cars.

A tragic gas leak had killed the driver of the truck. I texted my husband. I called and apologized profusely to my one-year-old's sitter for being so late.

Three hours later, I was on my way home. I had to run to the grocery store, pick up my 4-year-old from preschool, and make dinner. With three young children, I didn't have time to panic, process, or recover. I had to just keep going.

It was only later that night, after 11:00 p.m., that I felt the effects of that experience. My husband tried to calm me down. I was inconsolable. I wanted to scream or cry or run, but I was paralyzed and terrified.

The next day, I couldn't do anything. My anxiety was telling me that I was in danger. I wasn't, but the panic was still there. I was dreading trying to sleep again.

My sister told me to go immediately to a psychiatrist. I did. The psychiatrist talked to me for about 1 minute and then handed me a Xanax (an anti-anxiety pill) and a cup of water: "You are having a panic attack, and you've been in it for almost 24 hours. We need to get you calmed down."

Having a doctor hand me something I could swallow immediately soothed me. I was able finally to speak enough to tell the psychiatrist that I had seen a terrifying accident, and that I had never really suffered from anxiety or panic attacks before. I begged her to please make the anxiety stop.

The psychiatrist prescribed Xanax for a couple of weeks and then Cipralex, a commonly-used SSRI antidepressant that treats both depression and anxiety, to take long-term. She also said that it was imperative that I find a therapist and explore what was going on in my mind. I guess she assumed the trigger was deeper than just seeing a gasoline truck in flames.

Dr. Heitler: Traumatic events can trigger intense panic either during or at some point after the dangerous event has concluded. Eventually, especially with a chance to talk about what happened, the anxiety calms down. In LC’s case however, the parasympathetic nervous system , whose job it is to calm feelings of fear , was not functioning.

Fortunately, the anti-anxiety pill, Xanax, is fast-acting and effective.

Fortunately also, the psychiatrist had suggested that Lia speak with a talk therapist. Talking about the thoughts that were barraging her would enable Lia to digest her thoughts and feelings, both from the recent trauma and from prior events that had troubled her for some time.

Unfortunately, the psychiatrist did not offer non-pill options to calm the intense anxiety reaction. As the saying goes, to a man with a hammer, the world is a nail.

In this case, the hammer was in fact effective. Xanax brought Lia immediate relief. There are, however, non-pill options that can produce the same immediate calming effect. Both acupoint tapping and a visualization called the spinning technique would probably have done the job equally well. In addition, Lia easily could learn to do these techniques on her own at home should the anxiety return.

LC: The thing is . . . I knew that I needed therapy. It had been a long time coming. An unspoken trauma from the past was finding its way out, visiting me in dreams , and violating random moments in my life. I had been doing my best to silence it, shushing it desperately, hoping that it would just go away. So I started therapy. And I started the antidepressant drugs. And I was able to breathe. For a while.

Therapy opened my mind to myself. I had closed it years before. Re-opening it was as if a door had been kicked down. The halls and rooms of my mind were inviting me to explore, to wander, and to get reacquainted with my inner-world.

The SSRI seemed to be working too. I was more calm. I was more at ease. I wasn't barking at my husband about crumbs on the counter or scrubbing toys with bleach every night. I was laughing a little more, yelling a little less, more balanced.

What was from therapy, and what was from the SSRI? I didn’t care. I was just relieved to be breathing normally.

Dr. Heitler: Multiple studies of the treatment of serious emotional distress conclude that the combination of medication and psychotherapy is more potent than either alone. Lia’s case exemplifies this principle. Pills and talk therapy can potentiate each other, that is, cause each other to be more effective than either treatment alone could be.

At the same time, newer therapy techniques, such as the Body Code and Emotion Code, enable a therapist to radically shorten the time and intensity of talk therapy. Within one session or several, an Emotion Code therapist can pinpoint the earlier problem and immediately release trapped negative emotions so that they cease to have impact. With the underground spring that had been feeding anxious, angry and/or depressed feelings turned off, the feelings of vitality and well-being that we call mental health can emerge.

Marriage therapy also might well have helped Lia. My policy is when anyone who is married seeks therapy with me, I encourage them to bring their spouse. In almost all cases, underlying marital issues have been fanning the flames of negative emotions.

The spouse also can have a significant role in fostering a return to mental health. For instance, an anxious or depressed person may have an impulse to spend his evenings isolating and ruminating, saying troubling thoughts over and over to himself. Rumination exacerbates anxiety and depression. If husband and wife enjoy activities together in the evening, they are likely to be able to replace the rumination with pleasant interactions.

LC: I don't regret starting the antidepressant, the Cipralex. I truly feel like that drug saved my mind. It also probably held my marriage together for several more years. But by a year later, I knew that something was off. I knew that it was the medication.

Dr. Heitler: An antidepressant, especially in combination with good talk therapy, can work miracles in enabling people to get back to functioning in a normal emotional zone. The difficulties tend to come with the duration of use.

By prescribing an antidepressant medication and then keeping her on it for more than an initial several months, LC’s psychiatrist had inadvertently invited increasingly negative side effects. The negative side effects which had begun while Lia was taking the pills became even worse when she tried to get off the pills.

LC: At about a year, I started feeling fuzzy, num­­b, and detached. I would have several-minute episodes of not knowing what I was doing or how I got there. Then the confusion would dissipate, and I would be left thinking that I was just imagining it. But it would happen again. Fleeting, but tangible. Almost leaving a taste in my mouth.

I shared this with my husband, but he was worried about the anxiety returning if I messed with my medication. I waited.

Dr. Heitler: LC’s husband’s concerns had some genuine validity. The difficulty is that after a year of taking antidepressants, anyone who attempts to stop taking them must end their use very slowly. Otherwise, removal of the drugs can precipitate serious depression and/or anxiety.

It’s not that these emotions had been lurking there all along. Rather, antidepressants create drug dependency. The body forgets how to produce the chemicals that sustain well-being when they are being provided artificially by pills.

LC: The side effects worsened. I had no sex drive. I stopped feeling motivated to hang out with friends. I stopped caring about how I looked or what I was wearing. I was sinking. I had been saved from anxiety, and was now slipping into depression.

I made a unilateral decision to go off my meds. It wasn't a wise one. Looking back, I see that it was very much a desperate stand against the many factors in my life that I wasn't in control of — my devastation over my marriage that was quietly but quickly ending, my loss of focus on my passions and hobbies, my overweight and exhausted body, too strict in my religious life . . . the list goes on.

To simply argue that the SSRIs were ruining my life would be short-sighted and most likely wrong. I was ruining my life. But I was absolutely clear that the drug I was putting into my body every day was dragging me down and making it much harder to move forward. I felt very much alone — and for the first time in a while, very clear in my mission.

Dr. Heitler: In addition to creating drug dependency when used for more than several months at a stretch, antidepressants can produce a number of further negative side effects. Weight gain, loss of sexual feelings, emotional numbness, and "brain zapping" are among the most common. LC experienced these, and more.

LC: Going off SSRIs cold-turkey is nothing short of a ride through hell. The physical and emotional effects of suddenly depriving your brain of serotonin is horrific.

I was tormented by anxiety. I experienced electric pulses starting in my head and traveling down my entire body. I found myself in tears over everything. I had so much guilt over the decision. But I couldn't put that pill back in my mouth.

I pushed. It was raw without the drug. My husband and I separated. I said goodbye to God on a park bench and said hello to myself. I sabotaged a friendship — not something I'm proud of. I lost 35 pounds. I started singing out loud. I started running.

I told the psychiatrist what I had done. Even though so many things were better, I was on the verge of another breakdown, and I didn't know what to do.

The psychiatrist prescribed a different drug, this time an SNRI (two chemicals for the brain's "happy" place instead of one). She explained that since I was in the middle of a divorce — a major life-crisis for anyone — it probably wasn't the best time to go off psychiatric drugs.

