recurrent episodes of brief depressive symptoms not lasting 2 weeks is not an uncommon clinical presentation . typically , they last only for a few days , but are associated with much morbidity . significant suicidal behavior has also been noted with such episodes . descriptions of brief depressions have been found historically in the work of a number of authors , but have been accepted as a diagnostic entity only in the latest editions of icd and dsm . treatment of recurrent brief depressive disorder ( rbdd ) has been controversial with evidence largely from case reports and series . our patient was a 48-year - old lady who was a local politician and who was carrying out her duties satisfactorily for the past several years . about a year and a half prior to her presenting to us , she developed symptoms characterized by low mood , anhedonia , easy fatigability , decreased concentration , hopelessness , and decreased sleep and appetite . these symptoms developed following a minor stressor at work and were clearly disproportionate to the stress . she had been an emotionally strong and confident lady earlier and was herself surprised at her current condition . she also developed prominent suicidal ideations and tried to kill herself by setting herself on fire , but was incidentally found and rescued by her maid . similar episodes occurred on almost a monthly basis for the next 18 months , each lasting 3 - 5 days . there was no history of mania or psychosis . in the inter - episodic period , initially , the patient did not realize that it was a psychiatric illness , but after several such episodes , she consulted a private psychiatrist who started her on escitalopram ( 10 mg ) . she changed psychiatrists and was tried on mirtazapine ( 15 mg ) irregularly for 3 months without improvement . she did not follow - up with one psychiatrist and therefore full doses were not tried . she eventually presented to us during an episode and was off all psychotropics at that time . we made a diagnosis of rbdd as per icd 10 and started her on paroxetine ( 10 mg ) . although her symptoms resolved in about 4 days time , the dose was gradually increased to 25 mg / day , but , in the following month , she again had an episode lasting for about 4 days . she scored 20 on hamilton depression rating scale this time and had somewhat less frequent suicidal ideation . about 25 days later , the patient again developed depressive symptoms in the form of mild fatigue and some decrease in self - confidence , which lasted for 3 - 5 days . however , the lack of confidence still prevented her from carrying out her duties in those 3 - 5 days , although otherwise she was symptomatically much better . however , with one session of supportive counseling , she managed to get back to work as well . in the subsequent month , although she complained of mild fatigue , there were no other symptoms and she started doing her duties satisfactorily . the patient was continued on the same dose and is on regular follow - up . three different double - blind , placebo - controlled trials of paroxetine in patients suggestive of episodes of rbdd have been negative . similar studies with fluoxetine , flupenthixol , citalopram , and mianserin have been negative , but small samples tried on carbamazepine , verapamil , and nimodipine have shown positive results . case reports of successful treatment have been published for lamotrigine , tranylcypromine , carbamazepine , lithium , mirtazapine , and olanzapine . the above discussion suggests that there is no unequivocal evidence of efficacy of any drug from methodologically sound studies . it needs to be highlighted that studies have tended to use samples with comorbid personality disorders , somatic illnesses , or frequent suicidal behavior . below , we have provided examples of methodological limitations of studies on paroxetine to illustrate this point . in a study of 91 patients treated with paroxetine , there was some effect in reducing suicidal behavior , but none on depressive mood , hopelessness , and anger . but paroxetine was also significantly more effective in patients who met fewer than 15 criteria for cluster b personality disorders than in those who met more than 15 criteria . thus , the presence of personality disorder might have led to the treatment of resistance and therefore might not paint the true picture of pharmacological treatment of this condition . it is therefore worthwhile considering antidepressants as the first choice in the treatment followed by mood stabilizers as second - line agents . including the current report , paroxetine , and fluoxetine are the only selective serotonin reuptake inhibitor ( ssri ) drugs that have yielded positive results . interestingly , these are the only two ssris that have additional noradrenergic properties at higher doses that can contribute additional antidepressant effects . unfortunately , there are hardly any reports of serotonin norepinephrine reuptake inhibitors , whether successful or otherwise , in this disorder . given the lack of clarity on distinct features of neurobiology of rbdd , this hypothesis is worth considering . while interpreting the results of this report , one must also remember that there are reports of recurrent brief depression going into spontaneous remission . one way to test this would be to suspend treatment and re - challenge if the episode returns . however , the present report being only a case report , needs replication in larger trials with representative samples .
recurrent brief depressive disorder is now a well - recognized type of depressive disorder . however , there is still no clear evidence base for its treatment . 
 the efficacy of several drugs including antidepressants and mood stabilizers in this disorder has been controversial . 
 methodological limitations need to be considered when interpreting the results of studies on efficacy of drugs in this disorder . 
 we report a case of recurrent brief depressive disorder that responded dramatically to paroxetine . 
 however , there is a need for larger , methodologically sound , double - blind , placebo - controlled studies .