DEPRESSION IN THE THIRD
DECADE OF LIFE IN DOWN PERSONS. REPORT ON THE FIRST OBSERVED THREE CASES.
Summary
Three cases of depression in female Downs
during their third decade of life are reported. While in two cases the
diagnosis was easy, in the third the presence of autistic traits first
addressed towards a diagnosis of psychosis.
Key words: Down syndrome, depression,
autistic traits, adult age.
In preceding investigations on the
depression in Down syndrome persons (Cocchi 1994 and Cocchi 1995) I reported
its prevalence within a series of 510 subjects, and clinical-therapeutic
histories of 45 cases. Already then I pointed out that I was dealing with particular
case histories.
So, because the appearance of depression
came out in subjects who were already taking a moderately antidepressant and
anxiolytic drug therapy (Cocchi, 1995 ).
Recently I observed three depression cases
in Down Ss which came out in their third decade of life. First I have seen all
three precisely for a psychiatric illness that is of easy diagnosis. Surely it
is of unusual therapeutic treatment, with the excuse that "As you know
about, they are Down persons."
Three cases.
Case 1.
January 2004: Female, 27 years, with Down
syndrome, as standard trisomy 21 (47 XX +21). She was born from a mother of 26
years, with premature delivery and birthweigh < 2500 grams, with cyanosis,
and not physiological high blood bilirubine.
During his first year of life she was normal
sleepy and normal feeding, without any pallor, any weeping for no reason,
without frequent illnesses from cooling, but with a modest tendency to
"gastroenteritis."
Walking occurred at 24 months, but she was
always hyperactive. She attended the full junior high school, but her academic
level, as the parents confirmed, does not work out between 1-2 years of
elementary school. She doesn't know how to read.
Currently she attends an
educational-rehabilitative centre. Since some years he has many more
difficulties in having relationships with other people and in serenely facing a
social life, if compared with other peer Down persons.
In fact, she prefers to stay alone or to
have favoured relations with persons she knows well. These persons look for
helping her in her difficulties, however without any saving up by his anger
excesses (often apparently groundless). During them they can get strong slaps,
kick and spit. Right after these outbursts she shows much sorrily of what she
has done. For her mother, in the aggressive moment she is not aware. She does
not meet the other to do anything and she keeps always some safety distance.
People may cross only if she agrees.
In some moments and with very fewer persons
that know her since a long time, she is affectionate and loves the caresses.
Even these moments and the related dynamics are always decided by her, who is
approaching the persons usually by her back. There is an other aspect of the
personality of the young woman, who seems wounded from the other people's gaze.
Then she is huddling on herself to avoid any ocular contact with the external
world. If someone crosses her "personal space," the mentioned
outbursts come out.
Moreover, she has strong links with her
daily rhythms, till that any change in the daily routine drives her to an
inhibition stop. She does not talk with anybody, stays with her head down and
covers her eyes with the hair, with her posture crouched and her hands hidden
in her pockets. Usually she has stereotyped behaviour with the fingers. She
could do little balls with the plasticine even for hours, by doing them rotate
between her hands.
In front of a ball she stops, and watches it
or turns it between her hands. Besides there are the echolalia and a personal
reduced language that are his preferred communication tools, mainly when she
has no stimulations and when refuses to do anything. In many occasions she
doesn't answer to the verbal calls, like a deaf person.
She shows a scarce interest for her
surrounding. The learning difficulty worsened because the poor attention and
the full indifference about what does not go according to her loved behaviour
(to go to hairdressing, eating, playing with the plasticine).
For all these reasons her life is much
limited, we do not know by a reversing block or by irrecoverable loss.
Following this description, the picture
seems belonging more to an autism form and other physicians diagnosed it as
such. She took, with zero results, neuroleptics and GABA catabolism inhibitors.
During the consultation I recorded: Regular
sleep with normal falling asleep, but initial insomnia in premenstrual days.
She often wakes up once for night to urinate.
In the mornings she is hungry at once, but
she is not particularly greedy of sweet things, if not ice cream and chocolate.
She doesn't appreciate the meat broth, eats few cooked vegetable, few fruit and
refuses the raw vegetable. For the rest, her diet is suitable.