That night I sat with the new pill in my hand. It took a serious pep talk to swallow it, but I did. I felt like I needed all the help I could get. I had three young children depending on me to keep it together, and I couldn't afford to let emotions destroy me. I had delved extensively into my past and had finally put to rest the lurking earlier trauma. I told myself I would take the drug, and when life settled down, I would get off.

Fast-forward a year and a half. A very similar cycle ensued. At first the SNRI filled me with renewed calm. It was like a rosy tint on life was just a pill away. And then . . . the fog set in. Again, about a year in, I felt that familiar detachment. I stopped caring about the little things. I started to feel like I was being numbed. Like I was underwater. Watching the world from below, too slow to stay actively involved in my own life. My sex drive started dying, and with it, my drive for life deteriorated.

With this new and more powerful drug, I again started feeling physical side effects. If I took the pill a few hours later than usual, I would get extremely nauseous. But if I took it in the morning, I would also get nausea and throw up. On the drug, I was more prone to migraines , I fainted several times that year, and I started gaining weight quite rapidly — despite my strictly healthy lifestyle.

This time around, I was determined to get off the drug safely. I checked in with a doctor. I started by taking off just one-quarter of the dose and did so every four weeks, allowing my brain to adapt each time.

Nonetheless, again it was hard, even painful. Each time I weaned down a dose, I had a week of horrible brain zaps. Even worse, I was much more reactive and impatient with my children. The weaning process took four months.

At the same time, I truly feel like this time around I experienced a beautiful and inspiring rebirth of myself. My senses feel heightened. My experiences are fully my own again.

Dr. Heitler: Paradoxically, ending her use of antidepressants turned out for LC to be the ultimate cure. With the pills no longer compromising her body’s chemistry, LC’s natural vitality eventually returned. So did her sexual feelings, ability to lose weight, eventual loss of the brain zapping, and a return of her former good-humored self.

LC’s conclusions: I'm still forming an objective opinion on the use of SSRIs. The power of these drugs, for better and for worse, is something that shouldn't be taken lightly. Off them now though, for me, heading away from antidepressants is heading in the right direction.

Dr. Heitler’s conclusions: Again, as I said at the outset, for a severe or suicidal depressive episode, antidepressant medications can relieve the intensity of dark thoughts and desperate feelings.

At the same time, Lia’s case illustrates well that antidepressants may:

• Have limited or no effectiveness for almost half of users
• Help somewhat, while many aspects of the depression remain
• Produce problematic side effects, like weight gain, decreased sexual feelings, brain zapping, nausea, clouded thinking, and numbing of feelings of joy as well as of negative emotions
• Create drug dependence when used for longer than a few months, and therefore difficult withdrawal symptoms, including withdrawal-induced depression
• Be prescribed for usages for which they are not intended (i.e., mild depressive reactions and anxiety) and for which non-drug options may be equally effective
• Be prescribed at length, for years rather than months, increasing the difficulties of eventual withdrawal

Susan Heitler, Ph.D ., is the author of many books, including From Conflict to Resolution and The Power of Two . She is a graduate of Harvard University and New York University.

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Clinical scenario, about the authors, author contributions, declaration of interest, a case of treatment-resistant depression in an older adult and a discussion of treatment options.

Published online by Cambridge University Press:  16 November 2021

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Treatment-resistant depression is a complex condition often requiring specialist psychiatric care. Many different psychiatric, physical and social factors can lead to a poor response to initial treatment of depression, and a careful assessment is required to determine the most appropriate management option. This can be particularly complex in the older population, who often have multiple physical and social comorbidities. We have used a fictional case to illustrate this, alongside an anonymised vignette of someone with personal experience of this condition. We have also provided an overview of the current evidence for treatment options, as well as a discussion of potential aetiological factors. By the end of this article, readers should understand the ambiguity of this diagnostic term, the aetiological factors that need to be assessed and the rationale for the treatment options available. They should be able to recognise how these ideas apply to the geriatric population.

You are reviewing a 70-year-old retired teacher, Mr F, admitted informally to a later-life functional ward with a relapse of depression. He has had low mood, anhedonia and fatigue for 4 months, and was admitted following treatment by his community mental health team because of concerns that he has been eating and drinking only when prompted by carers. Until recently he has been independent at home, but his family brought in carers to support his poor self-care when it became too difficult for his disabled wife to manage. This started with support with cooking and cleaning, but they were soon asked to do more for him as his function declined. He shows no evidence of psychosis, but admits to feeling hopeless, and when his family were packing his belongings for admission, they found a collection of tablets with a suicide note and an updated will. He refuses to talk about this and breaks down crying when asked.

He has had depression since his 20s, with five periods of low mood requiring treatment and one admission in his 40s that was resolved with electroconvulsive therapy (ECT). The other episodes initially responded to amitriptyline and later fluoxetine. He has been maintained on fluoxetine for 5 years. When he became unwell, he was switched to sertraline and then venlafaxine with no improvement. He has previously used a course of cognitive–behavioural therapy (CBT) to good effect, but during this bout of illness, he has declined any psychological input.

• What would be your approach to assessment?

• What is treatment-resistant depression (TRD)?

• What common comorbidities are relevant in later-life depression?

• What biopsychosocial factors need to be considered in formulation?

• What other differential diagnoses do you need to consider?

• How should you approach the management of TRD?

Definitions of TRD

TRD is a common but complex issue to treat or even define. Reference Brown, Rittenbach, Cheung, McKean, MacMaster and Clement 1 The most commonly used definition is clinically significant depression that has not responded to two different treatment courses given at adequate doses and duration, Reference Fava G, Cosci, Guidi and Rafanelli 2 sometimes with the additional requirement of a course of psychotherapy. Reference Brown, Rittenbach, Cheung, McKean, MacMaster and Clement 1 If the first definition is used, the sequenced treatment alternatives to relieve depression study (STAR*D trial) estimates that approximately 35% of those with depression have TRD. Reference Nemroff 3 Whatever definition is used, the important principle in clinical practice is to identify individuals for whom their depression is not responding to treatment and look for alternatives.

Approach to treatment

One principle of TRD management is to look for reasons for treatment failure that may then also affect future treatment choices. Reference Kornstein and Schneider 4 A list of common issues is provided below, but there are many more, and are patient-specific and multifactorial: Reference Parker, Malhi, Crawford and Thase 5

• Treatment factors: inadequate dose, inadequate course length and lack of psychotherapy option.

• Patient factors: poor concordance, side-effects, individual pharmacokinetics and medication interactions.

• Psychiatric diagnostic factors: misdiagnosis or comorbidity of bipolar affective disorder, psychotic depression, hypoactive delirium, vascular depression, alcohol and substance misuse, anxiety disorder, personality disorder, post-traumatic stress disorder, emerging dementia and obsessive–compulsive disorder.

• Medical comorbidity: to include hypothyroidism, Cushing's disease, Addison's disease, Parkinson's disease, HIV infection, sleep apnoea and pain. For a more extensive list, please see the referenced review. Reference Baldwin and Wild 6 These conditions can present with low mood, but other conditions (such as diabetes or coronary artery disease) can exacerbate depression through a cycle of low mood leading to poor management of physical health, which then exacerbates the physical symptoms of depression.

• Medications: antihypertensives (one large cohort study suggested that calcium channel antagonists and beta-blockers increase the risk of depression whereas angiotensin-converting enzyme inhibitors and angiotensin receptor blockers may decrease the risk Reference Wise 7 ), steroids, opiates, anti-Parkinsonian drugs and several others. Again, please see the referenced review for a more extensive list. Reference Baldwin and Wild 6

• Social factors: inadequate or unstable housing or employment, bereavement, social isolation, financial difficulties, uncertainties over immigration status and a variety of types of abuse.

• End-stage disease: in some individuals with highly recurrent disease, early onset or high genetic load, it may be that TRD is the end stage of a more severe illness.

