Tough, Multidisordered Case

My patient has a long history of recurrent major depressions with paranoid ideations that sometimes persist interepisode. His symptoms have hypomanic qualities at times, but are not true mania. He is also a compulsive overeater, experiences panic and has sexuality identity concerns. He is now going through a divorce, which has furthered his binge eating and compulsive computer usage. He has a good support system of friends, but has become increasingly isolated. What would you recommend for this patient? Is there any precedent for legal action for what seems to have been malpractice by a previous therapist, who never gave this patient meds to treat his disorders and used “reparative therapy” to correct his sexual preferences?

I appreciate the detailed history on what is clearly a very complex and difficult case – and, as you suggest, one which may not have been handled well by the previous psychiatrist. It seems to me that we should first separate the clinical issues from the legal ones and try to identify a set of prominent target symptoms. Then, I would try to identify pharmacologic and/or psychosocial strategies that might ameliorate these symptoms, ideally, without exacerbating the patient’s weight problem. Some of what you describe suggests the diagnosis of schizoaffective disorder; the treatment of which is rather poorly defined.

However, even though you note paranoid ideation, you don’t seem to stress this as part of the current symptom picture. Rather, the main target symptoms seem to be refractory depression; fatigue; poor concentration; suicidal ideation; and compulsive behaviors, all in the context of sexual identity and marital issues. The regimen of fluoxetine, alprazolam, methylphenidate and thyroxine seems to have been only partially effective. So, what to do?

You didn’t specify which other antidepressants have been used, so I can only offer what makes sense to me. Frankly, I think the situation is serious enough to warrant consideration of ECT; I say this knowing full well that the patient, and perhaps you, may not favor ECT at this time. And yet, it is clearly the most effective treatment we have for severe, refractory depression complicated by psychotic features. Given that this individual has had recurrent major depressions with psychotic features, I would also consider maintenance ECT (MECT). But let’s assume that you (and the patient) want to consider other options.

Should Cytomel (T3) be added? There is very little in the literature about combined T3 and T4 treatment of depression, though some clinicians insist that this combination is superior to either hormone alone. (I have never used the two together.) Adding Cytomel is a relatively low-risk option, except in so far as the patient’s hypomanic history is concerned. There is evidence that thyroid hormone(s) in the absence of a mood stabilizer can worsen manic symptoms in bipolar patients and this could also be true in schizoaffective patients.

Unfortunately, all the conventional mood stabilizers – lithium, valproate and carbamazepine – do have weight gain associated with them, though carbamazepine (CBZ) is probably the least likely of the three to promote weight gain. Much depends on how clearly this patient fits into the bipolar spectrum (e.g., does he have a strong family history of bipolarity?); so far, though, I gather he hasn’t become manic, despite the use of Ritalin and Prozac, without a mood stabilizer.

Assuming that he has a low risk of switching into mania, I would probably first try increasing the thyroxine to as high as 0.1 mg per day; unfortunately, it may take several weeks before you will see a response, if you do. Some clinicians go as high as 0.3 mg per day, in rapidly cycling bipolar patients maintained on mood stabilizers. However, without a mood stabilizer, I’d be hesitant to push it that high.

Again, assuming that you do not see him primarily as bipolar, I would consider increasing either the Prozac, the Ritalin or both, prior to adding new agents. In essence, push up what you are already using, rather than adding new agents. Other options (which you may have tried already) include augmentation with bupropion (good in bipolars, but may exacerbate psychosis in some patients), venlafaxine, a tricyclic (obviously a risk if he is suicidal) or mirtazepine. Unfortunately, mirtazepine (Remeron) often promotes weight gain.

You could also abandon the Prozac and try a different SSRI or go to an MAOI (but this would require a five week wash out, and it doesn’t sound like things can wait that long). Since serotonergic agents are thought to reduce binge eating and compulsive behaviors, I’d try to maintain some kind of serotonergic component to his treatment (e.g., fluvoxamine). Now, if this patient is in the bipolar spectrum (I think obtaining a history of his moods from family or spouse may be helpful in deciding), I might suggest a trial on either gabapentin (Neurontin) or lamotrigine (Lamictal). Neither is strongly associated with weight gain; Neurontin is much more user-friendly and has few drug-drug interactions. A good review of these agents is found in the June 1997, Biological Therapies in Psychiatry Newsletter.

Some bipolar patients may become manic with gabapentin or lamotrigine and a more conservative choice might be Tegretol. (Note CBZ may reduce alprazolam levels). Of course, ECT would be effective whether the patient is uni- or bipolar. I would certainly consider trials on the newer, atypical antipsychotic agents, such as risperidone and olanzapine. Clozapine has also been useful in this type of patient, but is very likely to promote weight gain.

With respect to psychosocial interventions, I wonder if a support group (e.g., for men with sexual identity issues) could be helpful in this case. With respect to the binge eating, cognitive-behavioral therapy has been found useful (see supplement to Psychiatric Times, October 1995; or contact Marsha Marcus, Ph.D., at the University of Pittsburgh School of Medicine and Western Psychiatric Institute – she is an expert on this disorder).

Finally, as to the legal issues related to the previous psychiatrist, you have probably heard of the famous (or infamous) Osheroff vs. Chestnut Lodge case. This case involved the claim that Chestnut Lodge had not provided pharmacotherapy for a man who suffered from a major depressive disorder (who was instead treated only with psychotherapy). The case was eventually settled out of court, in the plaintiff’s favor, establishing a general expectation of adequate and appropriate care. Though I can’t see much practical value of a suit in the case of your patient, you may want to explore these issues further. Good luck with this difficult case!