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 established 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

No, this patient’s anxiety levels would likely make psychotherapy ineffective

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

The patient is clearly suffering from a baseline of moderate to severe GAD, which appears to be complicated by adjustment disorder. He is reaching the end of his life span and is having pertinent medical issues that have increased his anxiety about mortality. As a result, he is much more functionally fixated about bodily sensations, side effects, and minor medical issues, which makes him appear to have illness anxiety

The patient also seems very fixated about obtaining adequate sleep and has developed intense fear about a lack of sleep and the impact it will have on his life span. Insomnia is clearly part of GAD, but this patient’s intense fear may need to be addressed clinically in a similar manner as the phobia associated with primary insomnia

The recent PCP has done an excellent job of escalating two antidepressant agents and adding a third antidepressant that is known for inducing sleep. He has “gone the distance” likely as much as a primary care clinician can for treating this TRA. The patient, therefore, is currently on a therapeutic and reasonably aggressive psychopharmacology regimen, but without a response

Again, if the combination of SSRI plus a BZ has been effective in the past, why have BZs not been used recently? There is no history of obstructive apnea, gait instability, cognitive impairment, addiction, etc.

Case outcome: interim follow-ups through one month

The patient is medically cleared in that there is no obvious contribution of his medical problems with regard to causing his psychiatric problems. His red cell count and iron levels are adequately monitored and treated. His blood pressure is well controlled. There is no evidence of metabolic disorder

The patient was offered a formal trial of CBT to address his generalized anxiety and phobia issues but he declined

As the patient seemed relatively comfortable on his current set of medications with regard to tolerability, knowing that he would have anxious difficulty changing medications or adding new medications, it was decided to keep him on the current medications

However, augmentation with the previously tried “as needed only” BZ, lorazepam (Ativan), was discussed. The patient states that he had no issues with the sedatives outside becoming aware that they were possibly addictive, which made him and his wife worried; therefore, he stopped them. With permission, this was also discussed with his spouse who corroborated his story

Lorazepam (Ativan) 0.5 mg/d was initiated as a standing dose and added to the current medication regimen

Question

If the patient responds dramatically to the addition of this BZ, what would you consider next?

Continue all four medications. He has treatment-resistant GAD and this pharmacodynamic regimen of complex polypharmacy is likely required to prevent relapse

As he was minimally responsive to maximal doses of escitalopram (Lexapro) and mirtazapine (Remeron), his marked recovery on the BZ suggests that the antidepressant treatments are no longer needed and they should be systematically tapered off

Continue the fully dosed, therapeutic escitalopram (Lexapro) and mirtazapine (Remeron) but discontinue the subtherapeutically dosed doxepin (Sinequan) in order to streamline his medications