Investigation of these possible causes begins with a thorough history (including developmental and social details) and collateral history, but may also require investigations such as blood tests or neuroimaging. Although some tests are routine and should be done on the majority of patients (e.g. thyroid function tests for hypothyroidism or full blood count for anaemia), others will only be required in certain conditions (e.g. computerised tomography or magnetic resonance imaging scan for dementia, or dexamethasone suppression test for Cushing's disease). The use of sequential clinical assessment scales can also be invaluable to help to monitor any response to treatment.

Another general principle to consider in older populations is that many patients will be dealing with their depression for the rest of their lives, and as such, any approach to treatment must take account of the chronicity of symptoms rather than just seeking to provide short-term interventions. This includes the impact their illness will have on their carers.

Next steps in treatment

Once the factors above have been considered and managed, the next step is a consideration of possible alternative treatments. Reference Voineskos, Daskalakis and Blumberger 8 Selective serotonin reuptake inhibitors (SSRIs) and serotonin-noradrenergic reuptake inhibitors (SNRIs) are usually first- and second-line treatments for depression. We will now consider some of the alternatives available (in no particular order) if these first choices do not provide an adequate response: Reference Taylor, Barnes and Young 9

• Lithium: one of several first-line agents used to augment antidepressants in unipolar depression. Reference Taylor, Barnes and Young 9 It is usually titrated to a plasma level of 0.4–0.8 mmol/L with the scope to increase to a maximum of 1.0 mmol/L. This is supported by National Institute for Health and Care Excellence (NICE) guidance. 10 One 2014 meta-analysis Reference Nelson, Baumann, Delucchi, Joffe and Katona 11 highlighted that many of the trials of lithium augmentation were completed with tricyclic antidepressants. Given that these are now less commonly used as a first-line agent, the meta-analysis aimed to compare this with trials using newer agents. Although the analysis was small (237 patients), it showed that the benefits of lithium augmentation are seen when paired with multiple different antidepressants. Importantly for this case, there is also some limited evidence Reference Buspavanich, Behr, Stamm, Schlattmann, Bschor and Richter 12 that lithium augmentation is as effective in older adults as in younger patients. However, in older populations, the rates of side-effects from lithium are higher. Reference Gitlin 13 Although the evidence suggests lithium can be effective for some, the need for regular blood tests, increased vigilance when physically unwell or dehydrated, and the risk of toxicity if not closely managed, all mean that lithium is not appropriate for every patient. Caution should be used in those with pre-existing kidney or thyroid disease or who are otherwise at high risk of intercurrent illness that could cause dehydration. Lithium also interacts with a wide range of medications that are frequently used in later life, so in cases of polypharmacy, a discussion with the pharmacy team may be of benefit.

• Second-generation antipsychotics: quetiapine, aripiprazole and olanzapine all have good-quality evidence supporting their use to augment SSRIs and SNRIs in TRD, and can be used dependent upon patient-specific factors such as physical comorbidities. For example, one randomised double-blind trial Reference Thase, Corya, Osuntokun, Case, Henley and Sanger 14 compared olanzapine, fluoxetine and combination therapy in 605 patients with TRD. It showed modest but statistically significant differences in response, with remission rates of 27% for combination treatment, 17% for fluoxetine and 15% for olanzapine over an 8-week period. The main drawbacks of this option are side-effects such as weight gain and cardiometabolic syndrome, but in select patients there is growing evidence of the utility of antipsychotics. Risperidone is another alternative, although the evidence to support its use is weaker and so would be considered as a second-line treatment.

• Mirtazapine: can be used as a monotherapy or in combination with SSRIs or SNRIs. There is evidence that these particular combinations are more effective than other antidepressant combinations. Reference Henssler, Bschor and Baethge 15 Patients should be warned about the theoretical risk of serotonin syndrome and specific side-effects should be monitored for, including weight gain and sedation. The latter makes mirtazapine an attractive choice in those suffering from insomnia, where sedation can be beneficial.

• Other antidepressants: although SSRIs and SNRIs have displaced older antidepressants as first-line treatments, tricyclics and monoamine oxidase inhibitors remain useful options, although various guidelines would recommend that other options listed here be tried first. Various papers have been published to this effect, but medications such as imipramine are often not as well-tolerated as more recently developed drugs such as sertraline. Reference Thase, Rush, Howland, Kornstein, Kocsis and Gelenberg 16 The STAR*D report showed only a 6.9% remission rate when tranylcypromine was used after three previous failed trials of medication, and it was not as well-tolerated as a venlafaxine/mirtazapine combination. Reference McGrath, Steward, Fava, Trivedi, Wisniewski and Nierenberg 17 As with many of the listed treatments, these medications show significant benefit in a minority of patients, but it has proven difficult to predict outcomes before trialling medication. However, tricyclic toxicity means that they must be used with caution, especially in individuals with a high risk of overdose. It is also worth noting that many trials, including STAR*D with its upper age limit of 75 years, exclude older patients, and so many recommendations in the older population are partially based on trials with younger patients. Other antidepressants such as moclobemide and vortioxetine can also be considered, with vortioxetine being a popular choice in certain countries across the globe such as Australia, Reference Voineskos, Daskalakis and Blumberger 8 as well as being suggested as an alternative treatment by the NICE. 18

• Psychotherapy: a Cochrane review from 2018 Reference Ijaz, Davies, Williams, Kessler, Lewis and Wiles 19 collated data from six trials ( n  = 698) comparing usual care with or without psychotherapy. The modalities used included CBT, intensive short-term dynamic psychotherapy, interpersonal therapy and group dialectic behavioural therapy. The study concluded that there is moderate-quality evidence to support the efficacy of psychological therapies in TRD, based upon self-reported and objective measures. However, most of the studies were small so this conclusion largely came from one study on CBT. The authors also highlighted that there were no available studies comparing response rates of psychotherapy to a change in medication.

• ECT: ECT continues to be shown to be an effective alternative to medication in treating depression, with meta-analysis evidence that it is superior to simulated ECT, placebo and various antidepressants. Reference Pagnin, dr Queiroz, Pini and Cassano 20 However, given its invasive nature, ECT is usually only used in life-threatening circumstances or after several other failed treatments. This is in line with current NICE guidance, 10 and its use should ideally only occur following a clear and detailed discussion of its risks and benefits with the patient. There is also some evidence of increased efficacy in treating suicidal intent in the context of unipolar depression in older adults versus younger adults. Reference Kellner, Fink, Knapp, Petrides, Husain and Rummans 21 Rarely, where there is an acute response to ECT but this is not maintained with solely pharmacological and psychological treatment, maintenance ECT may be discussed. The ECT minimum data-set for the UK for 2016–2017 Reference Buley, Copland and Hodge 22 reported that across the 76% of centres that supplied data, there were 141 patients undergoing maintenance ECT for recurrent symptoms of depression. This represents about 8% of those undergoing ECT in total, and so is a relatively uncommon use of ECT. As a result, evidence for its efficacy is sparse and largely relies upon case reports. Despite this, with specialist assessment, this remains a viable treatment option.

• Others: there are several other possible treatment options that are either currently available or being investigated. These include transcranial magnetic stimulation, Reference McClintock, Reti, Carpenter, McDonald, Dubin and Taylor 23 ketamine, esketamine, Reference Gupta, Dhar, Patadia, Funaro, Bhattacharya and Farheen 24 bupropion augmentation Reference Trivedi, Fava, Wisniewski, Thase, Quitkin and Warden 25 (listed among first-line choices by the Maudsley prescribing guidelines Reference Taylor, Barnes and Young 9 ), thyroid hormone, Reference Iosifescu, Nierenberg, Mischoulon, Perlis, Papakostas and Ryan 26 deep brain stimulation, Reference Drobisz and Damborska 27 vagus nerve stimulation, Reference Senova, Rabu, Beaumont, Michel, Palfi and Mallet 28 psilocybin Reference Carhart-Harris, Bolstridge, Day, Rucker, Watts and Erritzoe 29 and anti-inflammatories. Reference Kohler, Benros, Nordentoft, Farkouh, Lyengar and Mors 30

As there are many treatment options, decisions should be patient-specific and made collaboratively. If a patient is so severely ill that they lack capacity, a full discussion may not be initially possible, but can be conducted when their condition improves. Of note, there are various patient aids being developed to help with patient access to easily understandable information. Reference Shillington, Langenecker, Shelton, Foxworth, Allen and Rhodes 31

In complex cases, a multidisciplinary approach becomes important. On wards, nurses and support staff who often spend a lot of time with the patient may be able to help support them in understanding the information discussed, and pharmacists can assist with anticipating and advising on potential interactions in the context of polypharmacy. If more specialist advice is needed, a referral to a specialist centre for TRD, such as that run from the Maudsley Hospital, can be considered for a second opinion.

