Case outcome: interim follow-up, 24 months

This patient had fully relapsed

The SSRI, paroxetine-CR (Paxil-CR), is discontinued due to its ineffectiveness

The SGRI tiagabine (Gabitril) is tapered off as it was only partially effective, but mounting evidence suggests it may create seizures in non-epileptic patients

Continues on bupropion (Wellbutrin-XL) as she recollects this being the most beneficial for her depressive symptoms. It also has halted her weight gain and curbed her appetite

Next, she starts the more SERT-selective SSRI escitalopram (Lexapro) up to 20 mg/d to treat PTSD and residual depressive symptoms

She is also given low-dose atypical antipsychotic quetiapine (Seroquel) 25–50 mg at bedtime to help induce sleep, possibly improve depression, PTSD, and mood lability

• – It is felt to be too risky to use a potentially addictive BZ sedative–hypnotic, given her SUD history and well-maintained sobriety

• – This low-dose quetiapine is not expected to cause metabolic complications

• – If she has persistent hallucinations, then the dose could be increased to full antipsychotic potential at doses greater than 400 mg/d

• – Warned of low but possible TD/EPS risks

• – Warned of metabolic risks and primary care clinician is consulted

Does well on this combination and gradually has very good control of depression and PTSD symptoms

The “little man” leaves

A few weeks later, the “little man” hallucination comes back but without a full PTSD exacerbation

• – The quetiapine (Seroquel) is increased to 100 mg at bedtime with good effect once again

A few weeks later, the patient has increased problems with lability and anger at her AA and NA meetings, which is putting her sobriety at risk

• – Now offered a daytime 25–50 mg quetiapine (Seroquel) dose, which is utilized with good effect

  • In total, takes 150 mg daily along with the SSRI and NDRI combination therapy

After several weeks of no hallucinations and good affect control, she opts to lower the atypical antipsychotic slowly to avoid prolonged exposure and side effects

This goes well clinically and she continues on her baseline SSRI plus NDRI

Attending physician’s mental notes: 36-month follow-ups

Patient now is fairly stable and doing better

The SSRI and NDRI work well together

• – Symptoms are much less problematic

• – They appear to cancel each other’s side effects out in a win–win scenario

• – Denies side effects altogether

There is no increase in metabolic issues with the short-term, low-dose quetiapine (Seroquel) use, and an eye examination for cataracts was negative

Patient is compliant and we can extend her visits to quarterly, short appointments while we continue her supportive psychotherapy

Case outcome and multiple interim follow-ups to 60 months

The patient, throughout this time, has sustained months of doing very well with regard to relationships, returning to school, and being active in the community

She has occasional mild flare-ups of PTSD and BPDO symptoms but these are less frequent and less severe, likely as a result of ongoing sobriety, supportive psychotherapy, and a consistent set of well-tolerated medications

Occasionally, increased PTSD nightmares and the “little man” return

• – The patient self-titrates as-needed quetiapine (Seroquel) 50–150 mg daily doses

  • This treats insomnia and restores her sleep cycle

  • This treats bedtime hallucinations

  • This improves affective lability during the daytime

It is also determined that she has two types of insomnia

• – The spells mentioned here are usually PTSD related and fairly extreme in the patient’s point of view

  • The rapid onset of sleep, maintenance of sleep, and possible antipsychotic effect of her atypical antipsychotic is warranted and works well here

• – There is a second type of insomnia that is more insidious, where she has difficulty initiating sleep, increasing her fatigue and irritability with consequences next day

• – Does not wish to take the atypical antipsychotic routinely as it was “quite strong” with morning fatigue and potentially more serious risks (TD/EPS/metabolic)

• – For these transient bouts of insomnia that would last a few weeks at a time, she was offered the MT1/MT2 receptor agonist approved, non-addictive hypnotic (ramelteon [Rozerem] 8 mg at bedtime) with good results and no side effects

Now reliably alternates the quetiapine (Seroquel), ramelteon (Rozerem), or no treatment, depending upon the type of sleep she is, or is not, having