Attending physician’s mental notes: interim follow-up visits through 24 months

After Patient #1’s dystonia resolved, there was a return of his mood lability and dyscontrol while off the typical antipsychotic

• – He is given an atypical antipsychotic with less significant EPS risk and is titrated to 10 mg/d of aripiprazole (Abilify)

• – Experiences a gradual return of his better controlled affective state

• – Develops mild akathisia but tolerates this until it remits a few days later

• – This atypical antipsychotic did not escalate any metabolic symptoms

• – His cardiac condition is treated

• – MDD lifts and his ability to tolerate interpersonal stress improves

• – Returns to gainful employment

Patient #2 experiences increases in interpersonal stressors, and develops full MDD, plus his mood lability markedly increases

• – Offered aripiprazole (Abilify) augmentation as this had benefitted his twin brother (Patient #1)

• – Given the use of fluoxetine (unlike his twin) with its ability to markedly inhibit the CYP450 2D6 enzyme, and thus elevate his aripiprazole levels abruptly; he is titrated much more slowly

• – Ultimately he is titrated to 8 mg/d (given his fluoxetine use, his blood levels could be double or triple his oral intake), but receives no benefit

Patient #2 next is switched from the SSRI fluoxetine (Prozac) to the SNRI venlafaxine-XR (Effexor-XR) up to 150 mg/d in the hope that its noradrenergic potential would help alleviate his mounting MDD symptoms

He continues the aripiprazole, trazodone, and zolpidem-CR

• – There is mild metabolic worsening (blood pressure increases with the addition of the SNRI)

• – Unfortunately, the aripiprazole was not as effective as in his brother’s experience

Asks to stop this medication

SNRI could not be escalated due to HTN fears per the PCP

Elects to start another atypical antipsychotic, risperidone (Risperdal), and it is titrated to 2 mg/d while closely watching for metabolic symptom worsening

• – Returns several weeks later feeling that he is moderately improved globally with regard to all symptoms

• – However, weight increased 10 lbs and blood glucose passes 100 mg/dL

After informed consent, given only his partial risperidone plus venlafaxine-ER regimen response, and an acute increase in metabolic symptoms, he is offered a trial of another atypical antipsychotic associated with less weight gain and metabolic syndrome risk

Ziprasidone (Geodon) is now titrated to 120 mg/d

• – Insomnia is marked and a third sleep-inducing agent, ramelteon (Rozerem) is added up to 16 mg at bedtime

The patient now takes zolpidem-CR (Ambien-CR), trazodone (Desyrel), ramelteon (Rozerem), venlafaxine-ER (Effexor-XR), and ziprasidone (Geodon)

• – The patient returns finally sleeping well, with gradual remission of the MDD symptoms

• – Experiences much less anger and tendency toward aggression. Seems to be able to better control his behaviors

• – Metabolic symptoms return to usual baseline

Case debrief

Patients #1 and #2 are identical twins who both present with essentially the same type of MDD with clear comorbid personality disorder

Both are involved in long-term supportive, eclectic psychotherapy

Both were compliant with medication management once they noted some symptom reduction

Both showed improvement with a combination of serotonergic agents plus atypical antipsychotics

Both showed a remission of depression and better ability to cope with interpersonal stress with improved affective control

Both received supportive, problem-oriented psychotherapy but no formalized CBT, IPT, DBT, or DDP approaches