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Case Reports
 
A Case of “Double” Depression Under Outpatient Treatment Conditions
Leszek Tomasz Ros
 
The author has encountered in his professional practice the coexistence of “major depression” with psychic depressive attacks (dysthymic attacks) of the so called temporal epilepsy. Apart from major depression of medium intensity, other manifestations developed. These were, independent of the time of the day, suddenly occurring within several seconds, developing without any cause, attacks of very strong dejection, sadness, breakdown, feeling of lacking sense and hopelessness of life with slight obnubilation of consciousness and strong groundless fear. Detailed psychiatric examinations, observations of the patient during such attacks and EEG records confirmed the diagnosis of dysthymic attacks of temporal epilepsy. The author has treated the patient with sertraline starting from low doses, up to 100 mg daily - administered orally once daily in morning hours, clonazepam (Rivotril) in oral doses 1 mg in morning hours, 1 mg during lunchtime, 2 mg in evening hours, carbamazepine (Tegretol) 0.2 g tablets from low doses to 0.4 mg administered once daily in evening hours. Complete remission of major depression and complete regression of dysthymic attacks of “temporal epilepsy” were obtained.
 
Introduction

The concept of “double” depression was used here by the author conventionally. Sometimes the author has encountered in his professional practice the coexistence of “major depression” with psychic depressive attacks (dysthymic attacks) of the so called temporal epilepsy. Dysthymic attacks occur without convulsions and loss of consciousness. Sometimes they are accompanied by slight obnubilation of consciousness occurring without autopsychic and allopsychic orientation disturbances. The treatment in such cases is a rather difficult problem for the doctor, since completely different pharmacotherapy is used in “major depression” than in dysthymic attacks of “temporal epilepsy”. In treating a patient, the doctor should consider in detail what interactions between administered drugs could develop. Besides that, it should be kept in mind that typical tricyclic antidepressants still very useful in the treatment of major depression can even trigger dysthymic attacks of “temporal epilepsy”. Therefore, treating major depression, one should administer drugs that are safe, well tolerated and not entering into interactions with pharmaceuticals used in dysthymic attacks of temporal epilpsy. The same criteria should be accepted in selecting drugs for treatment of dysthymic attacks of temporal epilepsy.
 
Case Report
Female patient SA aged 39 never received any psychiatric treatment. The patient was born after normal pregnancy but by forceps delivery. In spite of that, during labour the head of the patient was not damaged so immediately after delivery she obtained 10 pts in Apgar scale. Her childhood was very succesful. Her mother was warm, quiet, very affective, caring and hard working. The father was quiet, very hard working, very caring about home and family, extremely responsible, affective, without addictions. The patient has one sister, two years older. The sister is quiet, well brought up, but sometimes peremptory, despotic, not tolerating objection, entering into conflicts, self-assured, slightly conceited. Despite that, the patient has constantly good familial relations with her sister. Both parents unfortunately are dead. The mother died suddenly of lung oedema in the course of acute left ventricular failure. The father died of lung cancer with multiple metastases to other organs. The patient got married at the age of 24. Her marriage has been good. In primary and secondary schoolsshe achieved very good results. Then she graduated from the Faculty of Polish Philology at the University where she achieved good results. Apart from death of her parents, the most terrible experience in her life was death of her first baby, one hour after labour. Then she gave birth to another child who lives and causes no major health or upbringing problems. No mental diseases occurred in the patient’s family. She denied any head trauma and loss of consciousness. She gave no history of major somatic diseases. The manifestations of major depression and depressive dysthymic attacks began simultaneously five months before starting treatment by the author. She used to work as teacher in primary school. Her job has been her passion. The disease started with extreme reluctance to her occupational work. Formal and emotional contacts were very good. Logical, normal current of thoughts, constant mood depression of medium intensity. Constant groundless anxiety. General feeling of helplessness - she had constantly a feeling intensity. Constant groundless anxiety. General feeling of helplessness - she had constantly a feeling that she could not cope with her occupational and home duties. Constant psychic stress, restlessness and psychomotor agitation. Strong fears that something tragic could happen to the health of a child during her lessons. Similarly panic fear that her own child would die of a sudden disease or due to traffic accident. Lack of appetite, insomnia of early awakening in the morning with impossible falling asleep again. She was weeping frequently. She was feeling worse than others and deserving contempt and condemnation. The patient denied other depressive delusions. She reported worst general feeling in morning hours, slightly better during day an best in evening hours. Feeling of lack of sense and hopelessness of life of medium intensity. She denied any suicidal ideation. Apart from major depression of medium intensity, the diagnosis of which was confirmed by detailed psychiatric examination, tests by Hamilton scale, Montgomery - Asberg scale, Beck’s Depression Self - assessment Inventory, ICD-10 scale and DSM III and DSM IV scales, other manifestations developed. These were, independent of the time of the day, suddenly occurring within several seconds, developing without any cause, attacks of very strong dejection, sadness, breakdown, feeling of lacking sense and hopelessness of life with slight obnubilation of consciousness and strong groundless fear. The above mentioned attacks occurred 2-3 times a week on the average and lasted for several minutes to several hours. They produced extremely strong sufferings for the patients and were just unbearable. Detailed psychiatric examinations, observations of the patient during such attacks and EEG records confirmed the diagnosis of dysthymic attacks of temporal epilepsy.

