A30-year-old white female was admitted voluntarily to our unit with symptoms of depression and had passive thoughts of suicide for the previous few months that progressively worsened in the week before her admission. She did not have previous suicidal attempts. The patient had a certificate from the university hospital psychiatric emergency department stating that she was referred by her therapist to the emergency department with complaints of depressed mood, hypersomnia, fatigue, feelings of worthlessness and indecisiveness, irritability, anxiousness, and suicidal thoughts accompanied with a plan. She also stated that suicidal thoughts had been present for the past 3 months and had markedly increased in the past week. The patient had previously been diagnosed with Moyamoya disease (MMD) and a history of transient ischemic attacks. She also had a history of craniotomies (performed in 2002 and 2012). At times, she has had symptoms of tingling and weakness in her left upper body and the left side of face, as well as symptoms of aphasia. She has had multiple visits to the emergency department for her symptoms and she has also been followed by a neurosurgeon since age 12 years. The patient denies manic symptoms being present currently or in the past. She denies delusions, paranoid thoughts, or ritualistic behavior of any type. She also denies any history of seizures or problems with memory. She states no history of drug and alcohol abuse. Unfortunately, this is not the first episode of depression from which the patient has suffered. The patient reports that her depression had an onset at age 12 years (about the same time she was diagnosed with MMD), and that she has had a chronic course with episodic variations since then. She has been treated with citalopram, escitalopram, buproprion, and venlafaxine in the past and reports no adverse side effects from them. Currently she is taking levetiracetam, aspirin, fluoxetine, and buspirone. Her family history reveals an abusive/violent father as well as several paternal family members with psychiatric disorders. The patient also has two siblings, both of whom are on psychotropic medications for anxiety and depression. She currently is in a romantic relationship. She is employed as a manger in a research laboratory. She worries about losing her job in the near future because she is at the completion of her research project. Deepti Kaul Mughal, MD, is the TMS Coordinator and Consultant at TMS of Jacksonville. Kalliopi-Stamatina Nissirios, MD, is a PGY-1 Resident, Bergen Regional Medical Center. M. Rehan Puri, MD, MPH, is a PGY-3 Resident, Bergen Regional Medical Center. Address correspondence to M. Rehan Puri, MD, MPH, Bergen Regional Medical Center, 230 East Ridgewood Avenue, Paramus, NJ 07652; email: mpuri@bergenregional.com. Disclosure: The authors have no relevant financial relationships to disclose. doi: 10.3928/00485713-20141208-02 A 30-Year-Old Female with Moyamoya Disease and Associated Depression