Case outcome: interim follow-ups through two months

The patient called the office several times reporting that his remarkable insomnia continued

The patient called the office several times in the middle of his transfusions where he was watching his pulse and blood pressure readings and reported they went higher and higher. He states he had to utilize some of his BZ to lower his pulse and blood pressure. He states he was very worried about dying, based upon reading his vital signs in real time

If the patient did not receive a return call in somewhat short order, he would contact support staff, also on multiple occasions

He was not having overt panic attacks but genuinely appeared concerned about these issues, which he equated to serious medical problems associated with premature mortality

His lorazepam (Ativan) was increased to 0.5 mg twice a day, which he admitted worked adequately for him in the past

Case outcome: interim follow-ups through three months

As before, the patient called the office several times reporting that his marked insomnia and medical problems continued

Additionally, as before, if the patient did not receive a return call in somewhat short order, he would contact support staff on multiple occasions.

His lorazepam (Ativan) was increased to 1 mg twice a day

Question

What would you do next?

Continue to titrate his BZ sedative standing dose as needed to treat anxiety to remission

Consider changing his current antidepressant regimen to an SNRI such as venlafaxine-ER (Effexor-XR) or duloxetine (Cymbalta), as both have GAD approvals

Consider removing ineffective TCA, doxepin (Sinequan), and augmenting his current antidepressant regimen with an atypical antipsychotic

Consider removing ineffective doxepin (Sinequan) and augmenting his current antidepressant regimen with a calcium channel blocking epilepsy medication such as gabapentin (Neurontin)

Consider removing all three to four ineffective medications and utilize atypical antipsychotic monotherapy

Attending physician’s mental notes: four-month follow-ups

Escalating the BZ lorazepam (Ativan) seemingly has no significant benefit initially

The patient began to utilize it in more of an as-needed fashion, and repeatedly called for increasing doses, suggesting a penchant toward overuse

Given these factors, it must be strictly utilized in twice-a-day fashion without flexibility on the patient’s behalf to use as needed

The patient then calls for escalations in doxepin (Sinequan) or mirtazapine (Remeron) to treat his anxiety flare-ups during the day and his insomnia at night

Question

What do you consider next?

Continue escalating the BZ systematically but without any privileges of an as-needed basis

Streamline medication regimen by removing ineffective products and augmenting remaining products

Case outcome: interim follow-ups through four months (continued)

Patient again refuses formal CBT

Now is anxious about his escalation of BZ use and refuses any systematic titration but prefers to leave the dose as it is because it is providing some anxiolytic relief

After full informed consent, is agreeable to streamlining his medications as follows

• – Tapering off of doxepin (Sinequan) as it is not helping his sleep and he is already on the highly H1 receptor antagonizing NaSSA antidepressant mirtazapine (Remeron)

• – Continuing his mirtazapine (Remeron), escitalopram (Lexapro)

• – Augmenting with the atypical antipsychotic quetiapine (Seroquel) with the prospect of tapering off the BZ once this atypical antipsychotic becomes effective