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Neurologist, Specialist in Movement Disorder Department of Neurology & Psychiatry Hospital BHB Eggenberg Bergstrasse 27 A-8021 Graz, Austria FAX 43-316-5989-2380 E-mail rm.bonelli{at}nextra.at
Published Online, January 17, 2003. www.theannals.com, DOI 10.1345/aph.1C352
Case Report. A 32-year-old woman with HD (42 cytosine–adenine–guanine repeats) of 6 years' duration was hospitalized due to a suicide attempt by jumping out of the window from the second floor. Before this suicide attempt, she had been treated with olanzapine (for the choreatic movement disorder) and riluzole. The woman developed a severe depressive episode at home, not adequately realized by her husband. The patient had known about the positive genetic test results for HD for 2 years, and the depression seemed to be unrelated neither to this fact nor to any other exogenic reason. Besides fracturing both calcaneus and lumbar vertebral body III, the patient presented in a depressive stupor. She was oriented and able to follow commands and speak, but did not answer with more than a word; her thoughts monotonously revolved around suicide. After admission, she was treated with mirtazapine 30 mg/d, which had to be increased to 90 mg/d in the next week. However, due to this medication the mood improved significantly in the next few weeks, and the patient started to speak after 5 days of treatment; suicidal thoughts disappeared after 2 weeks of treatment. We reduced mirtazapine to 60 mg/d after 2 months and to 30 mg/d after 9 months. The woman is seen in our outpatient clinic every month and has remained in a stable mood for >1 year.
Discussion. Depression in HD often precedes the onset of neurologic symptoms and responds to antidepressant medication, but may not be interpreted as a merely psychological response to the development of the disease.2 Thus, depression seems to result from neuropathologic changes. It was hypothesized that the neuronal loss in the medial anterior caudate is responsible for both the neurologic and emotional symptoms.1 In his original paper, George Huntington3 himself drew attention to "that form of insanity which leads to suicide." In fact, several studies1,4-6 have supported this statement by showing high suicide rates in HD. Six percent of deaths among affected persons result from suicide, and 28% of patients with HD attempted suicide at least once.4 Factors that increase the risk of suicide are having no offspring, being unmarried, having a family history of suicide, living alone, endogenous depression, and having no contact with others who have HD.5
Today, there are only case reports available on the treatment of depression from HD, and, moreover, there is no treatment recommendation for suicidal HD patients. Mirtazapine, a noradrenergic and specific serotonergic antidepressant, was selected because of its high antidepressive potential, the low adverse effects, and the sedative action. Furthermore, mirtazapine might have a faster onset of action than any selective seretonin-reuptake inhibitor. In summary, severe depression in suicidal patients with HD may be treated effectively and without significant adverse effects with high-dose mirtazapine.
References
This article has been cited by other articles:
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  K.A. O'Connor, M. Kingston, M. O'Donovan, B. Cryan, C. Twomey, and D. O'Mahony Antibiotic prescribing policy and Clostridium difficile diarrhoea QJM, July 1, 2004; 97(7): 423 - 429. [Abstract] [Full Text] [PDF]
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