Treatment resistant adolescent depression with upper airway resistance syndrome treated with rapid palatal expansion: a case report

Paul Miller,Avram R Gold,Mala Iyer

doi:10.1186/1752-1947-6-415

Abstract

IntroductionTo the best of our knowledge, this is the first report of a case of treatment-resistant depression in which the patient was evaluated for sleep disordered breathing as the cause and in which rapid palatal expansion to permanently treat the sleep disordered breathing produced a prolonged symptom-free period off medication.Case presentationAn 18-year-old Caucasian man presented to our sleep disorders center with chronic severe depression that was no longer responsive to medication but that had recently responded to electroconvulsive therapy. Ancillary, persistent symptoms included mild insomnia, moderate to severe fatigue, mild sleepiness and severe anxiety treated with medication. Our patient had no history of snoring or witnessed apnea, but polysomnography was consistent with upper airway resistance syndrome. Although our patient did not have an orthodontic indication for rapid palatal expansion, rapid palatal expansion was performed as a treatment of his upper airway resistance syndrome. Following rapid palatal expansion, our patient experienced a marked improvement of his sleep quality, anxiety, fatigue and sleepiness. His improvement has been maintained off all psychotropic medication and his depression has remained in remission for approximately two years following his electroconvulsive therapy.ConclusionsThis case report introduces the possibility that unrecognized sleep disordered breathing may play a role in adolescent treatment-resistant depression. The symptoms of upper airway resistance syndrome are non-specific enough that every adolescent with depression, even those responding to medication, may have underlying sleep disordered breathing. In such patients, rapid palatal expansion, by widening the upper airway and improving airflow during sleep, may produce a prolonged improvement of symptoms and a tapering of medication. Psychiatrists treating adolescents may benefit from having another treatment option for treatment-resistant depression.

Highlights

To the best of our knowledge, this is the first report of a case of treatment-resistant depression in which the patient was evaluated for sleep disordered breathing as the cause and in which rapid palatal expansion to permanently treat the sleep disordered breathing produced a prolonged symptom-free period off medication.Case presentation: An 18-year-old Caucasian man presented to our sleep disorders center with chronic severe depression that was no longer responsive to medication but that had recently responded to electroconvulsive therapy
This case report introduces the possibility that unrecognized sleep disordered breathing may play a role in adolescent treatment-resistant depression
The symptoms of upper airway resistance syndrome are non-specific enough that every adolescent with depression, even those responding to medication, may have underlying sleep disordered breathing

Summary

Conclusions

The sustained improvement of this adolescent’s treatmentresistant depression, anxiety and fatigue/sleepiness after RPE is a clinical finding of enormous importance to psychiatrists managing depression and their patients. The symptoms of SDB can be so non-specific (fatigue, insomnia, restless sleep) that every depressed adolescent may have them. Given the physically benign nature of RPE as a treatment and the control that may be obtained over symptoms, we believe that evidence of SDB should be sought in every depressed adolescent and, when present, treated and the resulted should be documented. Doi:10.1186/1752-1947-6-415 Cite this article as: Miller et al.: Treatment resistant adolescent depression with upper airway resistance syndrome treated with rapid palatal expansion: a case report. ARG performed the sleep consultation, interpreted the two polysomnograms and provided the follow-up care for our patient’s upper airway resistance syndrome. Author details 1807 Walt Whitman Road, Melville, NY 11747, USA. Disorders Center, 240 Middle Country Road, Smithtown, NY 11767, USA

Introduction

Findings

Discussion