Question

Based on what you know about this patient’s history, current symptoms, and treatment responses, do you think that a bona fide, formal trial of an established evidence-based psychotherapy is warranted?

Yes, a referral for PDP is warranted

Yes, a referral for CBT is warranted

No, this patient has had many years of supportive, eclectic style psychotherapy and further psychotherapy intervention is unlikely to be effective

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

The patient is obviously depressed and clearly has some personality traits that are likely to make her more resistant to medication treatment in general

The patient does have some clear strengths in that she is consistently gainfully employed and has had the ability to maintain successful relationships with significant others, peers, and those in authority. She seems to be in a solid recovery from her substance misuse. She is thoroughly compliant with medication management visits and taking medications as prescribed. Given these things, the use of ECT may not be warranted as it would disrupt her work, which she views as a positive and protective factor against further depressive decline

There is a history of compliance to antidepressant trials where full, therapeutic dosing has been utilized

Given her lack of formal outcome-based psychotherapy, this may be warranted at this time as well as maximizing the dose range of the medications she was on at the time of admission

It would make sense to discontinue her potentially dependence-forming BZ and her ineffective buspirone (BuSpar) and trazodone (Desyrel) agents

Case outcome: interim follow-ups through four months

Full dose, 120 mg duloxetine (Cymbalta) SNRI treatment failed to lead to symptom remission

The patient declined weekly, formal psychotherapy due to her busy work schedule

She agreed to streamline her medications and proceed with a new augmentation strategy. Her bupropion-SR (Wellbutrin-SR) was lowered by converting to a single bupropion-XL (Wellbutrin-XL) 300 mg dose. She tapered off buspirone (BuSpar) but continued trazodone (Desyrel) for insomnia. Her duloxetine (Cymbalta) was continued. The depression augmentation atypical antipsychotic aripiprazole (Abilify) was next titrated from 2 mg/d to 15 mg/d over the course of four months

Question

Considering her current medication regimen, what types of clinical monitoring might you utilize in the outpatient office setting?

Routine measurement of weight and abdominal girth due to the initiation of an atypical antipsychotic

Routine blood pressure monitoring due to the use of noradrenergic antidepressants and due to the initiation of an atypical antipsychotic

Intermittent blood draws to evaluate if there are elevations in blood glucose or lipids due to initiation of an atypical antipsychotic

Given her bariatric surgery, monitoring of any available blood levels is warranted to determine if there is a malabsorption issue

Attending physician’s mental notes: nine months

The patient had failed to achieve remission with multiple SSRIs, combination SNRI/NDRI, augmentation with 5-HT1A partial receptor agonism, and augmentation with a BZ

Starting an atypical antipsychotic is reasonable, based on available treatment guidelines, regulatory approvals, and randomized controlled trial empirical evidence

The atypical antipsychotics do carry TD and metabolic risks (HTN, hyperglucosemia, hyperlipidemia, weight gain) over long-term use, which should not be taken lightly as other augmentation/combination strategies may have more favorable tolerability profiles

Additionally, remember this patient was obese and required bariatric surgery and will be quite sensitive to any weight gain. Special attention should be paid to which atypical antipsychotic is chosen, not only based upon randomized controlled data but also based upon theoretical antidepressant activity and known metabolic profile

Clinically, aripiprazole (Abilify), quetiapine (Seroquel), quetiapine-XR (Seroquel-XR), lurasidone (Latuda), olanzapine (Zyprexa) have varying approvals and indications in treating depression

In this group, aripiprazole (Abilify) appears to have the most favorable metabolic profile (lurasidone was not available at the time), which minimizes comparative risk of weight gain, elevated blood glucose, elevated lipids, and elevated blood pressure

Other atypical antipsychotics have yet to be empirically proven as antidepressants. However, pharmacodynamically, asenapine (Saphris) has a molecular structure very similar to the antidepressant mirtazapine (Remeron). Lurasidone (Latuda) gained approval later, likely due to its serotonergic potential (5-HT2A, 5-HT1A, 5-HT7 receptor manipulation) making them theoretical antidepressant treatments as alternatives for this patient

• – They also appear to be clinically less metabolically challenging than some of the aforementioned atypical antipsychotics