Patient Case Study

Initial Presentation

Harry was fifty years old when he decided that he needed to find “a different approach” to treating his long-standing depressive symptoms. In the previous five years, he’d struggled with fatigue and low mood. Due to the symptoms, Harry had gone to his primary care provider who had listened sympathetically and prescribed an antidepressant. Unfortunately, the medication had only provided minimal benefits and the doctor tried switching the prescription to a different medication for depression. Neither drug provided adequate relief, so Harry’s primary referred him to a local psychiatrist.

Harry initially assumed he’d easily find relief with a mental health specialist. The psychiatrist added additional medications for Harry, including antipsychotics and benzodiazepines, but the depressive symptoms stubbornly refused to respond and Harry grew tired of the side effects. After five years of no relief, he wound up looking for alternative approaches.

Upon questioning, Harry described a low sex drive. He’d also slowly been gaining weight around the middle over the last decade. His sense of taste was poor and he often felt that he gravitated towards junk food. He was unaware of any family history of mental health conditions.

As far as sleep, Harry never felt rested upon awakening and his mouth was annoyingly dry in the morning. His wife also complained about how much he would snort and snore over the course of the night.

Based on his symptoms, comprehensive lab work and a sleep study was ordered to evaluate his condition further.

Initial Relevant Labs

• Total testosterone was low at 193 ng/dL
• Free testosterone was low at 22 ng/dL
• Plasma zinc was low at 58 mcg/dL
• Sleep study was positive for moderate to severe sleep apnea

Working Diagnosis

• Major depressive disorder secondary to sleep apnea, low testosterone and zinc deficiency

Initial Treatment for Depression, Sleep Apnea, & Nutritional Deficiencies

• Testosterone replacement injections
• Zinc picolinate 30 mg daily
• Continuous positive airway pressure (CPAP) treatment

Explanation

Low testosterone is a common finding in male patients struggling with depression (Fischer 2019). While the research is somewhat mixed, overall, it does support the fact that testosterone replacement in deficient individuals can help to improve mood (Walther 2019). Testosterone replacement can also help with reducing waist circumference and abdominal fat (Corona 2016).

Low levels of zinc have been associated with depression. In fact, as zinc levels decrease, depression symptom scores rise (Petrilli 2017). Treatment with zinc, typically as adjunctive therapy, has shown benefits in the treatment of major depressive disorder (Donig 2022).

Sleep apnea is a common condition. Rates of sleep apnea in the population are thought to range between 9% and 38%, with rising incidence as individuals age (Senaratna 2017). When present, sleep apnea can increase the risk for depression (Edwards 2020).

Follow-up Presentation

Two months later, Harry was feeling mostly recovered. While it had taken some adjustments, he finally got his CPAP working comfortably. His morning fatigue had resolved and his energy levels improved overall with CPAP use.

With testosterone supplementation, his libido had increased and it was having a positive effect on his relationship with his wife. He also noticed the beginning of some weight loss.

After being on zinc, his sense of taste had been restored. Harry found that it was easier to make healthy food choices when foods had more flavor. He was also convinced that both the testosterone and zinc had led to improvements in his mood and sense of well-being.

Follow-up Treatment

Treatments were continued as initially prescribed.

Case Summary

Harry’s case is a good reminder of how mental health can be related to other health issues, including, hormonal dysregulation, sleep apnea and nutrient deficiencies. When a patient isn’t responding to antidepressants or other medications, it’s always worth stepping back and doing a comprehensive assessment to better understand what other factors could be contributing to depressive symptoms. By taking a broader view, it’s often possible to further improve, if not resolve, mental health issues.