Laboratory tests : -Basic laboratory blood and urine analyses gave normal results

-Chest radiogram was normal,

-ECG record was normal,

-EEG record at the beginning of the treatment : Record with predominating irregular alpha wave activity of 35 µV amplitude. Besided that, series of beta waves were visible. Against this background in both temporal regions many times developed short series of waves of sharp shape, and sometimes 5.5 - 7 Hz theta waves with sharp waves of amplitude up to 50 µV with a tendency to generalized synchronization. Arrest reaction - marked. Hyperventilation - unchanged. Opinion : record with moderately intense pathological changes in both temporal regions. EEG record after one-year treatment. In the record rapid activity predominated of 20-40 µV amplitude (probably drug-induced). In posterior parts of the brain groups of alpha waves occur, of 10-12 HZ frequency and 40-60 µV amplitude. In both temporal regions isolated theta waves occur. Arrest reaction - marked.

Hyperventilation - without influence on the record. Photostimulation - causes following rhythm. Opinion : record normal.

-eye fundus examination: normal,

-neurological examination: no focal and meningeal symptoms,

-physical examination was normal,

-cranial computed tomography : normal

The author has treated the patient with sertraline starting from low doses, up to 100 mg daily - administered orally once daily in morning hours, clonazepam (Rivotril) in oral doses 1 mg in morning hours, 1 mg during lunchtime, 2 mg in evening hours, carbamazepine (Tegretol) 0.2 g tablets from low doses to 0.4 mg administered once daily in evening hours. Complete remission of major depression and complete regression of dysthymic attacks of “temporal epilepsy” were obtained.
 
Discussion
The author selecting sertraline for treatment of major depression as typical selective central serotonin reuptake inhibitor took many factors into account. Sertraline is a very safe, well tolerated and effective drug in the treatment of endogenous depression.1-13 Many authors believe14 that initial 50 mg sertraline daily dose is usually an effective therapeutic dose and simultaneously an optimal dose in the treatment of major depression, taking into account both effectiveness and tolerance in the case of most patients. These authors14 think that in the case of absent appropriate reaction during 24 days, sertraline dose can be increased at one-week intervals by 50 mg daily up to 200 mg daily dose. These authors14 believe that sertraline should be administered most frequently once daily and the hour of the day is without importance. The author of this paper administered the drug once daily. The drug was given always in morning hours in order that the interval between sertraline and carbamazepine administration was longest possible (carbamazepine was administered always once daily in evening hours) to avoid unnecessary interactions between these drugs. Very few authors15 report extrapyramidal adverse effects connected with sertraline administration. A review of literature15 made possible to identify 13 published cases of extrapyramidal symptoms induction by sertraline. In the patient treated and described above, slight extrapyramidal manifestations developed after sertraline. They were quickly controlled by Rivotril which was administered by the author of the paper in order to treat dysthymic attacks of temporal epilepsy and correction of fear in major depression. Carbamazepine given by the author for treatment of dysthymic attacks of temporal epilepsy exerted no adverse effects.
 
References
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