Case outcome: interim follow-ups through three months

The patient is medically cleared without any concerns

• – Lipids are well controlled

• – Cardiac state is stable

• – Laboratory test results are normal

• – Nutritionally, she is meeting her minimal requirements despite her current weight and stature

Psychotherapy was halted due to psychomotor and cognitive impairment

A second trial of ECT was attempted. It was unclear if first trial was bilateral and conducted for at least 12 sessions. This second trial was also ineffective

A reduction and streamlining of medications was refused as patient and spouse felt the medications were helpful to some degree, and feared a clinical worsening despite her current severe symptoms

An inpatient stay was considered but her medical health was stable and she was not a danger to herself as her spouse is able to meet her instrumental activity needs

TMS and DBS options were experimental and not readily available at the time. However, VNS was available at a local study site and this was more vigorously considered

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 use of an atypical antipsychotic

Routine blood pressure monitoring due to the use of noradrenergic stimulant medication and the atypical antipsychotic

An understanding with the primary care clinician that they will help monitor these as well and be responsible for continued treatment and monitoring of the patient’s pre-existing hyperlipidemia. If not, independent monitoring of laboratory test results should occur in the psychiatric setting

Topiramate (Topamax) has warnings about acidosis and requires blood draws to establish good renal function and then an absence of bicarbonate wasting over time. Patients on this medication should also be warned about acute eye pain and vision changes due to glaucoma, and about a loss of sweating (oligohydrosis) and risk of heat stroke and further weight loss

Attending physician’s mental notes: four months

Much collateral clinical information has been collected but no treatment changes issued as yet

She has failed to achieve remission with multiple antidepressants, psychotherapy, and ECT

Informed consent regarding lithium or thyroid augmentation was provided versus an experimental course of VNS

At the time, VNS was not an approved treatment and two experimental open-label pilot studies showed good tolerability and reasonable effectiveness in highly treatment-resistant MDD patients

Clinically, the patient perceived the offered medication augmentations to have end organ damage issues and the MAOI medications to have too many drug interaction issues. She was despondent that her previous medications had manipulated her brain monoamines excessively and to no avail. Hence, she had lost faith in pharmacotherapy

The patient visited a VNS study team and was felt to be a good candidate for VNS given that

• – VNS is indicated for the adjunctive long-term treatment of chronic or recurrent depression for adult patients who experience MDEs and have not had an adequate response to four or more adequate antidepressant treatments

• – These four trials could be medications, psychotherapies, or ECT. This patient has had more than double the amount of qualifying treatment trials

• – Present data would suggest that patients who have failed four medications (even with ECT) have very poor chances of achieving remission and then maintaining it, making experimental VNS a more viable option