Early Depressive Stupor Responsive to Moclobemide (1999)

ABSTRACT The clinical application of moclobemide, a new reversible monoamine oxidase type A inhibitor is being extended within the depressive group of disorders. The following case history describes its successful use in the early stage of depressive stupor. Keywords: Depressive Disorder; Moclobemide; Stupor INTRODUCTION The antidepressant moclobemide, chemically a benzamide derivative, is the first short-acting reversible inhibitor of monoamine oxidase (MAO) type A (Freeman, 1993). It affects noradrenalin, serotonin and, to a lesser degree, dopamine neurotransmission in the central nervous system (Nair et al., 1993). Unlike traditional, irreversible MAO inhibitors (e.g. phelzine), moclobemide has negligable hepatic toxicity, a very short half-life (two hours) and does not require a tyramine-restricted diet up to a dosage of 600 mg/day (Gieschke et al., 1987; Nair et al., 1993). Due to the favourable side effect profile, the full therapeutic dose can be given from the start of treatment resulting in rapid onset of its clinical action. Moclobemide has been proven to be as effective as tricyclic antidepressants in controlled trials (Freeman, 1993; Angst et al., 1995). Although moclobamide is reported to be effective in depression accompanied by psychomotor retardation, to the best of our knowledge no case reports or controlled trials have been published on its efficacy in depressive stupor. Spear et al. (1997) reported a case of a 72-year-old woman whose stupor resolved after two days of treatment with moclobemide 300 mg/day and diazepam 10 mg/day. However, the case description clearly suggests that the suspension of stupor was largely due to the administration of diazepam. CASE REPORT This paper reports on a 73-year-old woman who was admitted for assessment following inability to cope at home and complaints of poor sleep. On specific inquiry she gave a five-month history of uncharacteristic anhedonia, social isolation, somatic preoccupation, poor sleep, and poor appetite. She was not suicidal. No other complaints were elicited, in particular, there were no features of a dementing illness, psychotic process, or anxiety-based disorder. On examination, she was appropriately dressed and maintained eye contact as she smiled and readily explained the above changes in terms of her poor hearing, eye sight, and persistent tremor following an earlier cerebrovascular accident. Although there was mild agitation present, careful observation over the next eight days failed to confirm any other features of a suspected depressive illness or of any other disorder. In particular, she slept and ate well, was noted to be conversing with others and seemed to enjoy being on the ward. A Hamilton Rating Scale for Depression score of l3 and Mini-Mental State Examination score of 23 were recorded. Discharge planning included multiple offers of support and help with meals-on-wheels, district nursing and home-help, all of which were declined. The patient was discharged home. 10 days later she was readmitted. She had been found at home lying in bed motionless except for her eyes, which followed the author across the room. After considerable coaxing, she uttered a single phrase saying that she wanted to die. She had not eaten since the previous day and repeatedly refused to take any fluid despite poor tissue turgor. Unable to consent to admission, she was brought in as an involuntary patient. The patient's past psychiatric history included a course of ECT 30 years previously, notes of which were no longer available. Her past medical history included hypertension, angina, and a minor cerebrovascular accident eight months earlier resulting in a right-sided tremor that had been unresponsive to antiparkinsonian medication. A computed tomograpy (CT) scan of the brain three months prior to this admission was suggestive of multiple infarcts, with damage being reported particularly in the frontal lobes. …