Abstract

Introduction:
Depression is a leading cause of disability worldwide. Approximately 85% of patients with depression have significant symptoms of anxiety and demonstrate mixed symptoms of anxiety and depression. Up to 30% of patients treated for anxiety or major depressive disorder (MDD) are treatment-resistant. High prevalence rates of attention deficit hyperactivity disorder (ADHD) and personality disorders (PDs) in patients with major MDD and anxiety have been reported. In addition, the role of hormonal imbalance in the pathogenesis of anxiety and depression has been discussed and emphasized in the literature.
Methods:
This report describes a 34-year-old obese male with a diagnosis of treatment-resistant chronic mixed anxiety and depression, associated with recurrent self-harm, suicidal thoughts, and suicidal attempts. The patient received multiple antidepressants with neither subjective nor objective improvement. Given the chronicity and severity of his illness, the patient has been reassessed to explore the presence of other potentially treatable etiologic factors. Re-assessment included a clinical interview, blood tests, vital signs, anthropometric characteristics, and self-rating questionnaires to assess for ADHD (ASRSv-1.1) and personality disorders (including borderline personality disorder (BSL-23)). Besides, the Hamilton rating scales for depression (HAM-D17) and anxiety (HAM-A) have been used to quantify the depression and anxiety symptoms severity. The patient has been treated with a combination of testosterone gel, methylphenidate, and iron supplement. The effect and side effects of the treatment were monitored during a follow-up period of 11 weeks.
Results:
Clinical and laboratory reassessment revealed a severe degree of anxiety and depression on a background of clinically significant hypogonadism, ADHD- borderline personality disorder comorbidity, and anaemia. At week 11 of treatment, the patient achieved complete remission in all his signs and symptoms, including suicidal thoughts and self-harm behaviour. At the end of the follow-up period, the patient reported >95% improvement in his symptoms. Clinically significant and meaningful improvement in ADHD (complete remission) and borderline symptoms (91% reduction from baseline). Parallel to this improvement, HAM-D17 and HAM-A demonstrated reduction from baseline respectively -85% and -78%. The patient reported his full contentment with his treatment and improvement in his family life, social relationship and work.
Conclusion:
Treatment-resistant anxiety and depression are associated with severe physical and psychological symptoms associated with impairment of daily living skills and social functioning, and high suicidal risk. Successful management of this relentless mental health illness might be hampered by an underlying indiscernible physical and/or mental illness and, therefore, requires an integrated diagnostic approach to better understand other factors that manifest themselves in anxiety and depression and contribute to poor treatment response.

Key words: mixed anxiety and depression, Hypogonadism, ADHD, Borderline personality disorder, Anaemia