CASE: Near-fatal combination
Inpatient psychiatry refers Mr. B, age 50, to our outpatient psychiatry clinic. Two weeks earlier, he tried to kill himself by sitting on a stepladder, tying a noose around his neck, and consuming large amounts of quetiapine, trazodone, and vodka. His wife found him unconscious on the floor with facial abrasions, empty pill bottles, and the noose lying next to him.
Emergency medical personnel brought Mr. B to the ER. His total Glasgow Coma Scale score of 3 indicated he was comatose. Pulse was 65 bpm (low-normal), and blood alcohol level was 106 mg/dL, suggesting he had ingested hazardous amounts of vodka. Quetiapine and trazodone blood levels were not measured.
Gastric lavage was unsuccessful because the orogastric tube became curled in the distal esophagus. Mr. B was successfully intubated and admitted to the intensive care unit. After 2 days, he was medically stable and regained consciousness, though he was delirious. He was transferred to inpatient psychiatry, where the attending psychiatrist diagnosed major depression and alcohol abuse disorder.
Before presentation, Mr. B had been taking venlafaxine, 75 mg/d, and mirtazapine, 30 mg at bedtime. His previous outpatient psychiatrist had added methylphenidate, 40 mg/d, to augment the antidepressants—which were not alleviating his depression—and the attending continued all 3 medications. Prior trials of sertraline, bupropion, trazodone, quetiapine, and aripiprazole were ineffective.
By the time Mr. B is transferred to us, his suicidal thoughts have remitted but he is still notably depressed. He is anergic, feels hopeless about the future, has markedly diminished self-worth, feels excessively guilty over past actions, is socially withdrawn, and shows a blunted, depressed affect. He also complains of insomnia despite taking mirtazapine at bedtime.
HISTORY: Depression and drugs
Mr. B says he has felt depressed on and off since his teens, and his current episode has been continuously severe for 1½ years. He began abusing alcohol and benzodiazepines during this episode but says he has been clean and sober for 2 weeks. He tried to kill himself 2 other times over 6 months by overdosing on alprazolam and was hospitalized after both attempts. He has no history of mania or psychosis.
Mr. B also abused opioids. In college, he was prescribed codeine for back pain after a sports injury. He experienced profound relief from depression after his first dose and soon began abusing codeine and other opioids for mood effects, including diphenoxylate/atropine and “cough syrup.” He says he has never used heroin.
Twenty years of illicit opioid use destroyed Mr. B’s occupational and social functioning, leaving him unable to work in his chosen field. During that period, he was frequently unemployed, socially isolated, and unable to sustain romantic relationships.
At age 40, Mr. B entered a methadone program, began working steadily, and got married. Five years later, he tapered off methadone and to our knowledge remained continuously opioid-free until presentation. Mr. B’s depression persisted while using opioids and worsened after stopping methadone. He also completed an 8-week residential substance abuse treatment program several months before presentation.
HISTORY: Family problems
Mr. B says he was emotionally abused as a child and described his father as excessively rageful. He says he entered a highly skilled profession to please his father but did not enjoy it and has not worked in the field since his early 30s. He has been unemployed for 1 year because his depression makes him feel “unworthy” to work.
The patient’s marriage of 10 years has been riddled with conflict. His depression, substance abuse, suicidality, and unemployment have fueled his wife’s resentment and anger.
The authors’ observations
Mr. B’s depression is challenging because of its severity and many possible causes and perpetuating factors. In addition to acute psychological stress and recent alcohol and benzodiazepine abuse, he has endured long-term opioid addiction. Although he had stayed opioid-free for 5 years, his past addiction contributed to his depression.
Whether Mr. B’s depression or opioid dependence came first is unclear. Either way, past opioid dependence can worsen depression prognosis.1 Opioid dependence might cause a withdrawal state that lasts years after acute withdrawal has subsided, although some researchers dispute this concept.2 According to Gold et al,3 long-term opioid use can cause endogenous opioid system derangements and depression after exogenous opioid use has ceased.
Depression is difficult to diagnose unambiguously in patients who have been using alcohol or anxiolytics because these CNS depressants’ effects might mimic depression. Patients whose symptoms suggest dual disorders commonly alternate between traditional psychiatric interventions and chemical dependence treatment.