Major Depressive Disorder (MDD)
Virtual clinic

Max is a 25-year-old man who works in mid-level management at a successful marketing firm.

Max was diagnosed with a mild major depressive episode (MDE) three years ago when he presented to his general practitioner (GP) with depressed mood, insomnia, fatigue, diminished ability to think or concentrate, and persistent feelings of worthlessness. He reported that his symptoms began after he unexpectedly lost his job. At that time, his GP administered the Patient Health Questionnaire-9 (PHQ-9). Max’s score was 9, indicating mild depression severity.1 After ruling out somatic illness that might cause depressive symptoms and investigating possible psychosocial stressors, the physician suggested that Max undergo 12 sessions of cognitive behavioural therapy (CBT). After treatment, the only symptom was mild depressed mood some days (PHQ-9 score of 1), indicating clinical remission of the MDE.

One year ago, Max again presented to his GP with depressed mood, anhedonia, insomnia, fatigue, diminished ability to think or concentrate, and persistent feelings of worthlessness. These symptoms had been present for 12 months without improvement despite Max re-initiating CBT with his earlier therapist. The therapist suggested that Max consider pharmacologic treatment because he was having extreme difficulties with his job and was on probation at work. At that time, Max’s score on the PHQ-9 was 21, indicating a severe MDE. He told his GP that he found it increasingly difficult to complete tasks at work and at home, and he reported being uninterested in and too fatigued to socialise or pursue hobbies. He also reported experiencing panic attacks several times per month for the past two months.

The physician asked Max about his psychosocial situation, and Max could not think of any triggering situation or factor for his depression and panic attacks. Max reported being in a stable, long-term relationship that he found supportive. His employment situation was steady, and there were no unusual psychosocial stressors present. Again, the physician investigated possible somatic causes of depressive symptoms and panic attacks but found nothing remarkable. The physician diagnosed major depressive disorder (MDD) and panic disorder, and he suggested that Max continue CBT and begin treatment with a selective serotonin reuptake inhibitor (SSRI). Max agreed.

After four weeks of treatment at the lowest recommended dose, Max continued to experience a severe MDE with a PHQ-9 score of 22. He continued to experience panic attacks. The physician discussed adherence and possible side effects with Max. He noted that he had some mild nausea and diarrhoea, but that these had improved over time. Max confirmed that he was taking his medication as prescribed. The physician optimised the dose of the SSRI to the maximum recommended dose; however, at Week 8 of treatment, there was no response.

Given the lack of response, the GP suggested switching from the SSRI to a serotonin-norepinephrine reuptake inhibitor (SNRI) using a cross-tapering strategy. Max agreed. After the cross taper was completed, Max reported that he experienced fatigue and nausea, but that these were manageable. After four weeks of treatment at the standard dose of the SNRI, Max’s PHQ-9 score was 21, indicating a continued severe MDE and no response to the SNRI. The physician optimised the dose of the SNRI to the maximum recommended dose. After four additional weeks of treatment at the maximum recommended dose, there was no response (PHQ-9 score of 21) and Max continued to experience panic attacks.

Given that Max’s MDD has failed to respond to two adequate trials of antidepressant treatment, the GP diagnosed Max with treatment-resistant depression (TRD). With this diagnosis and the co-morbid panic disorder, he decides to refer Max to your psychiatric clinic for higher-level care.

In this virtual clinic activity, a renowned thought leader addresses the optimal therapeutic approaches to the management of this MDD patient. This case study have been developed with the assistance of Univ.Prof.Dr.h.c. mult..Dr.med. Siegfried Kasper, Professor of Psychiatry and Head of the Department of Psychiatry and Psychotherapy at the Medical University of Vienna, Austria. Supported by an independent educational grant from Janssen Pharmaceutica NV.