Current medications

Duloxetine (Cymbalta) 90 mg/d (SNRI was started after his SSRI failure by PCP)

Alprazolam (Xanax) 1 mg two times per day (BZ)

Question

In your clinical experience, would you expect a patient such as this to recover?

Yes, his premorbid health and functioning were very good

No, sometimes a devastating, late-life event causes chronic, unremitting depression

Attending physician’s mental notes: initial evaluation

This patient has his first MDE now. It is acute and triggered by a psychosocial stressor

It seems more than an adjustment disorder as it is pervasive, lasting over time, and clearly disabling

His initial failure on an SSRI is not alarming and he has recently been given a higher dose of an SNRI and started CBT, fostering a good prognosis

However, his older age of onset, loss of income, status, and some mild marital strife are concerning

Question

Which of the following would be your next step?

Increase the duloxetine (Cymbalta) to the full FDA dose of 120 mg

Increase the alprazolam (Xanax) to a higher, more effective dose

Augment the current medications with a third agent to accelerate response

Do nothing additionally outside waiting for SNRI and CBT effectiveness to occur

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

This patient seems to be on one of the gold standard approaches to treating depression

First, an adequate trial dose/duration of an SSRI

Now started on an adequate dose/duration of an SNRI

Is starting bona fide CBT

Things look good in that the current regimen is a reasonable one

However, there is concern regarding his passive suicidal thoughts, which provoked a discussion about safety planning

He also seems very guilt ridden and ruminative about his failure. Will need to continue to investigate if this is delusional

He does meet criteria for MDD, SAD, and GAD

It is unclear if these are truly comorbid or if his depression is fostering the anxiety symptoms

• – The latter seems appropriate as he had no premorbid anxiety prior to the onset of his depression

If comorbid anxiety becomes more evident, his prognosis worsens

Further investigation

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

What about details concerning his past medication treatment and his current CBT?

• – Has taken paroxetine (Paxil) up to 40 mg/d

  • He tolerated it well and only had a minimal clinical response, which he states was not meaningful

• – CBT has just started

  • He has had three sessions so far

  • He likes his therapist and seems to have good rapport

  • This therapist is well known in the community and has a good reputation, where many CBT techniques are utilized although in an eclectic manner, over a longer time than the usual manualized 12–20 week duration

Case outcome: first interim follow-up visit four weeks later

Patient now has more CBT and time on his SNRI

He is no better and acknowledges the same symptoms as on his first appointment

He states that he has no side effects, which he appreciates

Question

Would you increase his current medications or change strategies?

Yes, continue both duloxetine and alprazolam at even higher doses

Continue duloxetine at higher doses but keep alprazolam as it is

Continue alprazolam at higher doses but keep duloxetine as it is

No, discontinue both agents as they have failed to allow for a clinical response and start new regimen