Case outcome: second interim follow-up visit at two months

The patient had his duolextine (Cymbalta) increased to 120 mg/d and his alprazolam (Xanax) increased to 1 mg three times a day

He has no side effects, is normotensive, and is reliably using his controlled substance

This approach maximizes his antidepressant and the anxiolytic augmentation increase may help his secondary anxiety symptoms

This approach leaves no doubt that a full trial was given and also allows more time for CBT to become clinically effective

The patient shows moderately better affective ranges, less psychomotor symptoms, and states an absence of suicidal thoughts as a result

He is felt to be 20%–30% better

Attending physician’s mental notes: second interim follow-up visit at two months

Despite being a little better, the patient is still not in remission after two months of treatment

He is half-way through a clinical course of CBT

He has a clinically meaningful response now in that he is not suicidal and has a better affective range

He is a bit less anxious and ruminative but he is not a 50% responder yet

As his primary illness is MDD, it is doubtful that escalating his BZ sedative–anxiolytic will help further

He is side effect free, which is positive

As this patient is now becoming possibly more treatment resistant with regard to his MDD, and he continues with comorbid anxiety features and has his first clinically meaningful response, switching away from his current SNRI may cause a loss of this initial clinical effect

Waiting longer will likely not promote full remission

His prognosis seems a bit worse compared to that assumed at the first visit

Increasing his sedative–anxiolytic is unlikely to remit his depression

Combination or augmentation strategies are discussed and considered by the patient

Question

What would you do next?

As he is a partial responder with minimal response, discontinue his SNRI and try a new antidepressant

As he is a partial responder with minimal response, has now failed two therapeutic trials, would combine with a second approved antidepressant

As he is a partial responder with minimal response, has now failed two therapeutic trials, would combine with an evidence-based augmentation agent

Continue to wait on the current regimen and CBT for full effectiveness to occur as he is side effect free

Case outcome: interim follow-up visits through seven months

The patient agrees to start a NaSSA antidepressant combination by adding mirtazapine (Remeron) to the existing regimen (SNRI plus BZ)

There is no initial change in status, patient is still depressed and anxious but not suicidal

Mirtazapine (Remeron) is increased to 45 mg/d

• – At this dose, profuse night sweats develop and cannot be tolerated

• – Outside diaphoresis, he was normotensive with no other side effects

Attempts are made to slowly lower both antidepressants (SNRI plus NaSSA) to mitigate side effects and to maintain his partial efficacy, but to no avail

Patient chooses to discontinue both antidepressants

Other strategies are considered and he agrees

• – To start bupropion-XL (Wellbutrin-XL), an NDRI, and is gradually titrated to 450 mg/d, and

• – To have the alprazolam converted to the slow-release preparation (Xanax-XR) for ease of use and once daily dosing

He continues with same MDD symptoms. The night sweats resolve but he now develops insomnia and nightmares

He has now failed to improve after 20 sessions of CBT