Impulsive Behavior and Recurrent Major Depression Associated with Dandy-Walker Variant
A 33-year-old man presented depression, aggressiveness, and impulsivity in his visit to the authors' hospital and was thus compulsorily admitted. He had a two-year depressive episode, was diagnosed as having major depressive disorder a year earlier, and has been on medication irregularly. He had a history of three-time admission to a psychiatric unit in the previous 12 months. His initial admission was a year earlier, after attempting suicide by ingesting pesticide. One day before admission, he presented verbal abuse and aggression. He had no family history of psychiatric disorder, including depression. The patient had two-year, withdrawn university education and he had had various jobs but never managed to keep any of them for more than two months. There was no evidence of substance use and head trauma in the history of the patient.\nBrain MRI () disclosed an enlarged cisterna magna, hypoplasia of the cerebellar vermis, and dilated ventricles, indicating Dandy-Walker variant. Intelligence testing (K-WISC) confirmed a normal range of intelligence (IQ: 94; latent IQ: 105). The result of the psychological testing showed that the patient had aggressive perceptions of other people, and that he had poor impulse control ability. The patient was anticipated to be sensitive to trivial external stimuli, to easily become angry, and to be aggressive. Beck Depression Inventory (BDI) and Hamilton Depression Scale (HAM-D) tests were performed the day after his admission, and the patient obtained 23/63 and 28/50 scores, respectively.\nMirtazapine treatment was started at a dose of 7.5 mg/day and the dose was increased to 45 mg/day on the fifth day, for the patient's depression. Valproate treatment was started at a dose of 450 mg/day for the patient's aggressiveness and lack of impulse control, and the dose was increased to 1500 mg/day on the 12th day of the patient's confinement. About a week after the initiation of valproate treatment, the patient's aggressiveness and uncontrolled impulsive behavior were slightly alleviated. Quetiapine was added for further treatment of his aggression. Quetiapine was added at a dose of 100 mg/day on the 12th day of confinement, and the dose was increased to 800 mg/day on the 20th day. The BDI score decreased from 23 to 9, and the HAM-D score went down from 28 to 10 after three months of treatment. The patient still presented some uncontrolled impulse and aggression, although these had improved much in the three months.