Case debrief

The patient has the common comorbidity of MDD, PTSD, and SUD

She has personality traits that leave her vulnerable to relapses

She had an uncommon hypnogogic hallucination presentation

She has been fairly stable now for many years likely due to sobriety, sustained supportive psychotherapy, steady consistent medication management with fully dosed and rationally used polypharmacy (instead of many rapid medicine changes in reaction to new psychosocial, adjustment disorders)

The treating team was very good about communicating about the patient’s situations, symptoms, and likely etiology (adjustment based versus syndromal based) so that systems-based care was evident and very effective

The medication regimen continues in this fashion with continual good results

Take-home points

The patient had a balanced biopsychosocial approach by treating team members and great support through the AA and NA communities and her primary care team

• – This is a win–win, textbook collaboration situation that ideally should be emulated in these complex patient types, in that all providers were communicating and working together

The patient had, in addition, win–win polypharmacy situations

• – Her SSRI and NDRI canceled out each other’s side effects while providing additive clinical effectiveness regarding her many comorbidities

• – Her quetiapine (Seroquel) low dose was able to function as a multipurpose drug in that it: (a) induced and (b) maintained her sleep, (c) alleviated her hallucination, and (d) provided agitation control and mood stability during the day AND it did not increase her metabolic disorder given its low dose and intermittent use

The atypical antipsychotics likely should not be considered first-line drugs for insomnia, as they do carry risk for TD, EPS, and metabolic disorder that approved and other off-label hypnotics do not carry

Performance in practice: confessions of a psychopharmacologist

What could have been done better here?

• – Hindsight is 20/20

• – It likely was a bit risky, in terms of potential drug interactions, having the patient on a full dose of paroxetine and bupropion simultaneously

  • If she happened to be a poor CYP450 2D6 enzyme metabolizer, then her seizure risk could increase as her bupropion levels could have elevated

  • Use of tiagabine (Gabitril) in addition to these two medications and the 2D6 interaction risk promoted an even greater seizure risk

• – Use of a more metabolically friendly atypical antipsychotic with a mild to moderate sedating profile might have been preferred to the quetiapine (Seroquel) used in this case (perhaps asenapine (Saphris))

Possible action items for improvement in practice

• – Memorize drug interaction tables or use software or the internet to screen for interactions

• – If more risky combinations are used, consider a blood draw laboratory test for CYP450 isoenzyme quantification or drug levels

• – Be aware that atypical antipsychotics possess positive mechanisms for inducing and maintaining sleep that are not just side effects but reasonable positive clinical effects