Cases That Test Your Skills

Depression, or something else?

Current Psychiatry. 2020 March;19(3):43-49

Ms. A, age 60, presents with severe headaches and depression, including a suicide attempt. She’s also been repeatedly sorting through her neighbors’ trash. What’s underlying her symptoms?

PDF Download

References

1. Madhusoodanan S, Opler MG, Moise D, et al. Brain tumor location and psychiatric symptoms: is there any association? A meta-analysis of published case studies. Expert Rev Neurother. 2010;10(10):1529-1536.
2. Bunevicius A, Deltuva VP, Deltuviene D, et al. Brain lesions manifesting as psychiatric disorders: eight cases. CNS Spectr. 2008;13(11):950-958.
3. Pearl ML, Talgat G, Valea FA, et al. Psychiatric symptoms due to brain metastases. Med Update Psychiatr. 1998;3(4):91-94.
4. Madhusoodanan S, Danan D, Moise D. Psychiatric manifestations of brain tumors: diagnostic implications. Expert Rev Neurother. 2007;7(4):343-349.
5. Ferguson SD, Wagner KM, Prabhu SS, et al. Neurosurgical management of brain metastases. Clin Exp Metastasis. 2017;34(6-7):377-389.
6. Husain ZA, Regine WF, Kwok Y, et al. Brain metastases: contemporary management and future directions. Eur J Clin Med Oncol. 2011;3(3):38-45.
7. Vecht CJ, Haaxmareiche H, Noordijk EM, et al. Treatment of single brain metastasis - radiotherapy alone or combined with neurosurgery. Ann Neurol. 1993;33(6):583-590.
8. Barry RL, Byun NE, Tantawy MN, et al. In vivo neuroimaging and behavioral correlates in a rat model of chemotherapy-induced cognitive dysfunction. Brain Imaging Behav. 2018;12(1):87-95.
9. Wu AS, Witgert ME, Lang FF, et al. Neurocognitive function before and after surgery for insular gliomas. J Neurosurg. 2011;115(6):1115-1125.
10. Taylor WD. Depression in the elderly. N Engl J Med. 2014;371(13):1228-1236.
11. Liguori C, Pierantozzi M, Chiaravalloti A, et al. When cognitive decline and depression coexist in the elderly: CSF biomarkers analysis can differentiate Alzheimer’s disease from late-life depression. Front Aging Neurosci. 2018;10:38.
12. Luijendijk HJ, van den Berg JF, Dekker MJHJ, et al. Incidence and recurrence of late-life depression. Arch Gen Psychiatry. 2008;65(12):1394-1401.
13. Potter GG, Steffens DC. Contribution of depression to cognitive impairment and dementia in older adults. Neurologist. 2007;13(3):105-117.
14. Taphoorn MJB, Klein M. Cognitive deficits in adult patients with brain tumours. Lancet Neurol. 2004;3(3):159-168.
15. Inouye SK, Westendorp RGJ, Saczynski JS. Delirium in elderly people. Lancet. 2014;383(9920):911-922.
16. Sprung J, Roberts RO, Weingarten TN, et al. Postoperative delirium in elderly patients is associated with subsequent cognitive impairment. Br J Anaesth. 2017;119(2):316-323.
17. Kusljic S, Manias E, Gogos A. Corticosteroid-induced psychiatric disturbances: it is time for pharmacists to take notice. Res Soc Adm Pharm. 2016;12(2):355-360.
18. Cerullo MA. Corticosteroid-induced mania: prepare for the unpredictable. Current Psychiatry. 2006;5(6):43-50.
19. Dubovsky AN, Arvikar S, Stern TA, et al. Steroid psychosis revisited. Psychosomatics. 2012;53(2):103-115.
20. Habets JGV, Leentjens AFG, Schijns OEMG. Serious and reversible levetiracetam-induced psychiatric symptoms after resection of frontal low-grade glioma: two case histories. Br J Neurosurg. 2017;31(4):471-473.
21. Swart LM, van der Zanden V, Spies PE, et al. The comparative risk of delirium with different opioids: a systematic review. Drugs and Aging. 2017;34(6):437-443.

CASE Suicidal behavior, severe headaches

Ms. A, age 60, presents to the emergency department (ED) with depression, suicidal behavior, and 3 days of severe headaches. Neurology is consulted and an MRI is ordered, which shows a 3.0-cm mass lesion in the left temporal lobe with associated vasogenic edema that is suspicious for metastatic disease (Figure).

Ms. A is admitted to the hospital for further workup of her brain lesion. She is started on IV dexamethasone, 10 mg every 6 hours, a glucocorticosteroid, for brain edema, and levetiracetam, 500 mg twice a day, for seizure prophylaxis.

Upon admission, in addition to oncology and neurosurgery, psychiatry is also consulted to evaluate Ms. A for depression and suicidality.

EVALUATION Mood changes and poor judgment

Ms. A has a psychiatric history of depression and alcohol use disorder but says she has not consumed any alcohol in years. Her medical history includes hypertension, diabetes, and stage 4 non-small–cell lung cancer, for which she received surgery and adjuvant chemoradiotherapy 1 year ago.

On initial intake, Ms. A reports that in addition to the headaches, she has also been experiencing worsening depression and suicidal behavior. For the past 2 months, she has had a severely depressed mood, with notable anhedonia, poor appetite, insomnia, low energy, and decreased concentration. The changes in her mental health were triggered by her mother’s death. Three days prior to admission, the patient planned to overdose on antihypertensive pills, but her suicide attempt was interrupted when her family called. She denies any current suicidal ideation, intent, or plan.

According to her family, Ms. A has been increasingly irritable and her personality has changed in the past month. She also has been repeatedly sorting through her neighbors’ garbage.

Ms. A’s current psychiatric medications are duloxetine, 30 mg/d; quetiapine, 50 mg every night at bedtime; and buspirone, 10 mg/d. However, it is unclear if she is consistently taking these medications.

Continue to: On mental status examination...

Depression, or something else?

References

CASE Suicidal behavior, severe headaches

EVALUATION Mood changes and poor judgment

Pages

Recommended Reading