Case Study:

Eve is a thirty-two-year-old woman who comes to the therapist for treatment of depression. Her current symptoms include the following: depressed mood, apathy, anhedonia, hypersomnia, significant daytime fatigue, suicidal ideations, and low frustration tolerance. She has experienced five prior episodes of depression. The symptom picture was much the same during each episode, though in this most recent episode she reports that her suicidal thoughts have increased. She also is increasingly pessimistic about psychiatric treatment being helpful for her.

Eve's first episode occurred at the age of twenty-one and the second at age twenty-five. During these first two episodes of depression, each of which lasted approximately eight to nine months, she was functional but seriously depressed. She did not seek treatment; apparently in both cases she eventually experienced spontaneous remissions. In the next episode (her third, at age 27), she did see a psychotherapist and reports that it was somewhat helpful, but the treatment (psychotherapy alone) did not resolve her depression. Again she eventually recovered after twelve months. Again, it was likely a spontaneous remission.

Episode number four (age 29): Eve was treated by her primary care physician with Zoloft. She started this medication at a dose of 50 mg qd and she did tolerate it. After one month on this dose the dose was increased at first to 100 mg and then to 150 mg. After 3 months during which she did not show any improvement she was switched to Wellbutrin. Again she started with a low dose and was eventually increased to a dose of 300 mg qd. On both the Zoloft and the Wellbutrin, there was no significant improvement, but she remembers that she did experience increased irritability. Since the medication was not effective, she simply stopped taking it (four months into treatment). Eve continued to be depressed but somehow tolerated it and never talked to her doctor about it again. By twelve months her depression lifted.

Episode number five (age 30): This time Eve saw a psychiatrist and was tried on a number of different drugs: Effexor (up to 300 mg); Wellbutrin added to Effexor (doses in the therapeutic range). On Wellbutrin and Effexor she showed a 10% reduction in symptoms on the Hamilton Depression Rating Scale, but her slight improvement was accompanied by increased irritability, and that was the reason she stopped this medication combination after six weeks. The next medication she was prescribed was Remeron (which she stopped after five days due to excessive daytime sedation). Next she was tried on Effexor and lithium (she discontinued the lithium after three weeks due to sedation and nausea). Before stopping she had attained a blood level of 0.6 and no noticeable improvement. Finally, she was prescribed Cymbalta; again, not successful. Her psychiatrist diagnosed her as having treatment-resistant major depression without psychotic symptoms.

She now seeks treatment for her sixth episode of depression, which began three months ago and has gotten increasingly more severe. Eve denies any history of psychotic symptoms, mania or hypomania, suicide attempts, or significant abuse of alcohol or other recreational drugs. She does drink four cups of coffee a day, attempting to stay alert and combat her constant fatigue. She takes a low dose of Inderal to treat a "mild case of hypertension." She was started on this medication about three months prior to her current episode of depression. She says that she has no other medical problems.

In her first episode the break-up of a romantic relationship seems to have triggered the depressive episode. This was the case again in her second episode. However, in all later episodes there were no noticeable psychosocial stressors occurring prior to the depression. The depressions seemed to "come out of the blue." She is currently married, in a stable and supportive relationship with her husband, and works as a university librarian.

Family history is significant. Her maternal grandmother (someone she never met) had had a number of psychiatric hospitalizations and she killed herself when she was twenty-nine years old. One cousin has had a "nervous breakdown."Eve does not know any details about this. A great aunt was a severe alcoholic, and mother suffers from moderately severe chronic depression.

Eve says that now she feels desperate and is plagued by recurring and intense suicidal impulses.

1. Make a diagnosis (and mention possible diagnoses/diagnoses to rule out), and explain the rationale for the diagnosis. What are the points in favor of a bipolar II diagnosis? What might account for the failure to respond to any of the prior treatments?
2. Given the diagnosis you have made, describe your medication treatment strategies. Discuss not only initial choices of medications but also your next-step strategy and why you've chosen it. (In doing so, be sure to provide a rationale for your choices.) What questions should be addressed about the class of medications that is chosen (e.g., mood stabilizers)?
3. Include a brief discussion of how you will integrate legal and ethical considerations of diagnosis, treatment, and consultation with medical professionals in light of the role and activities of the DEA.