Abstract
Introduction
Depression is a leading cause of disability worldwide. Approximately 85% of patients with depression have significant symptoms of anxiety and demonstrate mixed symptoms of anxiety and depression. The latter often runs a chronic course, becomes treatment-resistant and is associated with impairment of quality of life, social functioning, and a higher suicidal rate. Despite the substantial burden of treatment-resistant anxiety and depression on both patients and society, the currently prescribed antidepressants have limited treatment effectiveness.

Methods
This report describes a 28-year-old obese hypogonadal male with ADHD and treatment-resistant chronic mixed anxiety and major depressive disorder, associated with suicidal thoughts. The patient has been treated with a combination of testosterone gel and oral methylphenidate for 7 weeks. Following partial improvement, the combination treatment was augmented with sertraline (a selective serotonin reuptake inhibitor). The patient’s self-reported symptoms and the Hamilton rating scales for depression and anxiety have been used to quantify the symptom severity and monitor the effectiveness of treatment during a follow-up period of 14 weeks.

Results
Stand-alone testosterone- methylphenidate combination improved the subjective symptoms and objective measures in this patient. After 7 weeks of treatment, the patient reported a 60% improvement in his symptoms which has been in line with the improvement observed on Hamilton rating scales (>55% reduction from baseline). The addition of sertraline led to further improvement in the self-reported symptoms (> 90% reduction from baseline) and on the Hamilton rating scales (>80%).

Conclusion
The treatment approach for patients with treatment-resistant depression and anxiety needs to take into account the patient’s clinical profile including comorbidities, and biological characteristics such as body mass index and hormonal profile. Addressing deficits such as hypotestosteronemia and dopaminergic dysfunctions as in this patient might lay the cornerstone for clinically effective treatment, facilitates antidepressant action, and eventually reduces the suffering of the patient and the burden on the community.

Key words: Treatment resistant depression and anxiety, testosterone, methylphenidate