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Depression resistant to antidepressant medications or depression complicated by hypophoria? A case report.
Walter Paganin 1, Sabrina Signorini 2, and Icro Maremmani 3,4,5
1 Department of Mental Health ASL RM/5, Tivoli, Italy, EU
2 Centro Nautilus, Tivoli, Italy, EU
3 Vincent P. Dole Dual Disorder Unit, 2nd Psychiatric Unit, Santa Chiara University Hospital, University of Pisa, Italy, EU
- Association for the Application of Neuroscientific Knowledge to Social Aims (AU-CNS), Pietrasanta, Lucca, Italy, EU
- De Lisio Institute of Behavioural Sciences, Pisa, Italy, EU
Background. The clinical condition of depression resistant to antidepressant drug treatment (TRD) has been described since the early Seventies. In the case of Dual Disorder (Heroin Use Disorder/Depressive) patients, the tendency of psychiatrists to treat subjects with depression by using predominantly psychiatric drugs instead of agonist opioid therapy still persists. The aim of this case study presentation is to support this assessment. Case Presentation. A 45-year-old male with a history of opiate addiction, use and resistance to treatment was monitored for many years, while continuing to be treated with an antidepressant, while a correct methadone or buprenorphine treatment was avoided; the outcome was that no significant clinical improvement occurred until a very complex treatment system was applied. Comment. This patient was misdiagnosed as resistant to treatment. None of the doctors responsible for his health considered the possibility that the severity of his symptoms and the low level of his response to therapy might be due to a hypophoric/dysphoric syndrome induced by previous long-term opiate abuse and not responding to standard agonist opioid treatment. In such cases, good clinical practice suggests that agonist opioid therapy with over-standard dosages may be indicated in depressed patients with opioid addiction.
Key Words: Depression; resistance to treatment; hypophoria; Agonist Opioid Treatment; Dual Disorder; misdiagnosis.
This clinical case exemplifies the tendency of psychiatrists to treat subjects with dual diagnoses by using predominantly psychiatric drugs instead of a correct agonist opioid therapy . When the patient was first examined by us, it was clear that agonist opioid therapy had been incorrectly applied [15, 16]. The se- verity of the clinical condition would, in fact, have required treatment with a total opioid agonist, not with a partial agonist. In addition, the dosage of the partial agonist had always been insufficient, because the dos- ages prescribed to block the action of heroin were not enough to stop craving for the substance, due to the poor opiate power of the drug. Thirdly, an increase in therapeutic pressure (pharmacological and psycho- therapeutic) was accompanied by a decrease in the use of heroin and a parallel decrease in the need for the opiate drug. Thus the previous treatment had been interrupted several times – a change that destabilized the patient’s opiate system. The diagnosis, quite probably incorrect, was resistant depression (TRD). More likely, it should have been a diagnosis of depression complicated by the hypophoric syndrome, which is present in all heroin addicts, especially so in poly- users. This ‘double depression’ cannot be relieved just by antidepressants, because the hypophoric component, in the case of patients addicted to heroin, is sensitive only to opioids. Since addiction is not under control, depressive symptoms cannot be controlled either. In a proper treatment of the dual disorder of a heroin-addicted patient, the increase in therapeutic pressure (psychopharmacological and psychotherapeutic) must always be accompanied by optimal opiate agonist treatment [13, 19].
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