OVERCOMING TREATMENT RESISTANCE IN A PATIENT WITH PSYCHOTIC MAJOR DEPRESSION AND SEVERE HYPERCORTISOLEMIA: A CLINICAL CASE PRESENTATION AND A LITERATURE REVIEW

Abstract

In patients with major depression, there is well-known dysregulation of the HPA axis, including GR resistance, hypercortisolism, aberrant negative cortisol feedback, presenting itself as positive standard 1 mg dexamethasone suppression test, absence of nighttime cortisol suppression. Those HPA axis disturbances are more pronounced in cases with severe depression, and/or with melancholic features or psychosis, and in cases where treatment resistance is documented or suspected. Severe HPA axis disturbances may themselves predispose patients to treatment resistance or be the main reason for it. One method to overcome treatment resistance in such cases is using antiglucocorticoid therapy (for example, inhibitors of cortisol biosynthesis, like ketoconazole, or GR antagonist mifepristone, or a short course of high-dose synthetic glucocorticoid dexamethasone to suppress the HPA axis overactivity). In this article, we present a case in which the treatment resistance in a patient with severe psychotic major depression and severe hypercortisolemia was successfully overcomed by sequential use of high-dose dexamethasone (20 mg/day x 4 days) and high-dose mifepristone (600 mg/day for 14 days).

Keywords

• дексаметазон
• мифепристон
• ось гипоталамус – гипофиз – надпочечники
• гиперкортизолемия
• терапевтическая резистентность
• депрессия
• антидепрессанты