A Case of Depersonalization with Treatment-resistant Depression Successfully Treated with Sertraline-lamotrigine Combination

Abstract

The Editor, Sir, Some authors have suggested that almost all of the patients with severe and chronic dissociative disorders are chronically depressed (1). Depersonalization disorder is accompanied by other symptoms: anxiety, obsessive thoughts, rituals, somatic preoccupations, autoscopic experiences or subjective alterations in space and experience of time (2). We report a case of depersonalization with treatment-resistant depression which responded to sertraline-lamotrigine combination. A 37-year old woman presented to our clinic complaining of depression. She was treated for a major depressive episode and had not responded to a four-month course of duloxetine 60 mg per day. A screen for symptoms of major depression revealed that she had hopelessness, low energy, anhedonia, poor appetite, poor concentration, a strong sense of guilt and insomnia. On mental status examination, her speech was slow, and there was evidence of psychomotor retardation. Beck Depression Inventory [BDI] (3) was used to screen for depression; her BDI scores for depression was determined as 36. During the evaluation, fundamentally marked depersonalization symptoms were detected. The patient experienced persistent feeling of unreality, complaining of an increased feeling of detachment from surroundings, as though she were taking part in a movie or a dream. She also described feeling as if she were observing herself from the outside. She said: seem to be living in a world, which I recognise but don'tfeel. I feel as though I am not alive, everything feels unreal. The patient reported having the first symptom of depersonalization at 13 years of age. Her first contact with a psychiatrist was at 28 years due to depressive symptoms. Over the last nine years, serotonin reuptake inhibitors (SSRIs), serotonin-noradrenaline reuptake inhibitors (SNRIs) with quetiapine and risperidone augmentation, bupropion and tricyclic antidepressants led to minimal mood improvement, and her depression became more chronic. Duloxetine treatment was stopped and sertraline was started with the dose of 50 mg per day and was increased to 200 mg per day within two weeks. Lamotrigine (25 mg/day) was added and titrated to 100 mg per day within ten days. Her depressive mood and depersonalization symptoms were markedly improved. At the end of the 8th week of this treatment, she was euthymic with a BDE score of 10. This improvement has been maintained at the six-month follow-up with the same medication. Clinical trials suggested that the use of lamotrigine as combined treatment with SSRI was beneficial in a substantial number of patients with depersonalization (4, 5). There is evidence that glutamatergic hyperactivity could be relevant in the neurobiology of depersonalization. However, lamotrigine acts at the presynaptic membrane to reduce the release of glutamate, and it has been shown to reverse depersonalization-related phenomena induced by the N-methyl-D-aspartate (NMDA) receptor antagonist ketamine in healthy individuals (6). We suggest that augmentation of sertraline with lamotrigine may have been the key ingredient in this patient's recovery.