How I Treat: A Patient With Major Depressive Disorder, Generalized Anxiety Disorder

Balwinder Singh, MD | Mayo Clinic, Rochester, Minnesota

A 44-year-old woman presented to your psychiatry clinic with worsening depression and anxiety. She reported a long-standing history of depression, with the first episode at 11 years of age. She carried a diagnosis of major depressive disorder and generalized anxiety disorder. She had migraine headaches, which are well controlled.

This episode of depression has been going on for the last 18 months. She reported overwhelming sadness, anhedonia, fatigue, lack of motivation, low appetite, intense emotions with crying spells, and passive and intermittent, active suicidal ideation. She received weekly psychotherapy and had adequate trials of antidepressants (desvenlafaxine, escitalopram, duloxetine, nortriptyline, and augmentation with bupropion and aripiprazole). She took lorazepam as needed for anxiety. She had difficulty tolerating vortioxetine. Due to limited response with monoaminergic agents, she was treated with electroconvulsive treatment with minimal response and significant short-term cognitive impairment.

Her baseline quick inventory of depression symptomatology–self-report (QIDS-SR) score was 17. She was treated with intranasal esketamine twice per week for 4 weeks, along with her oral antidepressant (duloxetine). After 8 treatments (induction phase) of intranasal esketamine 56 mg, her depression symptoms improved significantly, with a 53% improvement at the end of induction phase (QIDS-SR score of 8). She tolerated esketamine well, with mild dissociation in the first 30 minutes and sedation on the day of esketamine treatment.