Given that TRD is a chronic condition, thought also needs to be given to how long to continue a treatment when it is successful. Guidance generally suggests that at least 6 months of post-recovery treatment is needed to reduce the risk of immediate relapse. Whether to continue to maintenance treatment to prevent recurrence is patient-specific. This decision will depend upon factors such as the number and severity of previous episodes, the likelihood of recurrence, the patient's wishes, comorbidity and whether there are any persistent depressive symptoms. Reference Gautam, Jain, Gautam, Vahia and Grover 32 These need to be balanced against the ongoing risks of the effective medication, which is particularly important in the elderly population, who are often subjected to polypharmacy.

How does this apply to our patient?

There are many different treatment options for TRD, and studies directly comparing them mostly show limited differences in efficacy. However, clinical experience demonstrates that efficacy of each treatment varies significantly in individual cases, but it remains difficult to predict individual responses. Therefore, the decision becomes patient-specific and depends upon many factors, e.g. current severity of symptoms and risk, comorbidities, patient preference and previous treatment successes or failures. To illustrate this, we return to the case outlined above. Box 1 also provides reflections from our patient and family co-authors on their experience of this disease.

Box 1 A patient and their family's experience of treatment-resistant depression (consent was given by both the patient and their wife for their contributions to be used).

From Mr Phillips: ‘I felt severely anxious and was very agitated with a great loss of confidence. Also, very irrational, I couldn't concentrate and catastrophized about everything. No amount of reassurance from my family helped. Yet, at times in hospital, I was completely lucid, feeling that I had no control of my life and felt very emasculated and inadequate. I also felt my reputation was being damaged by being sectioned’

From Mrs Phillips: ‘We were in complete despair, frightened and totally shocked to see such a change in him; no-one could believe that the man they once knew who was decisive and intelligent could have changed so drastically and suddenly … I have been so grateful to the ward team for all their care and attention, persevering to find the correct medication for him…Thank God for the NHS!’

The first steps in Mr F's assessment were a thorough history, collateral history, physical examination and blood tests. This informed an initial risk assessment that established the need for admission owing to suicide risk and self-neglect, a management plan that included continuous line-of-sight observation, food and fluid chart and a multidisciplinary team discussion of how to support him with eating and drinking. This was successful and, with support, he was able to maintain a safe oral intake, allowing time for the team to consider the other aspects of his previous treatment and why his depression had failed to respond to them.

His wife had administered his medication for the previous 3 months, with no missed doses or side-effects. He was given sertraline 150 mg for 7 weeks followed by venlafaxine 225 mg for 6 weeks, with no improvement. This ruled out non-adherence, inadequate doses or treatment length as reasons for the lack of response. He was on no other medication that could have caused an interaction and had a past medical history of well-treated, diet-controlled type 2 diabetes mellitus and chronic kidney disease stage 3, with an estimated glomerular filtration rate of 45 ml/min/1.73 m 2 . An initial physical assessment, including blood tests such as a full blood count, thyroid screen, haemoglobin A1C, fasting glucose and vitamin B12, were all normal. He had no other symptoms to suggest an unknown physical comorbidity. He retired 2 years before admission, but before he became unwell, he had been enjoying retirement and had remained busy redesigning their garden and co-running a local men's social group. His relationship with his wife was happy, with no children, and they had an ageing Labrador whom Mr F would take on daily walks. His wife reported no use of illicit drugs or alcohol.

Over the next several weeks, Mr F was monitored for signs of comorbid psychiatric disorders. There was no evidence of anxiety or psychosis, and a collateral history ruled out the presence of any residual dysthymia or emotional instability between episodes of depression. He was noted to be forgetful and found it difficult to concentrate on tasks such as reading the newspaper. Given his age, dementia was considered a possibility. However, these concerns had only been noted months after his low mood began, so it was initially felt likely that any cognitive symptoms were secondary to the affective disorder. This was confirmed when he was followed up after discharge, when repeat cognitive testing showed no residual deficits.

When completing this assessment, the team met with Mr F and his wife to discuss management options. The first step recommended was combination therapy of venlafaxine 225 mg (his medication on admission) and mirtazapine titrated up to 30 mg. This was based upon evidence showing its efficacy and that Mr F was struggling to sleep. The potential weight gain side-effect was felt to be likely beneficial given his poor appetite. Alongside this, Mr F agreed to meet with the ward psychologist for assessment. It was hoped that this might give him the opportunity to talk about his stockpile of pills and suicide note.

Other possible options considered included lithium or antipsychotic augmentation and ECT. Lithium was not chosen because of his history of chronic kidney disease stage 3. Although there is increasing debate around the potential safety of the use of lithium in chronic kidney disease, Reference Gupta and Khastgir 33 for Mr F it was felt that there were better initial alternatives. A second-generation antipsychotic was not chosen because of his diabetes. Finally, ECT was considered at this early stage because of the severity of his presentation and its efficacy during his previous admission. However, it was discounted as he was not yet in a life-threatening situation that would warrant its immediate use and his wife was concerned about the potential effect it would have on his memory. Given that both research and the patient's own history show how effective a treatment it can be, if his initial treatment plan had failed, ECT would likely have been the next step in management. In this instance, he responded to the supportive ward environment, which gave the team time to trial medication-based treatment, but this must be a decision that is tailored to each individual and their circumstances.

It is not uncommon for older adults to have received treatment for depression with tricyclics earlier in life. As the individual moves through life, the tricyclic may be switched to a newer antidepressant with a better safety profile, or stopped because of a lack of ongoing clinical need. However, if tricyclics were well-tolerated and effective, they can be revisited with due caution around potential cardiac side-effects and risks if used in overdose. Mr F had previously been treated successfully with amitriptyline. In this instance, it was not felt to be suitable because he was suffering from a significant postural blood pressure drop and the team were concerned that amitriptyline would exacerbate this and increase his risk of falls.

Mr F tolerated the combination therapy well and, after a period of initial reluctance, he engaged in CBT, where he talked about his suicidal thoughts and overwhelming feelings of guilt that as a retiree he was no longer contributing to society. Regular assessment including use of the Montgomery–Åsberg Depression Rating Scale showed slow but steady improvement. He began to eat and drink and to enjoy engaging in social activities on the ward. He was discharged home on venlafaxine and mirtazapine with regular follow-up and ongoing psychology with his original community mental health team.

This fictional case highlights the complexity of managing TRD with treatment tailored to specific patient characteristics and personal preference. Good management depends upon a thorough history and assessment with collateral taken from family, and a collaborative approach that includes the patient and their family. Decisions can be made easier by a ready understanding of the current literature and clinical guidance, combined with discussion with medical and multidisciplinary team colleagues. The case also highlights the issues of excluding comorbidities and other confounding diagnostic factors. There are several newer treatment options currently being developed that offer hope for the future of the treatment of what can be a life-changing but ultimately often treatable illness. However, much of the evidence base remains focused on younger adults and there is a need for further large studies looking specifically at the older adult population.

