Attending physician’s mental notes: interim follow-ups through four months

As this patient has failed to respond to differing antidepressants, or a low-dose BZ, the use of an augmenting agent with a different pharmacodynamic mechanism of action seems warranted

He will need to be monitored for metabolic disorder more closely, onset of EPS, TD, development of vision change, if an atypical antipsychotic is started

Case outcome and multiple interim follow-ups to six months

Quetiapine (Seroquel) is titrated slowly from 25 mg/d up to 150 mg/d

Appreciates its sedating quality at night and reports that he does not need doxepin (Sinequan) at all

Reports that he is still anxious throughout the day and continues to require 1 mg of lorazepam (Ativan) standing dose as a result

Instructed to take 25 mg of quetiapine (Seroquel) twice during the daytime and to leave the remaining 100 mg to bedtime to continue treating his insomnia

Reports some success. However, now complains of significant daytime fatigue and requests to lower his quetiapine (Seroquel) and to again increase use of lorazepam (Ativan)

Patient is told not to escalate his BZ, and is asked to visit the office in order to discuss future treatment options. At this session he is offered

• – Another atypical antipsychotic with less sedation such as aripiprazole (Abilify)

• – Removal of all medications as being ineffective/intolerable and proceed with a GAD approved SNRI monotherapy such as venlafaxine (Effexor-XR) or duloxetine (Cymbalta)

• – Consideration of changing his Seroquel (quetiapine) to the slow-release version quetiapine-XR (Seroquel-XR)

This patient chose the latter and was switched to 150 mg of quetiapine-XR (Seroquel-XR) while he was maintained on his usual mirtazapine (Remeron) and escitalopram (Lexapro)

However, he called back a few weeks later to report that his GAD symptoms were gradually abating on the quetiapine-XR preparation, but his ability to fall asleep diminished and his insomnia was returning

Instead of manipulating his medication regimen at this point, he chose a CBT psychotherapy approach for his residual insomnia

Case debrief

The patient has a lengthy history of chronic GAD, which has been exacerbated by adjustment disorder issues and possibly complicated by legitimate primary insomnia. He initially responded to BZ monotherapy many years ago and more recently failed to respond to several initial antidepressant treatments

The antidepressants were maximized in the primary care setting prior to referral to psychiatric practice for further augmentation. Here, he was augmented with low-dose BZ but with some risk of misuse and inconsistent use. This approach was abandoned for the augmentation strategy of utilizing an atypical antipsychotic, which ultimately was effective for his TRA

Eventually, the patient did accept CBT for the treatment of his primary insomnia-like symptoms, which diminished over time

As the addition of the atypical antipsychotic became remarkably more helpful, his medications were streamlined, where the BZ and his antidepressant doses were halved

He gained 10 lb of weight but overall remained metabolically stable and without any abnormal movement disorder