When Depression Persists: Diagnostic and Therapeutic Complexity of Early-Onset Treatment-Resistant Depression in an Adolescent

Abstract

Early-onset depressive disorders may evolve into chronic, severely disabling conditions and become diagnostically challenging when trauma-related symptoms, historical psychotic manifestations, and deficit-like features coexist. We report the case of a 17-year-old male adolescent with an almost continuous depressive syndrome since approximately age 11, characterized by anhedonia, emotional numbing, fatigue, clinophilia, sleep-wake cycle inversion, social withdrawal, psychomotor and cognitive slowing, and major academic and social impairment. At age 14, after discovering the body of a close cousin who had died by hanging, he developed post-traumatic stress disorder. Auditory and visual hallucinations were reported during that period and resolved after approximately three months of risperidone; no established delusions or disorganized behavior were documented, and psychotic symptoms have not recurred for approximately three years. Trichotillomania subsequently emerged. Multiple pharmacological strategies were ineffective, only transiently effective, poorly tolerated, or limited by treatment availability. At the last follow-up, sertraline and lamotrigine had been initiated without reported adverse effects, but efficacy could not be assessed because the patient was lost to follow-up. This case highlights the difficulty of distinguishing severe chronic depression from negative symptoms of a schizophrenia-spectrum disorder, interpreting remote psychotic symptoms and psychomotor agitation, and monitoring possible bipolar evolution without premature diagnostic reclassification. Comorbid post-traumatic stress disorder and trichotillomania further complicated management. Longitudinal reassessment and individualized multimodal treatment are essential in severe early-onset treatment-resistant depression.