Paroxetine in the treatment of recurrent brief depressive disorder
Our patient was a 48-year-old lady who was a local politician and who was carrying out her duties satisfactorily for the past several years. About a year and a half prior to her presenting to us, she developed symptoms characterized by low mood, anhedonia, easy fatigability, decreased concentration, hopelessness, and decreased sleep and appetite. These symptoms developed following a minor stressor at work and were clearly disproportionate to the stress. The symptoms had developed abruptly and the patient had never experienced such symptoms earlier. She had been an emotionally strong and confident lady earlier and was herself surprised at her current condition. She also developed prominent suicidal ideations and tried to kill herself by setting herself on fire, but was incidentally found and rescued by her maid. These symptoms continued for 4-5 days and were spontaneously remitted. Similar episodes occurred on almost a monthly basis for the next 18 months, each lasting 3-5 days. The interval varied between 15 and 40 days. They were unrelated to her menstrual cycles. There was no history of mania or psychosis. In the inter-episodic period, the patient was fully functional and carried out all her duties satisfactorily. Initially, the patient did not realize that it was a psychiatric illness, but after several such episodes, she consulted a private psychiatrist who started her on escitalopram (10 mg). It was continued for 4 months with no improvement. She changed psychiatrists and was tried on mirtazapine (15 mg) irregularly for 3 months without improvement. She did not follow-up with one psychiatrist and therefore full doses were not tried. She eventually presented to us during an episode and was off all psychotropics at that time. We made a diagnosis of RBDD as per ICD 10 and started her on paroxetine (10 mg). She scored 24 on Hamilton depression rating scale[] at the time of presentation. Although her symptoms resolved in about 4 days time, the dose was gradually increased to 25 mg/day, but, in the following month, she again had an episode lasting for about 4 days. She scored 20 on Hamilton depression rating scale this time and had somewhat less frequent suicidal ideation. Paroxetine dose was further increased to 50 mg. About 25 days later, the patient again developed depressive symptoms in the form of mild fatigue and some decrease in self-confidence, which lasted for 3-5 days. She now scored only 7 on Hamilton depression rating scale during the episode. There were no ideas of hopelessness, helplessness, worthlessness, or suicidal ideation. However, the lack of confidence still prevented her from carrying out her duties in those 3-5 days, although otherwise she was symptomatically much better. However, with one session of supportive counseling, she managed to get back to work as well. In the subsequent month, although she complained of mild fatigue, there were no other symptoms and she started doing her duties satisfactorily. The patient was continued on the same dose and is on regular follow-up. Thereafter, for the subsequent 9 months, she maintained the full symptomatic improvement.