Emma Pope, BA, BMBCh, MRCPsych, is an ST4 Older Adult Psychiatric Trainee working with the South Devon Older Person's Mental Health Community Team at Devon Partnership NHS Trust, UK. Sabari Muthukrishnan, MBBS, DPM, MRCPsych, FHEA, is a Consultant Old Age Psychiatrist with Swindon inpatient services at Avon and Wiltshire Mental Health Partnership NHS Trust, UK; and Principal Investigator for a range of studies at Kingshill Research Centre, UK.

Supplementary material

Supplementary material is available online at https://doi.org/10.1192/bjb.2021.105 .

E.P. was primary author of text, researched for evidenced literature and coordinated the other authors. S.M. supervised and reviewed the text with alterations suggested, and liaised with J.P. and S.P. J.P. and S.P. provided a review of the text with suggestions of changes from a patient's perspective, and reflection on a patient's experience.

This research received no specific grant from any funding agency, commercial or not-for-profit sectors.

These are pseudonyms for a patient and his wife, who have contributed to the article as authors and with personal reflections but asked to remain anonymous.

Pope et al. supplementary material

Pope et al. supplementary material 1

Pope et al. supplementary material 2

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• Volume 46, Issue 6
• Emma Pope (a1) , Sabari Muthukrishnan (a2) (a3) , James Phillips (a1) and Sarah Phillips (a1)
• DOI: https://doi.org/10.1192/bjb.2021.105

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Patient Case Presentation

Figure 1.  Blue and silver stethoscope (Pixabay, N.D.)

Ms. S.W. is a 48-year-old white female who presented to an outpatient community mental health agency for evaluation of depressive symptoms. Over the past eight weeks she has experienced sad mood every day, which she describes as a feeling of hopelessness and emptiness. She also noticed other changes about herself, including decreased appetite, insomnia, fatigue, and poor ability to concentrate. The things that used to bring Ms. S.W. joy, such as gardening and listening to podcasts, are no longer bringing her the same happiness they used to. She became especially concerned as within the past two weeks she also started experiencing feelings of worthlessness, the perception that she is a burden to others, and fleeting thoughts of death/suicide.

Ms. S.W. acknowledges that she has numerous stressors in her life. She reports that her daughter’s grades have been steadily declining over the past two semesters and she is unsure if her daughter will be attending college anymore. Her relationship with her son is somewhat strained as she and his father are not on good terms and her son feels Ms. S.W. is at fault for this. She feels her career has been unfulfilling and though she’d like to go back to school, this isn’t possible given the family’s tight finances/the patient raising a family on a single income.

Ms. S.W. has experienced symptoms of depression previously, but she does not think the symptoms have ever been as severe as they are currently. She has taken antidepressants in the past and was generally adherent to them, but she believes that therapy was more helpful than the medications. She denies ever having history of manic or hypomanic episodes. She has been unable to connect to a mental health agency in several years due to lack of time and feeling that she could manage the symptoms on her own. She now feels that this is her last option and is looking for ongoing outpatient mental health treatment.

Past Medical History

• Hypertension, diagnosed at age 41

Past Surgical History

• Wisdom teeth extraction, age 22

Pertinent Family History

• Mother with history of Major Depressive Disorder, treated with antidepressants
• Maternal grandmother with history of Major Depressive Disorder, Generalized Anxiety Disorder
• Brother with history of suicide attempt and subsequent inpatient psychiatric hospitalization,
• Brother with history of Alcohol Use Disorder
• Father died from lung cancer (2012)

Pertinent Social History

• Works full-time as an enrollment specialist for Columbus City Schools since 2006
• Has two children, a daughter age 17 and a son age 14
• Divorced in 2015, currently single
• History of some emotional abuse and neglect from mother during childhood, otherwise denies history of trauma, including physical and sexual abuse
• Smoking 1/2 PPD of cigarettes
• Occasional alcohol use (approximately 1-2 glasses of wine 1-2 times weekly; patient had not had any alcohol consumption for the past year until two weeks ago)

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Leanne: A Case Study in Major Depressive Disorder, Recurrent

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3 Servicio Farmacia EOXI Lugo, 27003 Lugo, Spain; [email protected] (M.P.P.); [email protected] (A.d.l.I.C.)

Antonio de la Iglesia Cabezudo

Margarita echevarría canoura.

4 Sanitas Hospitales A Coruña, 15005 A Coruna, Spain; se.satinas@cairravehcem

David Facal

5 Departamento de Psicología Evolutiva y de la Educación, Universidade de Santiago de Compostela, 15782 Santiago de Compostela, Spain

Associated Data

The data presented in this study can be requested to the corresponding author. The data are not publicly available due to confidentiality and anonymity.

Depression is one of the most prevalent pathologies in older adults. Its diagnosis and treatment are complex due to different factors that intervene in its development and progression, including intercurrent organic diseases, perceptual deficits, use of drugs, and psycho-social conditions associated with the aging process. We present the case of a 75-year-old woman (who lives in the community) with a diagnosis of major depression with more than 10 years of history, analyzing her evolution and therapeutic approach.

1. Introduction

Depressive disorders are the most common psychiatric pathology in old adulthood. It is associated with various mental and biological stressors that affect the functional capacity and independence of old adults, reducing their quality of life. International studies show variable prevalences that range between 8.8% and 23.6% in Europe [ 1 , 2 ], could reach 60% in Latin America, and would exceed 38% in rural Asian populations. This geographical variability is due to methodological, clinical, and sociocultural differences. Recent studies in Spain inform that up to 36% of older people living in urban areas in the community suffer from depression [ 3 , 4 , 5 ]. Depression seems to be more frequent in the female sex. However, this observation could be biased because women present a greater longevity and/or a greater tendency to go to medical services than men, whereas men present a more severe somatic expression of psychiatric symptoms and/or a higher reluctance to express psychiatric symptoms than women [ 6 ].

Depressive symptoms include affective disorders such as sadness, apathy, emotional lability and crying, anhedonia, and nihilism; behavior modifications such as anxiety, irritability, insomnia, and hyporexia; and alterations in the course and content of thought, as well as cognitive and physical frailty. Among all the symptoms, autolytic ideation requires a specific comment, since depression is the main suicide risk factor in old age. Suicide constitutes one of the 10 main causes of death in the old adults, mainly in men aged 65 and over who use more lethal methods conditioned by loneliness and isolation [ 7 , 8 ]. In old populations, the etiology of depression is multifactorial: there are psychosocial causes derived from the aging process (family losses, work life, loneliness, environmental barriers, lack of resources, lack of social support) in addition to genetic and biological factors that contribute to the increase in frailty, geriatric syndromes, and dependency [ 9 , 10 ].

Its diagnosis is clinical, following the criteria included in the International Classification of Diseases (ICD-10) or the Diagnostic and Statistical Manual of Mental Disorders (DSM-5, APA 2014). In old adults, the diagnosis can be complex due to comorbidity and drugs that potentially induce psychiatric symptoms and iatrogenic complications, to adaptive disorders following age-related changes and/or to incipient cognitive impaiments. In any case, it can be an underdiagnosed disease due to circumstances related to its own nature, personality factors, and, also, because of the peculiarities of the healthcare systems [ 11 ].

To optimize its treatment, a transdisciplinary approach is required based on antidepressant drugs, such as selective serotonin reuptake inhibitors (SSRIs) or serotonin and norepinephrine reuptake inhibitors (SSNRIs), which have shown different therapeutic efficacy. It may also require, in many cases, mood stabilizers, anxiolytics, antipsychotics, tricyclic antidepressants (TCAs), or monoamine oxidase inhibitors (MAOIs) [ 12 , 13 , 14 ], plus psychosocial approaches (cognitive-behavioral psychotherapy, supportive psychotherapy), occupational techniques (re-education in activities of daily living, training in the use of technical aids), and physical training, which help to improve the prognosis and prevent relapses [ 15 ].

