“Mr. A” is a 32-year-old white man with a history of attention-deficit hyperactivity disorder (ADHD) and major depression. He recently presented to the clinic to discuss an episode of worsened mood after attempting to treat sinus congestion.
In the past, the patient had been successfully treated for ADHD with methylphenidate, and he experienced one acute depressive episode several years ago that was treated with an SSRI. He was not taking either medication this year. Several months before this case presentation, the patient took a depression rating scale, the Quick Inventory of Depressive Symptoms (QIDS), and scored a 7, which indicates mild depression. He noted that this had been his usual baseline throughout for the past several months.
Two weeks before presentation, the patient had worsening allergy symptoms and nasal congestion. He was originally taking loratadine 10 mg and added pseudoephedrine 120 mg every morning. This led to improvement in congestion along with rapid improvement in depressive symptoms. His QIDS score during treatment with pseudoephedrine improved from the baseline of 7 to 3, which is in the range of clinical remission. After 2 weeks of treatment, the patient elected to discontinue pseudoephedrine, at which point his depressive symptoms notably worsened to a QIDS score 16, which indicates moderately severe depression. His specific symptoms on withdrawal were profoundly decreased energy level, decreased concentration, psychomotor retardation, increased appetite, increased need for sleep, worsening of mood (feeling sad more than half the time), and a worsened view of self. These depressive symptoms continued for 4 days after drug cessation, after which he noted a partial improvement, back to premedication baseline (QIDS of 7).