Case of the month: 

Not ADD, not chronic fatigue, not “depression”

A 23 year-old female seeks consultation for unremitting depression and ADD. She had been first diagnosed at age 15 with chronic fatigue syndrome. A medical workup for possible causes of exhaustion was negative.  Eventually her doctors decided to treat her with amphetamine stimulants to give her energy.  Since age 16, she has taken one amphetamine or another, beginning with methylphenidate, later Concerta, and later Adderall. 

In the past year, she began to see psychiatrists, who changed her diagnosis from chronic fatigue syndrome to major depressive disorder. They continued Adderall and added various serotonin reuptake inhibitors (duloxetine, fluoxetine, sertraline) without success. She was changed eventually to bupropion.  

On evaluation, she was taking Adderall 20 mg twice daily plus bupropion SR 150 mg twice daily.

Besides exhaustion, her parents report that she has marked insomnia and notable cognitive impairment.  Her sleep is quite poor: she stays up very late, and has multiple awakenings in the night, followed by tiredness during the day.  Her cognition is poor also, with very impaired working and verbal and short term memory.  She has been slowed down in her college studies to the point that despite 5 years of college, she has only completed her sophomore year.  She has a great deal of trouble organizing herself for her college work and paying attention in class and in memorizing material for tests.  

Adderall gives her “30 minutes glimpses of normality”.  After she takes the medication, she reports that she feels “like myself” for about half an hour, with improved concentration and energy and mood, but then she goes back into her usual depressed, low energy, poor concentration state. 

She has these depressive symptoms continually, but 2-3 times per week, she has about 1-2 hours of spontaneous high energy states: “I feel elated, happy, like I can convince anyone to do anything.  I try to do things, but it doesn't last long enough for me to do anything. My thoughts go fast, I talk a lot, I feel super smart briefly, and then I’m back to my usual unhappy slowed down state.”

She reports repeated suicidal thoughts and wishes she was dead, but she has not tried to harm herself.  

She and her family deny past manic or hypomanic episodes lasting 4 days or longer. 

One psychiatrist suggested that she had type II bipolar illness, but he continued Adderall and added lithium 900 mg/d immediately.  She stopped lithium after two days due to heart palpitations.  

Family history provides evidence for a paternal aunt with severe depression that required ECT.  All other illness is denied.  

Medical history is otherwise normal and she has no drug allergies, nor does she abuse alcohol or drugs. She has no trauma history.  She has had no psychiatric hospitalizations or suicide attempts or self-harm or dissociative or psychotic states, and no eating disorder symptoms.  

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