Within the different age-related conditions that can interfire with the diagnosis of depression in old age, Charles Bonnet syndrome is characterized by the presence of complex visual hallucinations, triggered by vision deprivation in the absence of neurological, psychiatric, and/or systemic disorders. The patient usually perceives the hallucinations as not real, which reduces anxiety, although the content, duration, and frequency are variable. Charles Bonnet syndrome can be associated with age-related entities such as enucleation, optic neuritis, diabetic retinopathy, macular degeneration, cataracts, and glaucoma, among others. Accordingly, its prevalence is relatively high in geriatric patients. In patients with major depression, a differential diagnosis with psychotic disorders is required [ 16 , 17 ].

The main objective of the study has been to facilitate deliberation on the frequent interrelation between organic pathologies, depressive symptomatology, and their overlap in time in old patients, as well as to present the heterodox therapeutic approach in this case, taking into account the complexity of the health care model of the Autonomous Community of Galicia (northwest Spain) and the patient’s therapeutic choices.

2.1. Personal History

A 75-year-old woman, who is right-handed, and a resident of the urban area of the province of A Coruña (Galicia, NW of Spain). She is married and has two children (one female and one male) and two male grandchildren. She lives with her husband (74 years old), who provides care support for the patient’s visual deficits. A medium education of schooling is possessed, along with an administrative profession and adequate social resources.

2.2. Ethical Standards

The study was conducted in accordance with the “Request for authorization for access and publication of health data as clinical case/case series” as provided in the General Data Protection Regulation (EU Regulation 2016/679 of the European Parliament and of the Council, 27 April 2016) and the Spanish regulations on personal data protection in force. Written informed consent was obtained from the participant. Due to visual deficits in the patient, the informed consent was read aloud and supervised by the caregiver.

2.3. Medical History

According to medical records, during this study the patient presented hypothyroidism, dyslipidemia, type II diabetes mellitus, macular degeneration, glaucoma, arterial hypertension, hypertensive heart disease, ChadsVasc4 persistent atrial fibrillation, extensive calcification of the mitral annulus, mild mitral regurgitation, moderate tricuspid regurgitation, lacunar stroke, vertigo, peripheral vascular disease, bronchial asthma, and acute bronchitis progressively diagnosed. The patient demonstrates no toxic habits.

The patient has been followed by the family medicine (FM) service of the center since the end of 2013, with the aim of carrying out a preventive approach, in coordination with doctors from other specialties such as cardiology, endocrinology, ophthalmology, neurology, and psychiatry.

In the initial clinical evaluation, previously diagnosed diseases were treated with levothyroxine sodium, Armolipid Plus, a nutraceutical based on berberine, red yeast, policosanols, coenzyme Q10, astaxanthin and folic acid, and Bimatoprost solution, to which clonazepam and duloxetine were added to treat anxiety-depression symptoms. The general physical examination showed no data of interest. A control analysis was requested, whose most significant results were glucose in serum/plasma 156 mg/dL, total cholesterol 300 mg/dL, HDL 48 mg/dL, LDL 232 mg/dL, TSH 0.93 mIU/L, and the need was emphasized for diet and physical exercise to adjust lipid levels, explaining that the patient ruled out lipid-lowering drug treatment due to fear of liver damage. The FM insisted on the convenience of carrying out a scheduled follow-up.

Between 2014 and 2018, the patient went to her FM and specialist doctors on different occasions to control her chronic diseases (mainly hypothyroidism, dyslipidaemia, Diabetes Mellitus, and Glaucoma). Acute diseases such as respiratory infection, viriasis, oral candidiasis, lump infectious breast, sciatica, or sacral-coccygeal trauma were successfully treated. She also received systematic immunization against the influenza virus. She underwent surgery for her visual pathology in 2016, with relative success and maintenance treatment consisting of Lutein, Bimatoprost, and Brinzolamide. Bronchial asthma with treated with Budesonide/Formoterol. Table 1 shows the main pharmacological treatment modifications made to date.

Evolutive drug adjustments.

Note: 2021-1 (February 2021). 2021-2 (October 2021). Boi-K: Potassium hydrogen carbonate 1001 mg and ascorbic acid 250 mg, with dose in mgs. c: capsule.

2.4. History of the Disease

The prevalent symptomatology referred to by the patient and her family throughout the depressive process consists of sadness, emotional lability and crying, low self-esteem, negativism, apathy, anxiety, insomnia, ruminant thinking, and occasional autolytic ideation. Regarding the loss of visual capacity and the secondary dependence to it, the diagnosis of glaucoma and macular degeneration has been subsequent to the onset of depressive symptoms.

Over the years, an evolution characterized by periods of emotional well-being with a significant reduction in symptoms and different relapses that required therapeutic adjustments has been observed. Monitoring of the depressive disorder is carried out by a psychiatrist outside the primary care center, who adjusts the psychotropic drugs periodically ( Table 1 ).

From a non-pharmacological perspective, she was treated in the center’s psychology department. Psychologists detected family problems, poor socialization, and a lack of acceptance of the disease with reactivity to support proposals, such as technical aids for ambulation or functional independence. She also attended therapeutic programs of the Spanish National Organization for the Blind (ONCE), where she currently receives supportive psychotherapy and participates in activities such as gymnastics and choir. Regarding physical activity, ONCE provides cardiorespiratory and muscular maintenance as well as psychomotor coordination training.

2.5. Supplementary Tests

The patient’s multiple pathologies and her evolution have required the performance of different complementary tests, the chronology and results of which are summarized in Table 2 and Table 3 . In August 2019, a routine electrocardiogram (ECG) was performed, showing atrial fibrillation (AF) at 120 bpm, initiating treatment with digoxin, diltiazen, and low molecular weight heparin (LMWH). Examined by the cardiology service, an echocardiogram was performed, which showed multiple valve disease, adjusting the treatment ( Table 1 ).

Control serum parameters.

Note: 2021-1 (February 2021). 2021-2 (October 2021). Parameters in mg/dl. Hgb A1c in %. Digoxinemia in nanograms/mL. niop: not included or provided.

Control cardiac and psychological paremeters.

Note: 2021-1 (February 2021). 2021-2 (October 2021). AF (Atrial Fiblilation). GADS: Goldberg Anxiety and Depression Scale. niop: not included or provided.

Assessed in August 2020, in neurology outpatient clinics in relation to a double episode of nocturnal disorientation, a cranial CT scan was requested that found a “small cerebellar hemorrhage” requiring hospitalization for neurological surveillance. Treatment with edobaxan is preventedly suspended due to its anticoagulant properties. A brain study is completed with MRI that does not clearly show the presence of hemorrhage, ruling out malformations or other lesions that cause bleeding. There was good evolution during the hospital stay. A control cranial CT scan was performed that showed a punctiform image in the right cerebellar hemisphere corresponding to calcification, so the patient was discharged and the edobaxan regimen was restarted.

During the COVID-19 pandemic, a SARS CoV-2 antigen screening was performed (November 2020) with a negative result.

2.6. Follow-Up during 2021

In December 2020, the patient went to the new FM service of the center showing a defective speech related to her visual difficulties, including a negativistic discourse with complaints as well as a nihilistic view of her circumstances and her future. She also maintained her heart disease, brain damage, anxiety-depressive symptoms, side effects of drug treatment, and secondary functional dependence. The clinical examination showed a temperature of 35.7 °C, heart rate of 70 bpm (atrial fibrillation), blood pressure of 150/75 mmHg, and O 2 saturation of 96%, resulting in normal physical and neurological examination. She reports complex visual hallucinations (people, animals, and objects) in the absence of cognitive impairment that appears to be Charles Bonnet syndrome.

During the months of January and June 2021, she attended four times for analytical control, assessment of the evolution and therapeutic adjustment (see Table 1 , Table 2 and Table 3 ), in coordination with her cardiologist and her psychiatrist. Different analytical parameters have been requested including hemogram, proteinogram, kidney function tests, and glomerular filtration. Hepatopancreatic, ionogram, markers of heart failure such as NT pro-BNP, iron metabolism, and anemias screening have shown data suggestive of normality.

