Psychotic depression associated with Graves' disease: A case report on treatment prioritization

Graves' disease can be accompanied by psychiatric symptoms, including affective and psychotic manifestations. When a well-defined psychiatric syndrome occurs concurrently with a medical illness, determining whether it is directly attributable to the medical condition or represents an independent psychiatric disorder precipitated by it can be difficult. Treatment sequencing becomes particularly important when psychiatric symptoms interfere with treatment of the medical illness.

A woman in her 50s was admitted with severe psychotic depression characterized by delusions of guilt, hypochondriacal and poisoning delusions, marked agitation, food refusal, and medication refusal. Graves' disease was diagnosed concurrently. Severe agitation prevented adequate nutritional support and initiation of antithyroid treatment, and intravenous haloperidol produced little improvement. After confirming hemodynamic stability and the absence of clinical features suggestive of thyroid storm, modified electroconvulsive therapy (mECT) was initiated in consultation with endocrinology and anesthesiology. Agitation markedly improved after the first session, allowing physical restraint to be discontinued and oral treatment to begin. Methimazole was subsequently initiated. The GRID-HAMD-17 score was 39 on hospital Day 11 and 2 on hospital Day 36. Six mECT sessions were administered, and psychiatric remission was maintained during 2 months of outpatient follow-up.

The etiological relationship between Graves' disease and psychotic depression cannot be determined from temporal association alone. Nevertheless, treatment decisions cannot always await etiological clarification. When severe psychiatric symptoms prevent treatment of a coexisting medical illness, rapid psychiatric stabilization may itself be necessary to enable medical treatment. In this case, mECT rapidly improved severe psychomotor agitation and behavioral dysregulation, thereby restoring the feasibility of treating the coexisting physical illness.