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

It is unclear whether this patient has had therapeutic trials on all medications, although some are well documented

Will need to build rapport, increase trust, and try to enhance adherence

Need to get to a good dose/duration for her current SNRI (duloxetine [Cymbalta]) as it has the ability to treat depression, anxiety, and neuropathic pain

However, there is concern regarding her suicidal thoughts from one to two months ago, which will need further exploration and a discussion about safety planning

She joined the practice already on higher doses of BZ use

• – There is no current indication of any misuse, but up until a few years ago, she had some substance misuse and was addicted to mechanistically similar barbiturate sedatives decades ago

• – Will need to continue to closely monitor and likely try to discontinue her controlled prescriptions over time

• – She states that her current treatment has helped her anxiety by at least 50%

Meets many criteria for various personality disorders, but on the mild to moderate severity spectrum

• – Will have to keep these dynamics in mind, again to improve rapport and medication adherence

Further investigation

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

What about details concerning her dissociative spells or mood swings?

• – She reports that she will just “zone out” when stressed

  • She will lose track of time

  • These episodes may last minutes to a few hours

  • She does not “wake” up in new or different places and there is no evidence of personality change

  • She cannot remember what she was thinking about during these times

She often has mood swings that go from euthymia to sadness, anger, or excessive happiness

• – These are never sustained more than one to two days, but often last only hours

• – These are often triggered by events in her environment

• – Her suicidal thoughts, intentions, and plans always occur after a stressful event with her significant other

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

Patient has decided to leave her current provider and attend sessions for psychopharmacology medication management in this setting

She has now additionally been placed on modafinil (Provigil) 200 mg/d and pregabalin (Lyrica) 150 mg/d by her rheumatologist to treat her fatigue and pain from FM

• – The other medications (duloxetine and alprazolam) remain unchanged

She feels no better and acknowledges the same symptoms as upon the first visit

She is experiencing a bit more fatigue on the alpha-2-delta calcium channel blocking neuropathic pain medication, pregabalin (Lyrica)

She states that she has no major, compliance-limiting side effects thus far and there is no misuse of any of her current controlled medications

Question

Would you increase her current medications or change strategies?

Yes, continue duloxetine, alprazolam, pregabalin, and modafinil at higher doses

Continue duloxetine at higher doses but keep others as they are

Continue modafinil at higher doses but keep others as they are

Continue pregabalin at higher doses but keep others as they are

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