The SARS-COVID-19 immunization is carried out between the months of March and April 2021.

In consultation with her FM and carried out in October 2021, the patient attends in the company of her husband; she is very cooperative, smiling, and showing emotional stability, with absence of parasuicidal ideation and Charles Bonnet syndrome, which she associates with increased physical activity and psychotherapeutic as well as to correct pharmacological control, despite the fact that anxiety levels remain high, referring to fear of loss of family support (the results are shown in Table 1 , Table 2 and Table 3 ).

3. Case Management from Family Medicine

Since it is a patient who lives in the community, the FM department of the health center has acted, coordinating the needs of monitoring of the different pathologies that she presents with the support of her family as a basic element of well-being. It is a classic FM strategy, implemented with the aim of achieving primary, secondary, and tertiary prevention.

4. Discussion

In the present case, the following areas of deliberation are raised: 1. Multifactorial etiology of the disease; 2. Diagnostic certainty; 3. Efficacy of psychopharmacological treatment; and 4. Role of the family in the patient’s care.

4.1. Multifactorial Etiology of the Disease

The main risk factors for depressive disorder in old adults have been frequently studied and include psychosocial circumstances of the aging process, personality factors, previous psychiatric pathology, intercurrent illnesses, and the interactions of associated treatments, although the level of influence of each factor is difficult to discriminate [ 18 , 19 ].

The present case could constitute a paradigm of the multicausality of depressive disorder in old adulthood, since, in a progressive and continuous way, several of the main factors associated with depressive symptoms that contribute to chronicity have been presented. In the psychosocial level, losses and grief, loneliness, environmental changes, and maladjustment stand out as potential etiological factors [ 20 ]. In this case, she is a person with a high cultural level, economic resources, comfortable habitat, and very stable social and family support. Regarding personality factors, some authors suggest that traits such as neuroticism increase the risk of presenting depressive symptoms in old adulthood [ 21 ]. It was not considered necessary to assess personality factors in a structured way, since an evolution of 10 years and the previous therapeutic approaches seem to be advisable, although it is true that the patient frequently refers to “a change in personality, from shyness to a certain disinhibition in the last years” associated with the general clinical picture that could be the result of antidepressant treatment. In the medical history, no references to previous psychiatric pathologies, consumption of toxic substances, or adjustment disorders were observed, with a stable work environment until her retirement.

Different studies associate metabolic diseases such as hypothyroidism and diabetes mellitus, or cardio and cerebrovascular disease, with an increased risk of suffering from depression, relating it to the multiple neuroimmunoendocrine changes in depressive patients. It has been observed that patients with depressive symptoms experience increased platelet activation that could predispose them to thromboembolic episodes. They also experience immune activation (NK cells and leukocytes) and hypercortisolemia, along with an increased adrenocorticotropic hormone (ACTH) and ACTH-releasing factor. In addition, they experience decreased insulin resistance, increased endogenous production of steroids, and the release of catecholamines, associated with an increase in arterial pressure and coronary vasoconstriction. Moreover, depressive symptoms constitute a poor prognostic factor in cardiovascular and metabolic diseases [ 22 , 23 , 24 , 25 ]. In this case, the protocol-based examinations showed no alteration justifying the role of physical factors in the depressive simptomatology. On the other hand, the polypharmacy used to control these diseases constitutes a known precipitating factor of depressive symptoms in old adults. Thus, drugs such as digoxin, diuretics, oral antidiabetics, and antihypertensives have been frequently associated with a greater risk of depression in these populations [ 26 ]. We cannot determine the level of influence of these drugs on the prognosis, but we can consider that their interactions with antidepressant drugs could make remission of the depressive symptomatology difficult.

In the clinical evolution of the patient, we consider the loss of vision to be key in the chronification of depressive symptoms due to the psychological repercussions as a factor of anxiety, insecurity, and fear; the functional repercussions for the instrumental and basic activities of daily life that limit self-care and potentiate iatrogenic risks; and the social repercussions related to leisure activities and increased consumption of resources, all of which favor frailty and limit self-perception of health status.

On the other hand, we consider the presence of a Charles Bonnet syndrome characterized by hallucinations to be of interest, which are commonly perceived as real by the patients and are related to visual deficits. Although the underlying mechanism is not well understood, it seems to be related to a brain’s continuous adjustment to significant vision loss. Old adults affected with Charlet Bonnet syndrome can avoid reporting to their doctor because of fear that the hallucinations could be related to a severe mental disorder. The clinical management consists of health education, explaining to the patient the nature of the disorder, the prevalent symptomatology, making them aware of the symptoms, and explaining that it is part of their visual deficit and not relevant to their depressive symptomatology. Eventually, pharmacological treatment with neuroleptics, benzodiazepines, antidepressants, and antiepileptics is required [ 16 , 17 ].

4.2. Diagnosis of Depression

As a complex diagnosis, major depression in old age involves assessing cognitive functions, behaviors, and the impact of any affective disorder on the functional capacity and quality of life of the patient. Following the DSM-5 criteria [ 11 ] facilitates the discrimination between a depressive disorder and a mixed adjustment disorder that could be better explained according to the current situation of the process. For the diagnosis of major depressive disorder, the criterion of temporality greater than two weeks, the presence of a depressed mood most of the day, and anhedonia, or a marked decrease in interest or a displeasure in almost all activities, are included; in addition, the presence of at least five additional symptoms are included, such as insomnia, hyporexia, loss of energy, inappropriate feelings of guilt and worthlessness, and self-destructive ideation, among others. In the case of mixed adjustment disorder, the diagnostic criteria include five groups (A–E), so that the anxiety-depressive symptoms occur in response to an identifiable stressor or factors that occur in the following three months. At the beginning of the stressor (A), the symptoms are clinically relevant with an intense and disproportionate discomfort in relation to the intensity of the stressor, generating a significant deterioration of social functioning or of other areas (B), other mental disorders are excluded (C), the symptoms do not represent a normal grief (D), and once the stressful event or its consequences have ended, the symptoms do not persist for more than another six months (E). In the case reported, it is not possible to fulfill criterion E because the most significant stress factors, those that generate the most discomfort and maladjustment, have become chronic so their resolution is not possible. Structured cognitive assessment has not been carried out because of the absence of progressive decline.

4.3. Efficacy of the Psychopharmacological Treatment

As has been reported, the pharmacological approach in this case is highly complex. Until the advent of SSRIs, the treatments of choice were TCA and tetracyclic (ATTC) antidepressants, but the potential induction of anticholinergic effects can cause cardiovascular alterations (orthostatic hypotension, arrhythmias, electrocardiographic alterations), changes in intestinal motility (constipation, paralytic ileus), urinary retention, and pupillary dilatation, among others, discouraging their use. Currently, SSRIs and SSNRIs are the dominant pharmacological approaches for depression in old adults, motivated by their ease of use, versatility, efficacy, and safety, in addition to their cost-effectiveness.

SSRIs (fluoxetine, fluvoxamine, paroxetine, sertraline, citalopram, escitalopram) work by blocking the reuptake of serotonin (5-HT) through inhibition of the adenosine triphosphatase (ATPase)-dependent sodium/potassium transporter (NA+/K+) in presynaptic neurons. With some differences between them, they have effects on other neurotransmission systems such as noradrenergic or dopaminergic. They are metabolized by liver enzymes, especially cytochrome P450 2D6, and have different pharmacokinetic characteristics. The main indication is major depression, although they are also useful in conditions such as obsessive-compulsive disorder or anxiety disorders. The most frequent side effects are gastrointestinal (nausea, burning, diarrhea), related to intestinal 5-HT receptors, which are minimized with a staggered dosage of medication. A variable percentage of patients treated with SSRIs manifest a sensation of activation of the central nervous system with agitation, nervousness, and insomnia that usually responds to moderate doses of benzodiazepines, such as alprazolam, lorazepam, or clonazepam. In general, they present a moderate risk of pharmacological interactions, and they are very safe drugs, as studies of lethal overdose show [ 27 , 28 , 29 , 30 , 31 , 32 ].

