Attending physician’s mental notes: initial evaluation

Nothing unexpected on mental status examination

Because she has had chronic, unremitting symptoms without any full inter-episode recovery, this makes her depression chronic. She should also be considered resistant as she has failed antidepressants from at least three different classes (TCA, SSRI, NDRI) and augmentation strategies as well

The best diagnosis for this patient may be chronic MDD

During ongoing care, will need to better assess for personality disorder, and observe for an AUD relapse

Increasing duloxetine (Cymbalta) to the 120 mg/d FDA limit seems reasonable in that it is more similar to her previous successful TCA trial than her failed SSRI trials. Duloxetine also likely increases NRI at higher doses that may be more effective in her case. Finally, it would be a definitive, full-dose clinical SNRI trial

Medically, she reports her liver is fine despite her past history of excessive alcohol use, but laboratory specimens should be sent for analysis regardless when duloxetine is used on AUD patients

In this case, she would be on maximal SNRI, NDRI, and 5-HT1A partial receptor agonist rational polypharmacy with the full-dose duloxetine being utilized

• – Rational polypharmacy occurs when drugs are added together to maximize their positives and complementary mechanisms of action and ideally when drugs can mitigate each others’ side effects as well

  • In this case there is some redundancy in NRI that could result in HTN, dry mouth, nausea, or activating side effects, which is not rationale but rather a calculated risk that must be monitored

  • Alternatively, the NDRI might mitigate sexual dysfunction and weight gain from the SNRI and provide unique dopaminergic facilitation for better antidepressant effectiveness overall

  • The 5-HT1A receptor partial agonist may facilitate greater activity of the SNRI and may mitigate sexual dysfunction of the same SNRI

Further investigation

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

What about details concerning this patient’s personality style or diagnostic and routine rating scale information?

Upon entering into patient practice, she was given diagnostic questionnaires regarding psychiatric disorders. Clinically significant scores were noted for MDD, persistent depressive disorder, social anxiety disorder (SAD), bulimia nervosa (BN), drug and alcohol misuse

These findings triggered the clinician to investigate further. The SAD symptoms seem to be more longitudinal and consistent with avoidant personality traits. The elevated score for BN seems relevant to past history where she was a comfort eater and gained weight. She is sensitive about weight-gain status post successful bariatric surgery. She clinically does not have an eating disorder now. The patient admits to two years of sobriety but answered questions based upon urges to use alcohol. Urine toxicology was negative

At admission, she was given diagnostic questionnaires regarding personality disorders. This revealed elevated schizoid, avoidant, and borderline traits but not necessarily disorders

In practice, utilizing routine outcomes-based rating scales is becoming more routine and is highly suggested in MDD treatment guidelines. She was given the Inventory of Depressive Symptomatology (IDS) and scored in the moderate range for MDD as well