Take-home points

This case emphasizes the need for full therapeutic trials of antidepressant treatments, augmentations, combinations, psychotherapy, and liaison with primary care and other specialty providers

This case also illustrates how some generally anxious patients with hypochondriacal thinking can be very difficult to manage given their high medical service utilization rates and difficulty tolerating medication regimens

Many psychotropic agents are now available in immediate-release and slow-release preparations. Typically, slow-release preparations maintain lower plasma levels of drug concentration and theoretically yield less side-effect burden

In this patient’s case, the side effect of somnolence was actually a positive therapeutic effect. While trying to mitigate daytime fatigue by using a slow-release preparation, there was a loss of clinical effectiveness in treating his insomnia. These pharmacokinetics must be weighed when choosing a psychotropic, and sometimes combining an immediate-release and a slow-release preparation of the same psychotropic may be quite effective and clinically warranted

• – Some prescribers consider using both immediate-release and slow-release preparations in the same patient, but for different clinical reasons

  • The immediate-release quetiapine has a faster peak plasma level that is clinically associated with greater sedation and somnolence. It may peak within an hour and work as an off-label hypnotic for some patients

  • The slow-release preparation may not be sedating enough within its first three hours after ingestion to induce sleep, but it may therapeutically last longer throughout the day to provide less sedating anxiolysis

  • The immediate-release version is used to improve sleep and the slow release for anxiolysis

FDA approval for GAD include some of the BZs, buspirone (BuSpar), venlafaxine-XR (Effexor-XR), and duloxetine (Cymbalta), and some of the SSRIs. Although none of these agents were utilized in this case, it is important to know which agents are formally approved for use and to advise the patient when off-label approaches are utilized

Performance in practice: confessions of a psychopharmacologist

What could have been done better here?

• – The lorazepam (Ativan) dosing was limited due to fear of its misuse. In this case, the fear of misuse was not about addiction but more toward ataxia or fall potential. It certainly could have been maximized further

• – The use of antihistamine products to promote better sleep is reasonable. In this case, both mirtazapine (Remeron) and doxepin (Sinequan) were utilized but with limited results. Possibly, utilizing more BZ sedative at night may have improved sleep or use of a more formal BZ receptor agonist (BZRA) such as zolpidem (Ambien) or zaleplon (Sonata) might have been more effective

Possible action items for improvement in practice

• – Instead of escalating polypharmacy in this geriatric but fairly medically stable patient, perhaps streamlining medications back to an FDA-approved SNRI would make sense. In this case, venlafaxine-XR (Effexor-XR) would be approved and also have a minimum of drug–drug interactions

• – Discussing options outside of medications is always warranted. Psychotherapy, CBT in this case, may ultimately be helpful and relatively side effect free