Case outcome: initial visit

Patient is educated about his working diagnosis being complicated due to his minor levels of several symptom clusters, his clear AUD, and that picking an approved monotherapy may be difficult

He is educated about the conflict of interest in that he presents being worried about alcohol misuse and is also on two addictive sedative-type medications

Admits he has used them concurrently with alcohol in the past, but has not dose-escalated his prescription medications on his own

Feels his lower-dose SSRI, sertraline (Zoloft), is partially effective and asks to keep it as it is and not to “give up on it”

Agrees to taper off his potentially addictive zolpidem-CR and alprazolam with minimal resistance, assuming that his insomnia can be controlled by another regimen

Further investigation

Is there anything else you would especially like to know about this patient?

Can anyone corroborate his history with regard to his possible hypomania spells?

• – Family members deny noticing any of these

• – There is no evidence of mood elevation, euphoria, expansive thoughts during these spells

• – There have been no impulsive, dangerous, or risky behaviors associated with these

Question

What would you prescribe in addition to continuing the sertaline (Zoloft) SSRI?

Add another antidepressant with more sedating qualities, such as a SARI (trazodone [Desyrel], trazodone-ER [Oleptro]), a NaSSA (mirtazapine [Remeron]), to offset the agitation he developed on higher-dose SSRI and better treat his insomnia

Add an atypical antipsychotic that is more sedating in nature

Add a 5-HT1A receptor partial agonist anxiolytic, buspirone (BuSpar)

Add an antiepileptic agent such as gabapentin (Neurontin), divalproex sodium (Depakote), or topiramate (Topamax)

Add an alcohol cessation medication such as acamprosate (Campral), naltrexone (ReVia), or disulfiram (Antabuse)

Case outcome: first interim follow-up visit one week later

Agrees to lower the controlled medications

Attempt is made to select a medication that may control a majority of his target symptoms in one monotherapy

Off-label gabapentin (Neurontin) is chosen for this reason as it has some peer-reviewed trial data supporting its use

• – In SAD

• – In PD

• – In insomnia, as there is evidence that it may promote more restorative slow wave sleep and has sedating clinical side effects

• – In alcohol-dependent and-abusing patients for

  • Detoxification as an adjunctive treatment

  • Alcohol withdrawal adjunctive treatment

  • Reducing alcohol consumption

  • Improving alcohol cessation

• – A similar agent, pregabalin (Lyrica) has strong data supporting its use in GAD but carries a C-V mild addiction propensity label in the United States per the FDA

  • In the United States, possibly addicting drugs are given a class labeling based upon severity of risk

  • C-I drugs are highly addictive and most often are illegal, e.g., cocaine

  • C-II drugs include stimulant medications and opioid pain medications

  • C-V drugs would be of the least addictive potential

• – Both agents are neuronal alpha-2-delta ion channel inhibitors that were initially approved as adjunctive treatment in epilepsy, but have gained more popularity in the treatment of neuropathic pain disorders and FM

• – Pregabalin also has a sedating side-effect profile, which may be utilized to induce sleep as a therapeutic effect instead of an adverse effect