Her bowel function inclines to atonic
constipation.
She bears well both the cool and the heat,
does not show behavioural differences between morning and afternoon. In
premenstrual days she is more emotionally sensitive. The menses' cycle is short
(less than 28 days).
During the consultation she was hiding after
a screen, but it seems she payed full attention. At the moment of going out she
gave me a kiss on my cheek.
As for my experience in autistic Down Ss, We
are dealing not with autism, but with depression with autistic traits. Ex
juvantibus, the therapy with amitriptyline + perphenazine and bromazepam will
confirm us if this diagnostic hypothesis was right.
September 2004: The followup confirmed the
diagnosis of atypical depression.
Case 2.
November 2003.
Female, of 22 years at the first
consultation, with Down syndrome Down as standard trisomy 21 (47 xx +21). Born
from a mother of 25 years, she did not suffer in embryonal and foetal age and
her delivery was to term, with birthweigh of 3150 grams. Since she was a baby,
she had never taken some illnesses from cooling. She ate and slept regularly.
Walking came out to about 18 months. She had bedwetting till 6-7 years. Biking
was never achieved. The presence of a light convergent squint leads to suppose
a previous brain suffering (at birth?) in the origin areas of oculomotor nerves.
Parents brought her to consultation for
depression and inhibition lasting since nearly a year. She often cries, and has
developed phobic troubles for windows' curtains. Motor stereotypies, but not
rocking appeared. Treatments with fluoxetine or venlafaxine, did not show any
results but induced her atonic constipation.
She suffers from the cold, doesn't
appreciate sweet things, a few the meat broth, eats f
ewer fruits and vegetable. The milk and
dairy products intake is normal. At the mornings she has breakfast because a
little forced by the parents. The diet is suitable, with the above exceptions.
Falling asleep is easy, has some drooling in the sleep, reports of bad dreams.
Since more than one year her menses stopped.
She had confirmed the diagnosis of depression.
Case 3.
January 2004.
Female, of 22 years, with Down syndrome as
standard trisomy 21 (47 XX +21), born from a mother of 26 years. No reports of
troubles in embryonic and fetal age. Delivery happened to term, with normal
lenght, with birthweigh of 2540 grams. During the first year of life the
parents observed a light constipation and normal easiness to illnesses from
cooling, not changed later on.
Walking was achieved at 23 months. She
attenden a professional school for the flowers cultivation. She had an
epileptic fit in her 16 years, probably following the light stumulation in
disco.
Since her birth to a year and half ago she
hade care by prof. Lejeune first and prof Rethoré then ( with folic acid,
deanol aceglumate, levotiroxine, selenium).
Since about a year she shows evident
asthenia symptoms with great psychomotor inhibition that led to suggest a
depression. The drug treatments stopped on suggestion of an Italian
neuropsychiatrist when the girl showed first symptoms of psychomotor inhibition.
She inclines to postpone breakfast, eats
cooked vegetable, but few raw vegetable and fruits. She does not like sweet
things, only ice cream and some chocolate, she likes the meat broth. Since her
infancy, she was spastic constipated and now too. Daily bruxism is another
symptom.
Usually, she goes to bed late, and has
difficulties to wake, has no drooling in the sleep, and rarely speaks. In early
morning she is full slowed, but she quickens in the afternoon, speaks more in
the afternoon. She has opposition, but not like The Contrary Mary.
Now she has many furuncles on the face, is
indifferent to warm and to cool, does not have pallor days, nor fat hair, nor
oversweating. Still she has some articular cervical blocks, but not skin
paresthesias as in childhood. Menses run normally. In the premenstrual days she
has frequent hotflashes, irritability and nausea. In the first day of the
menses, diarrhea and vomit can occur. She masturbates by rubbing.
In past, when she spent by the sea, she was
more irritable. She liked going on horseback.
I confirmed the diagnosis of depression.
Discussion.
This third report is now only clinical and
anecdotal, but differently of the two preceding ones, has the third decade life
as the frame of reference, and depressive symptoms at the moment of my first
examination.
Then the depression did not appear in Down
subjects already in therapy with drugs, (Cocchi, 1995 ), some of them surely
even antidepressants ( l-glutamine, carbamazepine, s-adenosil-l-methionine,
5-hydroxiitriptophan).
