Add-on lithium for the treatment of unipolar depression: Too often forgotten?

Abstract

A 61-year-old man presented in the emergency department with increasing fatigue and irritability, which had started 2 months prior in the context of urinary retention due to benign pros-tatic hypertrophy. One month later, he was successfully operated, but his anxiety increased sharply in association with low mood, anhedonia, lack of motivation , poor concentration and decreased sleep and appetite. He had no suicidal intent. A severe major depres-sive episode was diagnosed. The patient's history showed more than 10 untreated and undiagnosed episodes of depression lasting anywhere from 1 week to several months. He had no history of suicide attempts, (hypo)manic episodes, delusions or hallucinations. He denied using any drugs. He did not smoke, and he drank alcohol occasionally. Some obsessive-compulsive traits were identified. Family history revealed that his brother committed suicide at the age of 27. His mother, 2 maternal uncles, and his paternal grandfather all may have suffered from depression. The patient was admitted full-time to the psychiatric ward for 1 month, followed by day hospitalization for 2 months. He was then treated with up to 40 mg of escitalopram, a recommended first-line antidepressant, 1 and 50 mg of trazodone for sleep. Partial remission was observed for several weeks. Bupropion was then added to improve efficacy, but was soon stopped owing to increased urinary retention. When entering our outpatient program, the patient's self-report Quick Inventory of Depressive Symptomatology (QIDS) scores 2 reached 20 out of 42. Trazodone was replaced by 15 mg and then 30 mg of mirtazapine for its effect on anxiety and sleep, but mirtazapine was then stopped owing to intolerance. Because of lack of improvement after 12 weeks, escitalopram was replaced by venlafax-ine XR, another efficient first-line anti-depressant, 3 and the dose was gradually increased over 2 months to 375 mg/d. The patient reached a partial remission state (QIDS = 11) but still felt functionally impaired, as confirmed by the Quality of Life Enjoyment and Satisfaction Questionnaire. 4 Of note, the patient was particularly compliant and active in his treatment, which included individual cognitive behavioural therapy and physical activity. Lithium was then introduced in an augmentation strategy, with a dose of up to 900 mg/d and a plasmatic level of 0.6 mmol/L within 1 month. Lithium, rather than antipsychotics, was used as an add-on agent primarily owing to family history of depression and number of depressive episodes, which have previously been associated with lithium augmentation response. 5 Side effects, including shaking and postural instability , were observed. Depression and quality of life scores started to improve quickly within the following month.