Case outcome: first interim follow-up visits four and eight weeks later

At the first follow-up visit, opts to leave the medications as given, to await her laboratory results and levels and collaboration with outside physicians

At the follow-up visit, she acknowledges the same MDD, GAD, PTSD symptoms as in the initial office appointment and agrees to increase the mirtazapine (Remeron) antidepressant to the full 45 mg/d dose and taper off the ineffective divalproex (Depakote)

Now recollects that her trial of lamotrigine (Lamictal) in the past was somewhat helpful and free of side effects

• – She asks if this can be restarted and it is titrated slowly per usual guidelines to avoid serious rash complications

Reports that she is having fluctuating anxiety and agitation and reveals that she takes her alprazolam (Xanax) as needed, but sporadically

• – She may “take three tablets a day for a few days, then zero tabs, then perhaps one or two….”

• – It is possible that on her off-use days she is having rebound anxiety as a side effect

She is convinced to take 2 mg/d routinely to avoid this possible rebound phenomenon, keep consistent drug levels present, and to also provide better longitudinal anxiety control

Shortly after this follow-up visit, she begins seeing a new, psychodynamically oriented psychotherapist who felt she required inpatient psychiatric stabilization, and she was admitted for a 10-day stay

Question

What would you suggest to the inpatient psychiatrist regarding possible treatment options?

Continue mirtazapine (Remeron) full dose as it has not had enough time therapeutically to become effective

Continue to titrate lamotrigine (Lamictal) as it has not reached its usual effective dose as an off-label depression augmentation

Switch the ineffective mirtazapine to a TCA or an MAOI antidepressant

Augment the current medications with an atypical antipsychotic, lithium, or thyroid hormone

Start ECT treatments

Start VNS treatments

Start TMS treatments

Attending physician’s mental notes: second interim follow-up visit at three months

Despite being a little better, the patient still has significant MDD symptoms

She has a clinically meaningful response now in that she is not suicidal, is less anxious, and has better affective range, but she is not a 50% responder yet

She now has side effects of increasing fatigue and sedation

• – This type of side effect makes her feel more guilty as she is “able to do less, and is less functional” as a result

She takes medications known to have serious, long-term side effects

• – She is warned of, and monitored for, metabolic disorder, which appears not to be a problem now

• – She is warned of, and monitored for, TD/EPS, which appears not to be a problem now

• – She is warned of, and monitored for, BZ misuse, which appears not to be a problem now

• – She is warned of, and monitored for, rashes, which appear not to be a problem now

Case outcome: second interim follow-up visit at three months

The patient returns from hospitalization taking

• – Olanzapine (Zyprexa) 7.5 mg/d (atypical antipsychotic)

• – Lorazepam (Ativan) 4mg/d (BZ)

• – Lamotrigine (Lamictal) 50 mg/d (mood stabilizer)

• – Mirtazapine (Remeron) 45 mg/d (NaSSA)

• – Zolpidem-CR (Ambien-CR) 12.5 mg at bedtime (BZRA)

This regimen differs in that she was augmented with an atypical antipsychotic, her sedative alprazolam (Xanax) was changed to lorazepam (Ativan), and zolpidem-CR (Ambien-R) was added to improve sleep

• – The patient now has a moderately better affective range, fewer psychomotor agitation symptoms, and states an absence of suicidal thoughts

• – She is felt to be 20%–30% better after her inpatient stay