Case outcome: interim follow-up visits through nine months

A Lyme disease expert deems patient to be suffering from this neuropsychiatric illness

Based on this opinion, the mounting fatigue-related side effects, and pressure from family members, she stops her psychotropic regimen and starts multiple antibiotic therapy (doxycycline, rifampin, zithromax) for Lyme disease

• – MDD returns fully within a matter of weeks

• – A full course of antibiotics has failed to treat her possible Lyme disease and its secondary depression

• – She is amenable to restarting her psychotropics but again wants to avoid fatigue

Restarts fluoxetine (Prozac) up to 40 mg/d and is started on the less-sedating atypical antipsychotic aripiprazole (Abilify) up to 4 mg/d as it is often clinically less sedating than olanzapine

• – It is an approved MDD augmentation strategy

Given that the fluoxetine (Prozac) inhibits CYP450 2D6 hepatic enzymes, the aripiprazole dose is likely elevated in her plasma (likely equivalent to 8–12 mg/d)

• – This atypical antipsychotic is also approved as an adjunctive treatment for MDD at this dose range

Restarts lorazepam (BZ) and trazodone (SARI)

This new regimen attempts to re-create the last semi-effective regimen but with the hope of less sedation

She experiences some MDD symptom relief again but also complains of daytime sedation

• – She will not tolerate this problem

Trazodone (Desyrel) and lorazepam (Ativan) are lowered significantly to help resolve this sedation side effect, with reasonable results

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

The atypical antipsychotics seem to be helpful in controlling her depression to a certain degree

When the MDD improves, then the anxiety symptoms are also much better controlled

• – This suggests that her GAD and PTSD symptoms are likely subsyndromal and being driven, or escalated, by her depressive state

Compliance issues are clear in that she will not tolerate fatigue-related side effects

Will need to keep working on the medication regimen to hopefully gain a full remission of symptoms

Question

Antibiotic treatment did not alleviate her alleged Lyme disease-induced MDD. What does this mean?

Her MDD is not from Lyme disease as her symptoms did not resolve

Her MDD still could be from Lyme disease as this infectious illness may have caused damage to her nervous system and her MDD symptoms continue as a result

Case outcome: interim follow-up visits through 15 months

Develops EPS (akathisia) on aripiprazole (Abilify), which is not resolved with BZ therapy

Insists on a tapering off of the atypical antipsychotic

• – Refuses future atypical antipsychotics

• – Refuses to take other akathisia antidotes (beta-blockers, anticholinergics)

Continues on fluoxetine (Prozac) and is sequentially augmented with stimulants, then L-methylfolate (Deplin) 15 mg/d, then combined with bupropion-XL (Aplenzin) 348 mg/d, and finally therapeutically dosed trazodone-ER (Oleptro) 300 mg/d

As the anxiety fluctuates, she is tried on several different BZ anxiolytics for better symptom control

• – These interventions do not prevent an MDD full relapse

She begins drinking alcohol, which has never been a clinical issue

This abrupt misuse is successfully treated with acamprosate (Campral) 1998 mg/d

• – This glutamate metabotropic receptor antagonizing drug unfortunately did not help lower her anxiety, despite anecdotal reports suggesting it has anxiolytic activity

• – This medication was also paired with a harm-reduction, stage-of-change, motivational-interviewing therapeutic approach

Rehospitalization occurs as she becomes incapacitated and more suicidal

• – A family member makes contact and states that he had never disclosed this to the patient, but also has had chronic depression and was successfully treated with ECT many years ago

• – After informed consent, the patient undergoes ECT treatment while on the inpatient service