Attending physician’s mental notes: initial evaluation

This patient seems to be typical of many patients referred for inadequate response to antidepressants in that she is in her 30s, moderately depressed, and has failed mostly SSRI treatment in primary care settings

The previous psychiatrist changed classes of medications from the SSRI to an SNRI and achieved a partial response

• – This approach follows most MDD guidelines where, if there is a failure on initial SSRI montherapy, then a switch to a novel pharmacological class antidepressant is the next step

A stimulant augmentation was added to promote more clinical symptom response and also likely to avoid side-effect weight gain in this case

Unfortunately, she is not in remission, which requires further action and prescribing

Common practice suggests looking at the current medication regimen, and if safe, reasonable, and rational, doses can be increased within approved limits to see if remission can occur before adding yet another medication

She has minimal side effects and likes her current regimen, hence compliance looks to be favorable

Further investigation

Is there anything else you would especially like to know about this patient?

What medical details concerning this patient are you concerned about?

• – She has a history of AUD but has been sober for three years. She is taking duloxetine (Cymbalta) now, which has warnings about its use in acute alcoholism due to liver damage issues

  • Her liver function tests are normal

• – She has a history of being overweight but underwent successful bariatric surgery

• – Does she have any history of BN?

  • No, psychiatric interview at present shows no eating disorder and psychological evaluation prior to bariatric surgery also showed no contraindication

• – She has chronic depression; therefore, is there a medical cause such as hypothyroidism or anemia?

  • Thyroid panel is normal. Cell count is normal and she is on iron replacement

Question

Based on what you know about this patient’s history, current symptoms, and treatment responses, do you think that maximal doses of her antidepressant are warranted at this time?

Yes, clinical experience dictates that increased doses work better in some patients

Yes, psychopharmacology textbooks suggest that increased doses may work better in certain patients

No, her doses are clinically adequate

No, her dose is average and the FDA suggests no benefit from higher doses

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

The patient is clearly depressed

Her medications are well tolerated and have room to be maximized with regard to dose

The patient has a good supportive psychotherapist and should continue with that, but perhaps consider augmenting this psychotherapy with group CBT

She seems to be a typical treatment-resistant patient, but has good prognostic factors

Case outcome: interim follow-ups through three months

The patient’s duloxetine (Cymbalta) SNRI is maximized to 120 mg/d without clear benefit or improved partial response

Methylphenidate-ER (Concerta) is next increased to 54 mg/d without clear benefit. There are no additional side effects

• – Blood pressure, heart rate, and weight are monitored

Lamotrigine (Lamictal) is gaining popularity as a bipolar maintenance treatment and as an antidepressant augmentation as it has minimal day-to-day side effects

• – Less stringent unipolar depression augmentation trials have suggested effectiveness, whereas more stringent monotherapy trials suggest little benefit over placebo

• – Lamotrigine also has a purported mechanism of action that is novel (glutamate dampening by inhibiting the release of glutamate into the synapse) compared to the patient’s current regimen, which uses a rational polypharmacy approach where each psychotropic contributes a novel mechanism of action to the regimen

• – Lamotrigine is known for minimal to no weight-gain effects, but does have serious, but rare rash adverse effects to consider. Given this, it must be titrated very slowly, which makes it an inopportune acute antidepressant treatment as it takes six to eight weeks to reach 200 mg/d

Patient is mildly depressed now given the partial response noted earlier. Therefore, a slow titration is acceptable clinically. The lack of weight-based side effects is comforting in this case

Fortunately, she gains no weight, has no side effects, but she has no mood stabilizer benefit despite dosing of lamotrigine up to 300 mg/d