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MRI in primary lateral sclerosis

To the Editor: Although Gainotti’sl review suggests that anosognosia and major depression may not coexist, Starkstein et a12 recently reported two cases of major depression following an acute right hemisphere stroke despite the presence of anosognosia. We previously reported3 a case that strengthens the opinion of Starkstein et al. This 44-year-old man suffered from major depression with psychotic characteristics within 8 weeks after a right parietal stroke. He had slight left hemiparesia and total anosognosia. He was either apathetic or restless. He denied feeling depressed, but said that he was probably already dead, and that the end of the world was in the near future. Haloperidol (15 mg/d orally) failed to improve the patient. Themes of delusion were suggestive of melancholia, and we treated the patient for major depression with delusion using amitriptyline (75 mg/d orally), and the patient was left free of any delusion within 1 month. He then reported feeling depressed he improved under clomipramine (150 mg/d orally). This case report suggests the following hypothesis: this patient neglected his handicap and his mood, and this kind of alexithymia led him to delusion. Alexithymia has previously been reported in masked depression: where the patient denies feeling depressed but has various medical complaints. Moreover, patients with severe depression often deny feeling depressed but report morbid delusions. The right hemisphere is considered as having a major function in the perception of emotion. We suggest that the atypical presentation of depressed mood after right hemisphere stroke may be a consequence of neglect of the mood. Following right hemisphere stroke, a psychiatric examination should consider the possibility of depression before unusual mental disorders are diagnosed.