Psychotherapy history

Has not had psychotherapy outside visiting a counselor a few times in college

Patient evaluation on initial visit

The patient presents with a mixture of subsyndromal depression and anxiety

Has brief, discrete periods of activity elevation that seem driven by anxiety in new situations

• – Possibly hypomania

Now has a problematic, acute escalation in his drinking pattern, which left him temporarily more depressed and even suicidal

Seems motivated to change his drinking pattern, but would like to address his depression and anxiety symptoms as well

Current psychiatric medications

Zolpidem-CR (Ambien-CR) 6.25–12.5 mg at bedtime as needed for insomnia (BZRA)

Alprazolam (Xanax) 0.5–1 mg/d as needed for anxiety (BZ)

Sertraline (Zoloft) 50 mg/d (SSRI)

Question

Do any of these medications concern you regarding this patient’s comorbidities?

Yes, given his alcohol misuse, his BZRA (zolpidem-CR) should be tapered off

Yes, given his alcohol misuse, his sedative–anxiolytic (alprazolam) should be tapered off

Yes, his SSRI (sertraline) should be discontinued due to history of possible mood elevations and hypomania

No, he seems to be partially treated and some patients may require dose escalation for better symptom control

Attending physician’s mental notes: initial evaluation

Seems to have minor depression and minor anxiety symptoms but does not meet a full DSM-5 categorical diagnosis for any disorder

Has bouts of increased goal-directed activity that seem to be driven more by anxiety in new social situations, but hypomania must be considered as he may underreport the severity and duration of these episodes

He appears to be binge drinking and is starting to gain consequences and repercussions from his drinking. He has a few DSM-5 AUD symptoms, perhaps placing him in the mild to moderate category of severity

Will have to have three or four subsyndromal DSM-5 symptom clusters, but they have added up to cause enough psychological distress that he wants to be treated now

Question

Which of the following would be your next step?

Discuss with the patient which target symptoms (anxiety, depression, insomnia, hypomania, alcohol use) are most impairing and select a medication based upon this rationale

Focus on alcohol sobriety as this has the highest risk for causing suicide in this patient

Focus on mood stability as he might be a bipolar II or cyclothymic disorder patient

As he has no definitive categorical disorder, refer for psychotherapy to address his long-term dynamic issues, anxiety and depression symptoms

Refer for psychological testing to better delineate his symptoms

Attending physician’s mental notes: initial evaluation (continued)

He is distressed and now motivated for active change

Views his alcohol use as a problem and being “out of control” and relates some of it to self-medicating his stress, anxiety, and depressive symptoms

Bouts of increased energy seem to be driven by novelty in new social situations and tasks, which may be a personality trait, a response to anxiety, but differentially do not seem to be a sustained mood elevation or bipolar disorder phenomenon

Sees the alcohol use as the main issue and insomnia as the second most impairing target symptom

The use of excessive alcohol, a BZ, and a BZRA hypnotic are troubling

• – There is no evidence of misusing these controlled medications, but he is at higher risk for becoming addicted to them or accidentally overdosing

• – They are marginally effective now anyhow