Case outcome: interim follow-up visits through 36 months

Now returns with some mild depressive symptoms and anxiety is also a bit worse

SSRI is increased to the maximal approved escitalopram (Lexapro) dose of 20 mg/d

This intervention markedly helps alleviate the MDD and SAD for many more months

Unfortunately, toward the end of this three-year euthymic period, he returns more depressed, requiring an intervention

Question

What would you do next?

As lamotrigine has now failed as a maintenance drug from a depression standpoint, it should be tapered off

As escitalopram has failed to treat his depression it should be tapered off

As lamotrigine has worked well prophylactically against mania, it should be continued

As he has now failed three SSRIs and an NDRI, a switch to a novel class of antidepressants is warranted despite a slightly increased inherent risk in mania escalation

Case outcome: interim follow-up visits through 48 months

The depression is now interfering with school and threatens to impede his career

This is problematic as he has just been accepted at another premier graduate program out of state, to which he hopes to transfer

The now ineffective escitalopram (Lexapro) is tapered off and he starts the SNRI desvenlafaxine (Pristiq), and is warned of increased manic escalation risks over the last SSRI approach

Continues on higher-dose lamotrigine (Lamictal)

As he is due to move, he will have less social support as he is away from his family and will have less monitoring of his symptoms as he is farther away from his psychiatric practitioner

While away, he was “feeling well” and stops his medications

This was followed by a depressive relapse, a self-imposed restart of his unipolar SNRI, desvenlafaxine (Pristiq), without restarting the mood stabilizer, and a more sustained hypomanic spell ensued

• – This caused him to leave school again

Both medications were re-established

• – Euthymia and a relative lack of SAD were also re-established

Recovered enough to move away again and take a job in another city while contemplating a return to graduate school

While at the new location, he suffered an increase in insomnia and anxiety to a moderate degree and developed a persistent rash causing the lamotrigine to be discontinued

With strong encouragement, he starts another mood stabilizing atypical antipsychotic agent in its place, aripiprazole (Abilify), to avoid future hypomania, and its use may effectively thwart the new anxiety and dysphoria symptoms as it is an augmentation to continuing desvenlafaxine (Pristiq) use

• – A few weeks later, the patient called reporting restlessness and more insomnia

• – From a distance this appears to be akathisia

• – Starts atenolol 25 mg/d as an antidote to this EPS

• – Weeks later, reports that he left his apartment due to manic level behavior; e.g., spending and legal problems that were more pronounced and sustained than previously reported

Back in session finally, it was clear that his akathisia was actually goal directed and impulsive hyperactivity that was associated with a sense of invincibility and elevated mood

The severity level of this mood episode is high enough for him to qualify as a bipolar I patient as he has met his first full manic criteria episode

Again, the pattern appears to be fueled by relatively unopposed antidepressant use as the aripiprazole (Abilify) dose at the time (10 mg/d) was subtherapeutic as an anti-manic agent and not able to prevent or stop the emergence of a manic episode