Further investigation

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

What symptoms does the patient consider critical?

• – Insomnia – she does not sleep well in general and this may be caused either by depression, PTSD, or her current SSRI

• – Nightmares and flashbacks – these are very problematic as they trigger in the patient other symptoms such as mood lability and potential for violence and drug use

• – Depression – for her, this is secondary. Her depression is usually caused by PTSD flare-ups, their aftermath, and her interpersonal stressors

• – She feels that controlling her PTSD and sobriety will mitigate her depression

Question

Based on what you know about this patient’s history, current symptoms, and medication, what would you do now?

Try another SSRI

Switch to an SNRI

Augment with a mood stabilizer

Augment with bupropion-XL (Wellbutrin-XL)

Augment with buspirone (BuSpar)

Augment with a sedating atypical antipsychotic

Augment with prazosin (Minipress)

Augment with a BZ sedative–hypnotic

Augment with a melatonin receptor agonist hypnotic

Augment with an antihistamine hypnotic

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

Given the higher burden of PTSD and that she is failing an SSRI that is approved for PTSD and MDD, she will need to be tapered off and switched to another medication

Will need to make a decision to try to treat all of her symptoms at once or treat single target symptoms in order of severity

Formal CBT, such as exposure therapy for PTSD, is not available in the community and she has good rapport with her supportive therapist and her sponsors; therefore, these treatments should continue

The other approved medication for PTSD is sertraline (Zoloft), which makes clinical, regulatory, and guideline-based sense

Avoiding potentially addictive products is clearly warranted

Case outcome: interim follow-ups through three months

Next, she is cross-titrated off paroxetine (Paxil) and onto paroxetine-CR (Paxil-CR)

The patient states she has been on paroxetine (Paxil) for some time now and is comfortable with it as it has helped partially

As informed consent is given, steering her away from continued paroxetine use, her resistance increases

States paroxetine at higher doses in past has been problematic for her

• – She is offered a newer option and she states she would like to try the slow-release CR preparation

• – It is titrated to 50 mg/d

• – There is no clear benefit

Is offered a switch to another SSRI, sertraline (Zoloft), or to use a combination strategy bupropion-XL (Wellbutrin-XL)

After weighing the options and giving informed consent, knowing that sertraline (Zoloft) is mechanistically similar to her paroxetine-XR (Paxil-CR), she opts for the NDRI bupropion-XL (Wellbutrin-XL) combination in the hope of a different outcome than with her SSRI, but also that it may curb her weight and improve her energy

Titrated up to 450 mg/d as a combination with the SSRI, and the depression and vegetative symptoms do improve somewhat, but she continues with her usual partially treated PTSD symptoms and insomnia

Considering her current medication regimen, do you have any concerns?

Does she have a history of seizures or eating disorder, as bupropion products may induce seizures in these patients?

• – She does not

The paroxetine-CR (Paxil-CR) is a robust inhibitor of the p450 2D6 enzyme system, for which bupropion products are a substrate

• – Is it possible that this drug interaction might elevate her bupropion plasma levels and induce a seizure?

She is benefitting from this combination

• – Perhaps bupropion levels might be drawn, or

• – Perhaps augmenting her remaining PTSD symptoms with an antiepileptic medication might be a win–win situation, where symptoms and side effects are reduced simultaneously