Question

Are you comfortable resourcing materials with the patient present in session?

Yes, this type of informed consent is medicolegally protective

Yes, this approach often increases patient’s comfort level as it is felt to be a thorough process

No, this takes too much time in session

No, this likely makes the patient feel that the clinician does not know enough in that he/she needs to look it up

Case outcome: interim follow-up visit at four months

The patient was started on low sertraline (Zoloft) 12.5 mg/d

• – Even though there is little CYP450 enzyme risk, given that it is metabolized by many pathways she is proficient in, she has had reactions to SSRI and SNRI in the past

• – Starting on a very low dose makes clinical sense to reduce potential side effects and nocebo effects

She calls stating there is now marked anxiety and worsening depression

• – This is attributed to the sertraline

• – As a result, she is placed temporarily on alprazolam (Xanax-XR) 0.5 mg/d with some relief

• – This might be typical activating side effects due to excess serotonin that she experienced on previous SSRI and SNRI therapy

• – This might be anxiety and a nocebo effect (hysterical side effects)

• – It is unlikely that this is a CYP450 deficiency-induced toxicity because sertraline is metabolized through several CYP450 pathways

Attending physician’s mental notes: interim follow-up visits through four months

Patient has now failed two SSRIs and one SNRI due to side effects, and failed an NaSSA (mirtazapine) antidepressant

Zolpidem-CR allows some improved sleep and she agreed to escalate alprazolam for daytime agitation control, but has gone back to adamantly refusing all potentially anxiogenic antidepressants

As we seem to be restricted to treating patient’s surface symptoms of insomnia and anxiety, she is reoriented and advised about proper sleep hygiene and motivated to start psychotherapy, which she agrees to do

Case outcome: interim follow-up visits through six months

Medications have reverted back to a combination of zolpidem and zolpidem-CR for sleep and alprazolam for daytime agitation, which again are manipulated with advice between visits

She is a bit better in these areas but continues to have full MDD symptoms and to be incapacitated most of the time

Psychotherapy has started but has not helped much as yet

She asks about medication options that are not “full-blown” antidepressants, use different non-SSRI/SNRI mechanisms, and do not interfere with her CYP450 metabolic deficiencies

She ultimately agrees that mirtazapine (Remeron) was helpful and asks to be retitrated, only to call back later stating it had to be stopped, again due to fatigue (which was not a significant problem when used previously at even higher doses)

She asks again about medication options that are not full-blown antidepressants, use different mechanisms, and do not jeopardize her deficient CYP450 metabolic pathways

• – Offered lithium, which is 100% renally excreted and not CYP450 metabolized

• – Offered paliperidone (Invega), which is mostly renally excreted and requires no hepatic metabolism

  • It is an atypical antipsychotic that may help control agitation and possibly depressive symptoms in an off-label manner

• – Offered the selegiline transdermal patch (Emsam) MAOI antidepressant, which tends to avoid first-pass liver metabolism

• – Offered alpha-2-delta calcium channel blocking epilepsy medications such as gabapentin (Neurontin)

  • It is also renally excreted and may have off-label anxiolytic potential

She accepts lithium now as a montherapy for MDD

• – Declines the patch as she feels that there was no way for her to “control her dose”

  • Further exploration of this reveals that she would often halve or quarter her doses of previous medications