Introduction

This case report concerns a young 19-year-old boy who, after the sudden death of his father in a serious road accident, a death for which he felt responsible even though he was not at fault, fell into a deep depression, diagnosed by the psychiatrist as major depression according to DSM V [1]. In fact, since the day of his father's death, he persisted for most of the day in a very marked depressed mood with thoughts of suicide, marked lack of interest in any activity, including the more pleasant ones such as going out with friends or playing sport, hypersomnia during the day and insomnia with difficulty falling asleep at night, a very marked sense of guilt concerning his father's premature death, an inability to maintain concentration when reading books or newspapers, and a marked loss of appetite even for his favourite foods.

Treatment

The patient, on the advice of the family and the attending physician, started a psychotherapeutic course with the NHS psychiatrist, who prescribed, following the guidelines [2-5]: Fluoxetine 20 mg/day, a serotonin re-uptake inhibitor (SSRI) drug, combined with a tienodiazepine, Ethylazolam 1 mg at night before going to sleep, a therapy that the boy refused to take because he did not want to take psychotropic drugs of any kind, however he accepted the weekly psychotherapy meetings. The family, worried about the boy and his future, decided to hear another opinion and turned to us to evaluate a therapy that could help the boy and was accepted and well tolerated by him. Talking to the boy, it is decided to absolutely continue the psychotherapy sessions, he is advised to take up cycling, his favourite sport and his lifelong passion, and he is prescribed, following the most recent discoveries and evidence [6-12], and having assessed his inflammatory indices (especially CRP and IL-6) [13,14] through haematochemical examinations, an anti-inflammatory drug combined with probiotics, with this dosage ibuprofen 400mg every morning upon waking, vitamin D3-cholecalciferol 100mcg in the evening after dinner, combined with vitamin K2 60mcg after breakfast on alternate mornings, and a probiotic containing the following strains: Bifidobacterium lactis W51, Bifidobacterium lactis W52, Enterococcus faecium W54, Lactobacillus acidophilus W22, Lactobacillus paracasei W20, Lactobacillus plantarum W21, Lactobacillus salivarius W24, Lactococcus lactis W19, 80mg in the morning at breakfast, and 80mg in the evening at dinner, all to be taken for 14 consecutive days, until the next follow-up visit. After the 14 days have passed, the boy returns for his check-up visibly improved, he is beginning to grieve, and is slowly overcoming his sense of guilt, realising thanks to psychotherapy that he is not to blame. He reports that he feels better since taking the recommended therapy, he does not complain of any discomfort related to side effects, he feels more lucid, less apathetic and less depressed, and with more desire to do. He has taken up cycling again and rides about 50 km three times a week, and is considering enrolling at university, perhaps working part-time as a waiter or clerk in some shop or restaurant. It is therefore decided to continue the therapy for another 14 days, but reducing the dosage of ibuprofen to 400mg every other day. Follow-up visits every 14 days continued, and after the first month it was decided to further reduce the ibuprofen to 400mg two days a week (Monday and Thursday), continuing the probiotics and vitamins, arriving at the second month of treatment where it was decided to stop the ibuprofen altogether, while continuing the rest. After 3 months of treatment and psychotherapy, the first month one meeting a week, then two meetings a month, the boy visibly improved, no longer showing any obvious symptoms of major depression, so it was decided to schedule monthly internist check-ups, and 6 months after his father's death the boy could be declared completely cured, having returned to a normal life and even enrolled at university, faculty of medicine and surgery, passing the admission test.

Conclusions

This clinical case is intended to emphasise how important the therapeutic alliance with the patient is, especially in mood disorders, and how important it is to act on inflammation and the intestinal microbiota even in this type of disorder, with targeted therapies that are as personalised as possible.

Tables

References

1. Diagnostic and statistical manual of mental disorders (5th ed.) Arlington, VA: American Psychiatric Publishing.
2. American Psychiatric Association. (2010) Practice guideline for the treatment of patients with major depressive disorder - third edition. 157: 1-45.
3. American Psychiatric Association. (2010) Treating major depressive disorder a quick reference guide.
4. National Institute for Clinical Excellence. (2009) Depression in adults: recognition and management.
5. National Institute for Clinical Excellence. (2018) Depression in adults: treatment and management: short
6. Miller AH, Maletic V, Raison CL (2009) Inflammation and its discontents: the role of cytokines in the pathophysiology of major depression. Biol Psychiatry. 65: 732-741.
7. Kiecolt-Glaser JK, Derry HM, Fagundes CP (2015) Inflammation: depression fans the flames and feasts on the heat. Am J Psychiatry. 172: 1075-1091.
8. Kohler O, Krogh J, Mors O, Benros ME (2016) Inflammation in Depression and the Potential for Anti-Inflammatory Treatment. Curr Neuropharmacol. 14: 732-742.
9. Mörkl S, Butler MI, Holl A, Cryan JF, Dinan TG (2020) Probiotics and the Microbiota-Gut-Brain Axis: Focus on Psychiatry. Curr Nutr Rep. 9: 171-182.
10. Liu RT, Walsh RFL, Sheehan AE (2019) Prebiotics and probiotics for depression and anxiety: A systematic review and meta-analysis of controlled clinical trials. Neurosci Biobehav Rev. 102:13-23.
11. Chudzik A, Orzyłowska A, Rola R, Stanisz GJ (2021) Probiotics, Prebiotics and Postbiotics on Mitigation of Depression Symptoms: Modulation of the Brain-Gut-Microbiome Axis. Biomolecules. 11: 1000.
12. Spedding S1 (2014) Vitamin D and depression: a systematic review and meta-analysis comparing studies with and without biological flaws. Nutrients. 6: 1501-1518.
13. Howren MB, Lamkin DM, Suls J (2009) Associations of depression with C-reactive protein, IL-1, and IL-6: a meta-analysis. Psychosom Med. 71: 171-86.
14. Valkanova V, Ebmeier KP, Allan CL (2013) CRP, IL-6 and depression: a systematic review and meta-analysis of longitudinal studies. J Affect Disord. 150: 736-744.