The symptoms are primarily psychic and point
up this depression form not distinct from that of the non-Down adult.
These three depression cases in Downs are
only females. By now this doesn't want to say anything, because few to do
prevalence induction. Incidentally however I need remember that in the
preceding research (Cocchi 1995 ) there was female prevalence.
As for the origin of this depression, it is
possible that a reactive component due to the perception of the social impact
of the Down syndrome, makes up a causal factor. However I am always more
convinced that the same illness, because of its metabolic trouble of
homeostasis (Cocchi, 1993) be the primary cause.
While in two last cases the usual depressive
aspect is evident, the first one did get a diagnosis of autism. An autism
insurgent in adult age, in itself is much doubtful pathology.
I do not like to go further with suggestions
and explanations, which do not find sound bases in only three cases.
In the literature there are references to
the depression in Downs ( Szymanski and Biederman, 1984; Warren, Holroyd and
Folstein, 1989). The one I reported in past (Cocchi, 1995) perhaps was the
first clinical and therapeutic casuistry sufficiently wide, related to subjects
living in their families. Moreover, it came out from the clinical experience of
an only physician.
Conclusion.
By now it doesn't exist more doubt that
subjects with mental retardation ( Matson 1982; Matson 1983; McGee and
Menolascino, 1990; Fleisher and Weiler, 1990 ) even Down ( Warren, Holroyd and
Folstein, 1989) can develop frankly depressive episodes in the third decade of
life. They threaten and embarrass diagnosis and intervention abilities of their
care-givers.
Following the three cases here reported, it
results that the depressive episodes could be much different from similar
episodes in not-Down persons, by presenting with clearly autistic-like
features.
References.
Cocchi R.: Drug therapy in Down syndrome. A
theoretical context. It. J. Intellect. Impair. 1993, 6: 143-154.
Cocchi R.: La depressione nel soggetto Down:
Indagine epidemiologica e clinica su 510 casi. Riv. Ital. Disturbo. Intellet.
1994, 7: 93-100.
Cocchi R., Occhialini O.: La viloxazina come
farmaco di scelta nella depressione degli epilettici e dei cerebropatici: 13
osservazioni. Rass. Studi Psichiat. 1981, 70, 1-9 (numerazione estratto).
Cocchi R., Occhialini O.: La viloxazina nei
bambini cerebropatici con o senza epilessia. Rapporto su 8 casi. In: Antidepressivi
atipici. Alternative ai triciclici nella terapia della depressione. Flaccovio,
Palermo 1982: 203-206.
Cocchi R. Depressione in 45 soggetti Down:
Resoconto clinico e terapeutico. Riv. It. Disturbo Intellet. 1995: 8: 255-260.
Fleisher M.H., Weiler M.A.: The prevalence
and specific aspects of depression in retarded individuals. In: Dosen A.,
Menolascino F.J.: Depression in mentally retarded children and adults. Logon,
Leiden, 1990: 51-61.
Matson J.L.: Depression in the mentally
retarded: A review. Educ. Train. Ment.Retard. 1982, 17: 159-163.
Matson J.L.: Depression in the mentally
retarded: Toward a conceptual analysis of diagnosis. In: Hersen M., Eisler R.,
Miller P. (eds): Progress in behavioral modification. Academic Press, New York,
1983.
McGee J.J., Menolascino F.J.: Depression in
persons with mental retardation: towards an existential analysis. In: Dosen A.,
Menolascino F.J.: Depression in mentally retarded children and adults. Logon,
Leiden, 1990: 95-111.
Szymanski L.S., Biederman J.: Depression and
anorexia nervosa of persons with Down syndrome. Am. J. Ment. Defic. 1984, 89:
246-251.
Warren A.C., Holroyd S., Folstein F.: Maior
depression in Down syndrome. Br. J. Psychiat. 1989, 155: 202-205.
Posted on Internet on February 2004. Copyright by Renato Cocchi, 2004.
Author's address: dr Renato Cocchi, via
Mercalli 10
42100 Reggio Emilia (Italy)
renatococchi@libero.it