Optimizing Treatment for Worsening of Major Depressive Disorder Case Presentation

A 35-year-old woman with a history of major depressive disorder and generalized anxiety disorder presented with worsening depressive symptoms. Her psychiatric history included chronic anxiety with insomnia secondary to anxiety, and her medical history was notable for cerebral palsy.

Over the past several weeks, she experienced a decline in mood characterized by decreased energy, anhedonia, hypersomnia, impaired concentration, and reduced functioning at work.
The day prior to presentation, she slept from approximately 9:30 PM until 11:00 AM and took the day off from work due to low energy and mood. She denied changes in appetite but reported reduced motivation for basic self-care activities like showering. Although her work environment remained stressful, there had been no recent change in workload or responsibilities.

She worked full-time in a windowless office and reported minimal exposure to daylight, noting that it was dark both when she left for work in the morning and when she returned home in the evening. She identified the shorter winter days as a contributing factor to her current symptoms.

At the time of presentation, she was taking escitalopram 10 mg daily and bupropion immediate-release 75 mg daily. This regimen had previously been effective; however, she felt it was no longer adequately controlling her symptoms. Attempts to increase escitalopram in the past resulted in emotional flattening, while higher doses of bupropion were activating and worsened insomnia. She was engaged in weekly psychotherapy, and propranolol 10mg PRN  had been helpful for situational anxiety in the past.

Laboratory testing earlier in the year showed a vitamin D level of 30 ng/mL.

This presentation raised a common clinical dilemma in the treatment of major depressive disorder with a seasonal component. First-line treatments for this condition include selective serotonin reuptake inhibitors, cognitive-behavioral therapy, and bright light therapy, either alone or in combination. While SSRIs are well established for both unipolar depression and seasonal affective disorder, light therapy has demonstrated robust efficacy for acute seasonal depressive symptoms. Network meta-analyses and randomized controlled trials have shown bright light therapy to be significantly more effective than control conditions and comparable in efficacy to antidepressant medications for seasonal affective disorder.

In this patient, further antidepressant dose escalation was limited by side effects, and switching medications carried the risk of destabilizing anxiety and sleep. Although bupropion extended-release has strong evidence for the prevention of seasonal depressive episodes when initiated prophylactically in early fall, it is also associated with higher rates of activating side effects, including insomnia, which this patient had previously experienced.

Given the temporal association of her symptoms with reduced light exposure, hypersomnia, and the constraints on medication adjustments, bright light therapy was initiated as an augmentation strategy while maintaining her existing antidepressant regimen. The patient was prescribed a 10,000 lux light box to use for 30 minutes every morning.

Following initiation of bright light therapy, the patient reported improvement in mood, energy, and daytime functioning without exacerbation of anxiety or insomnia.

This case illustrates the importance of considering circadian-based interventions when patients with major depressive disorder experience seasonal worsening and limited benefit from antidepressant optimization alone.

Nishi Bhopal, MD, is board-certified in psychiatry, sleep medicine, and integrative holistic medicine. She graduated from the University College Cork School of Medicine, completed her psychiatric residency at Henry Ford Health System, and a fellowship in sleep medicine at Harvard Medical School. She is the founder and medical director of Pacific Integrative Psychiatry, an online practice in California where patients receive a whole-person approach to anxiety, depression, and sleep disorders, including nutrition, psychotherapy, and integrative and functional medicine. In addition to her private practice, Dr Bhopal is the founder of IntraBalance, an educational platform for physicians and therapists that includes a YouTube channel and online courses on clinical sleep medicine for healthcare practitioners. Her passion is making clinical sleep medicine easy to understand and accessible to all.

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