SSNRIs, such as duloxetine and venlafaxine, are a second group of drugs especially useful in the treatment of depression in old adulthood. SSNRIs may have a faster onset of action than other antidepressants by modulation of beta-adrenergic receptors. Duloxetine is a potent 5-HT and norepinephrine reuptake inhibitor with low affinity for muscarinic or histamine receptors, whereas venlafaxine shares 5-HT reuptake potency with moderate effects on norepinephrine reuptake and few effects on other neurotransmission systems. In addition, they present a low risk of pharmacokinetic interactions due to low potency in the inhibition of liver enzymes of cytochrome P450, a factor that facilitates their use. The FDA indications for this group of drugs are major depression, generalized anxiety disorder, and social anxiety disorder. Since they have a mechanism of action similar to that of tricyclic antidepressants, SSNRIs have shown their usefulness in some pain disorders, which makes them especially useful in older patients and in depression associated with neuropathic comorbidity. They share some of the gastrointestinal side effects with SSRIs, however, they differ from these in the moderate risk of increased blood pressure, somewhat less frequently in prolonged-release venlafaxine, which requires periodic monitoring in the first months of treatment and is solved by adjusting the dose. Other side effects described are syncope, ortostatic hypotension, and anticholinergic symptoms, such as dry mouth, urinary retention, and constipation, which in old patients must be monitored. Exceptional cases of fatal overdose have been described. Its level of efficacy compared to SSRIs seems somewhat higher, even though the data are discrepant [ 33 , 34 , 35 , 36 , 37 , 38 ].

In recent years, the approval of mirtazapine for the treatment of depression has led to its frequent use in old adults. It is an antagonist of alpha 2-adrenergic receptors that acts by increasing the release of norepinephrine that achieves a rapid increase in 5-HT levels, achieving modulation of the serotonergic system. Mirtazapine is metabolized through cytochrome P450 enzymes without being an inducer or inhibitor of these enzymes, so there are no interactions with other psychotropic agents, which facilitates the combination. Its main indication is major depression, used alone or in association with SSRIs/SSNRIs. Compared with paroxetine, it showed a faster response and fewer dropouts associated with adverse effects. Among the most frequent side effects are drowsiness (which advises its use at night) and increased appetite and weight. Furthermore, it seems to increase the levels of cholesterol and triglycerides secondarily, which, associated with its potential cardiovascular effect, makes it necessary to monitor blood pressure [ 39 , 40 , 41 ].

The therapeutic strategy is of great interest in this case. Since it is a highly complex case, the management of psychotropic drugs had to be careful, requiring consideration not only of the efficacy and probability of remission, but also of the minimization of secondary organic complications, to guarantee safety. In addition, the progressive appearance of comorbid, cardio, and cerebrovascular factors has required pharmacological adjustment. The potential interactions of the treatment must be considered, with the aim being its optimization. We consider the combined use of venlafaxine and mirtazapine to be successful due to its efficacy and safety, as evidenced by the adequate adherence of the patient to treatment and medical controls. In the case of duloxetine, its potential modification of blood pressure levels could question its use in this case [ 42 ]. The Goldberg Anxiety and Depression Scale (GADS) carried out in October 2021 suggests a remission of depressive symptoms and an improvement in the patient’s attitude. However, based on the results of the interview and the GADS (A7/D0), the use of benzodiazepines to control anxiety and insomnia symptoms does not seem clear.

4.4. Role of the Family in the Patient’s Care

This case presents many of the specific challenges in managing geriatric patients in the Galician health care model (northwest Spain). The guarantee of citizens’ health rights has been defined in the Spanish constitution since 1978. However, in 2002 there was a decentralization of competences in different areas, including health, according to the Law of Cohesion and Quality of the National Health System, which established a framework in the 17 autonomous communities of the Spanish State, but with peculiarities according to each territory. Regardless of this framework, the citizens, using their freedom, choose in each health situation whether to be treated in the public health system (in Galicia, the Servicio Galego de Saúde, or SERGAS) or in the free market system (private clinical services companies and/or consultations by private professionals), or both. The reality is that this mixed system can condition the efficiency of geriatric and psychiatric interventions in complex cases, hindering actions from primary health care because decision-making is dispersed. In this context, relevant information for therapeutic optimization is frequently lost.

The socioeconomic context of the patient allows clinical follow-up with good health resources, within a dual system (private and public) that contributes to effective health care, although its efficiency is limited by the heterogeneity of clinical opinions. As it has been mentioned above, the health care model in Galicia is based on a public, universal system in coexistence with private companies and entities of the social sector that provide health and care services, in addition to freelance professionals in health areas such as ophthalmology, psychiatry, internal medicine, or psychology, among many others. Between 2020 and 2021, the COVID-19 pandemic has required the adoption of restrictive measures in terms of prevention and mobility attitudes that seem to increase the incidence of psychiatric pathology in old populations [ 43 , 44 ], although in this case it does not seem to have conditioned the evolution of the patient.

We believe that a more intensive non-pharmacological approach would contribute to improving the prognosis; specifically, it would reduce anxiety-type symptoms and achieve a more objective self-perception of health. It would be an area for improvement using some of the usual techniques in similar cases, from cognitive behavioral to supportive or family therapy. In recent years, third generation behavioral therapies seem to contribute to intervention in psychogeriatrics. These include Acceptance and Commitment Therapy, Dialectical Behavioral Therapy, Mindfulness-Based Therapy, Behavioral Activation Therapy, Integral Behavioral Couple Therapy, or Functional Analytical Psychotherapy, which share an integrative vision of the psychological problems of old patients, considering their functional structure relevant, that is, the psychological functions of maladaptive behaviors in the context in which they occur [ 45 ]. These types of approaches may probably contribute to improve the quality of life and the health perception of the patient.

The evolution of the depressive disorder is linked to the role that her husband plays in psychological care and functional support for her activities of daily living. The long duration of the disease and the appearance of associated pathologies increase the intensity of care. The parallel aging of the husband and the incidence of medical and psychological problems could contribute to a potential claudication or the development of caregiver burnout [ 46 , 47 ].

5. Conclusions

The present work discusses the complexity of the diagnosis and treatment of depression in the geriatric patient. It is illustrated with the case of a patient (a 75-year-old woman) with depressive symptomatology with more than 10 years of evolution, also affected by different concomitant organic pathologies including visual deficits and Charles Bonnet syndrome. The interventions of different medical specialties are shown, and some psychopharmacological treatment options are discussed. The interactions of the different pharmacological treatments and the mixed care approaches are considered, with the aims of improving the case management and maximizing the quality of life of the patient in this type of complex clinical condition. The complexity of the healthcare system in Galicia (northwest Spain) and how difficult it is to handle complex geriatric cases in this context are discussed. In this regard, the most relevant limitation of this case in the lack of a specific approach, substituted for this patient by a mixed care model. Other limitations include the lack of a personality assessment using psychometrically valid tests, the lack of an explicit frailty assessment beyond the clinical observation of an increased bio-psycho-social vulnerability, and the lack of an objective assessment of the caregiver burden.

Author Contributions

J.C.-P. and M.G.D. conceived and designed the case report; J.C.-P., M.G.D., M.P.P., A.d.l.I.C. and M.E.C. collected the data and prepared the case report; D.F. critically reviewed the case report and prepared contributions regarding depression disorders and psycho-social care. All authors reviewed and revised the manuscript. All authors have read and agreed to the published version of the manuscript.

This research received no external funding.

Institutional Review Board Statement

This study was conducted in accordance with the Declaration of Helsinki. As a single case report, ethical review and approval was not applicable.

Informed Consent Statement

Informed consent, following the recommendation of the Galician Clinical Research Ethics Committee, was obtained from the participant.

Data Availability Statement

Conflicts of interest.

All authors declare no conflict of interest.

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