Case Presentation
An 18-year-old man presented for psychiatric evaluation with complaints of “I’ve been anxious, irritated and sad most of the time…” and “…inability to get motivated/concentrate and retain information.”
Other Symptoms Mentioned
- Depressed and anxious mood
- Disruptive behavioural episodes with increased emotional reactivity and somatic anxiety symptoms.
- He described these episodes as “…break down in tears/hyperventilation. I ‘d blow up over something insignificant it would turn into a 5-hour argument.”
- These episodes occurred in the context of but were not confined to interpersonal interactions, “I also suffered them when thinking about career/future prospects.”
Medical History
- No history of mood or anxiety symptoms or behavioural changes similar to those that had led him to seek treatment.
- Never taken psychiatric medications apart from melatonin for sleep at dosages up to 10 mg per night starting 6 weeks prior to the initial psychiatric evaluation.
- His entire history of prior psychiatric treatment was limited to three visits with a psychotherapist over the month before the evaluation, which were not regarded to have been of benefit.
- Family psychiatric history was limited to a paternal half-sibling who the patient viewed as possibly depressed but had never sought treatment.
- No history suggestive of a substance use disorder
- No history or evidence of psychotic symptoms in the diagnostic interview.
Timeline Of Clinical Case History
- Probable COVID-19 exposure 20 weeks prior to evaluation
- Onset of fatigue and cough 19 weeks prior to evaluation
- Onset of neuropsychiatric symptoms 16 weeks prior to evaluation
- Positive test for SARS-CoV-2 antibody 5 weeks prior to evaluation
Clinical Exam
- The patient scored 16 on the beck depression inventory (BDI) and 17 on the beck anxiety inventory (BAI).
Diagnosis
- Features in common with panic attacks including prominent somatic anxiety with a paroxysmal onset, as well as features evident in bipolar mixed states, including heightened reactivity of mood and irritability.
- The working DSM-5 psychiatric diagnoses were other specified mental disorder and mild neurocognitive disorder both due to covid-19
- According to a clinical hypothesis that the patient’s presenting neuropsychiatric symptoms were related to prior illness with covid-19.
Treatment
- The patient was begun on oral famotidine 20 mg twice daily as per the drug labelling.
- No psychopharmacological or other medications were prescribed
- Melatonin was discontinued
- No behavioural interventions or lifestyle changes were made
Follow Up
1 Week Later
- The patient said he felt “much better” and noted substantial improvement regarding his symptoms of heightened emotional reactivity and diminished motivation and sustained attention.
- He estimated the time interval between starting famotidine and symptomatic improvement at 4 days and described his state on the fourth day as “clear-headed,” “…I woke up and got out of bed without feeling awful….”
- He reported no side effects.
After 3 Weeks
- The patient’s BDI and BAI scores were 1 and 2, respectively.
- A friend familiar with the patient’s prior behavioural baseline described the patient’s behavioural change following presumed COVID-19 illness and prior to treatment with famotidine as “…more irritable or quiet…exhausted.”
At 4 Weeks
- Following the initiation of famotidine, the friend described, “… he seemed much more conversational as well as productive…very focused….”
- The patient continues to report he is doing well at the time of this writing,
Further Treatment
At 12 weeks, following the initiation of treatment with famotidine, which he continues to take at the initially prescribed dosage of 20 mg twice daily.