Late-Onset Agitated Depression with Anxious and Obsessive Features Triggered by Parental Decline: A Case for Integrated Pharmacology, Neuromodulation, and Psychodynamic Treatments

This case report highlights a 65-year-old male veteran with no psychiatric history who developed sudden-onset severe ruminative anxiety, intermittent depression, and panic attacks after visiting his elderly, immobile mother in a nursing facility. He described feeling unrecognizable, stating, “I’ve always taken care of everyone; I don’t feel like myself.” He had a seizure disorder diagnosed in 2020, experienced significant unintentional weight loss, and had a two-year history of mood decline noted by extended family.
Initial trials with sertraline and mirtazapine were poorly tolerated, worsening his mood, insomnia, and psychomotor agitation. Though lorazepam offered transient relief, he feared dependence. Clinical findings and collateral suggested obsessive-compulsive traits, possible mild excitatory catatonia, and emerging bipolar spectrum features. Valproate reduced agitation objectively but provided no subjective benefit. Lurasidone produced no change. After two doses of lithium, his depression worsened. He then requested inpatient admission due to escalating affective suffering.
At admission, fluoxetine and olanzapine were initiated alongside ECT. He denied active suicidality but endorsed passive death wishes and cognitive slowing. After two ECT sessions, he experienced some improvement in energy and cognition, although anxiety and low mood persisted. Psychodynamically, witnessing his mother’s decline disrupted his identity as a lifelong caretaker, triggering unresolved dependency conflicts, aging-related fears, and regression.
This case underscores the complex nature of late-onset first-episode depression with anxious distress, potential bipolarity, obsessive traits, and psychodynamic vulnerability. Early recognition and multimodal treatment—including mood stabilizers, second-generation antipsychotics, and ECT—alongside structured psychotherapy and supportive care, are crucial for clinical improvement.