Patient evaluation on intake

42-year-old woman with a chief complaint of depression and interpersonal stress

Psychiatric history

The patient states she was horribly abused as a child and had been addicted to alcohol and other substances for many years. Now has been sober for 10 years and attends AA and Narcotics Anonymous (NA) routinely with good results

Admits moderate levels of PTSD symptoms with nightmares, flashbacks, and panic attacks

Routinely experiences dysthymia (persistent depressive disorder) with intermittent full MDEs

Psychiatric review of symptoms suggests symptoms of marked mood lability, affective dyscontrol, empty depression, dissociative events consistent with mild borderline personality disorder (BPDO)

There is no history of inpatient psychiatric admissions, and rarely any suicidal gestures or self-injurious behaviors

Denies hallucinations and delusions, but states she is paranoid that people might mean her harm and always needs to “be aware of her environment”

She has been in legal trouble for reacting to social situations by striking out

• – This occurs usually when narcissistic injury occurs or if emotions are triggered by reminders of past abuse

The patient has been tried on

• – One SSRI, paroxetine (Paxil) 40 mg/d

• – One TCA, nortriptyline (Pamelor) 75 mg/d

Both monotherapies allowed for moderate improvements in her symptoms at best

Has attended supportive psychotherapy weekly for many years

Attends AA or NA daily and has a sponsor who is supportive

Social and personal history

Single, never married, and has no children

Has a General Education Diploma and attends college classes sporadically now

Past alcohol and SUD, but has been in remission for 10 years

No current legal issues but has some financial hardships

Medical History

Patient is overweight

Has CAD, DM2, chronic obstructive pulmonary disease (COPD), hyperlipidemia, GERD, HTN, glaucoma

Compliant with her primary care clinician who collaborates well with her psychiatrist

Family History

MDD in mother and aunts

SUD throughout her extended family

GAD in her mother

Possible ADHD in siblings

Current psychiatric medications

Paroxetine (Paxil) 40 mg/d (SSRI)

Current medical medications

Exenatide (Byetta)

Metformin (Glucophage)

Glipizide (Glucotrol)

Ramipril (Altace)

Albuterol (Ventolin inhaler)

Fluticasone/salmeterol (Advair Diskus)

Latanoprost (Xalatan)

Ezetimibe (Zetia)

Pravastatin (Pravachol)

Protonix (Pantoprazole)

Question

Based on this patient’s history and the available evidence, what might you do next, given that she still has moderate, residual depression and PTSD symptoms?

Try another SSRI

Switch to an SNRI

Augment with a mood stabilizer

Augment with an NDRI, like bupropion-XL (Wellbutrin-XL)

Augment with a 5-HT1A receptor partial agonist, like buspirone (BuSpar)

Augment with an atypical antipsychotic

Attending physician’s mental notes: initial evaluation

Patient has worked hard on sobriety and even to control her personality disorder symptoms

She is clearly depressed and agitated with PTSD

At the time, the only other approved agent for PTSD was sertraline (Zoloft), an SSR

Buspirone (BuSpar) and bupropion-XL (Wellbutrin-XL) are widely used, off-label depression augmentation options, which might help her

Perhaps it is best to see what symptoms the patient deems most important to treat first, PTSD or depression

As she is overweight with metabolic comorbidities, it may be worth choosing medications that limit risk of weight gain