Pretest self-assessment question (answer at the end of the case)

Which of the following are most accurate about gabapentin and its ability to treat psychiatric symptoms?

A. It alleviates mania

B. It alleviates panic attacks

C. It alleviates obsessive compulsive symptoms

D. It reduces alcohol consumption

E. A and C

F. B and D

G. All of the above

Patient evaluation on intake

27-year-old man states he is in between graduate school assignments and “has some concerns”

Has been depressed and anxious but is most concerned about his alcohol use

Psychiatric history

Became increasingly anxious two years ago and was placed on the SSRI sertraline (Zoloft)

• – Was experiencing bouts of generalized worries but these episodes would last weeks but never more than a few months

• – Would have minor panic attacks, but not major disabling ones. Sometimes these are triggered by stressors but many happen unexpectedly

• – He states he is socially anxious at times, but this occurs more often in academic circles compared to social circles

• – As a teenager, he had obsessive needs to have symmetry and to wash his hands, but has not had these symptoms since his late teens

• – He denies PTSD

Alludes to being depressed at times

• – Sleep is disrupted unless he takes the BZRA zolpidem-CR (Ambien-CR)

• – Experiences fatigue, amotivation, and admits to some low points where he has contemplated suicide

• – These may last a few days to a few weeks

Will have bouts of increased activity and less need for sleep

• – Denies mood elevation at these times, and these episodes usually begin when he takes on new tasks, jobs, interpersonal situations

• – He does feel more capable but denies any grandiosity or invincibility feelings at these times

• – These last from days to weeks depending upon his life events

The alcohol use increased over the last few weeks to the point of four- to five- day binges of excessive alcohol drinking where, for the first time, he started drinking in the morning

• – Never has been a daily drinker but admits to binges on weekends

  • Has had no legal, medical, or social consequences as a result

  • Does admit that once he has four to five drinks he often drinks several more and loses control of his ability to stop drinking

• – Admits that he has tried to cut back on drinking, would get annoyed if asked to stop, feels guilt now about his excessive use, and on his last binge he drank an “eye-opener” drink in the morning

  • After he tried to quit, he felt compelled to start drinking on the first morning of attempted sobriety

• – Increased tolerance over the years is noted but has never experienced alcohol withdrawal

• – Suicidal thinking escalates now when heavily intoxicated and the most recent alcohol binge scared him and convinced him to seek help

Social and personal history

Graduated from college and is working on a doctorate in the humanities

Has a girlfriend and has sustained meaningful relationships without difficulty

Drinks coffee in the morning, and only smokes cigarettes when drinking alcohol

Medical history

Denies medical problems

Family history

Thinks one of his grandmothers suffered from MDD

Mother takes an SSRI but he cannot recollect which one, and he is unclear if she is depressed, anxious, or both

He has no family members with schizophrenia or bipolar disorder

Medication history

Has been treated with two SSRIs by his PCP

• – In college he took paroxetine (Paxil) 20 mg/d but was drinking and smoking most of the time so is unclear if it helped, or not

• – Sertraline (Zoloft) has been used over the last year, ranging from 50 mg/d to 100 mg/d

  • 50 mg/d is partially ameliorative of his symptoms at best

  • 100 mg/d made him anxious and agitated

• – The BZRA zolpidem (Ambien) 10 mg at bedtime has been used for insomnia but became ineffective due to tolerance

• – Zolpidem-CR (Ambien-CR) was next used and is effective now

• – Alprazolam (Xanax) 1 mg/d has been used as needed for anxiety