Question

What would you do next?

Maximize the SNRI

Maximize the BZ

Augment with something else to better treat MDD

Attending physician’s mental notes: interim follow-up visits through nine months

Patient is still depressed and has mounting side effects and treatment ambivalence

It would make sense to keep her regimen simple and to monitor her

Case outcome: interim follow-up visits through 12 months

Elects to increase the SNRI, duloxetine (Cymbalta), but is nervous about increasing to 90 mg/d

She does agree to adding a smaller 20 mg capsule making her dose 80 mg/d instead, which she more readily accepts

The patient states later that she was more anxious on the higher SNRI dose and asked to taper it off

Next, she was advised to consider a TCA given their ability to treat depression and reduce pain

• – She agreed to desipramine (Norpramin)

• – It tends to have less sedation and anticholinergic properties than other TCAs

• – It is largely NE facilitating

• – The TCAs tend to have double the dropout rate, or medication discontinuation rate, when compared to the SSRI

After titration to the 50 mg/d low dose, she states that she again is too anxious, agitated, and insomnic on the TCA, and it is stopped

She is willing to try another antidepressant medication, but not another TCA as she feels they are “too dangerous”

Another SNRI, desvenlafaxine (Pristiq), is started, which she tolerated well and ultimately it was increased to 100 mg/d

She starts outpatient DBT as an augmentation strategy

She returns next with improved energy and concentration

Her desvenlafaxine (Pristiq) is increased to 200 mg/d for better effectiveness, theoretically enhancing noradrenergic tone

She continues on alprazolam (Xanax) 6 mg/d but begins to admit routine anxiety breakthrough symptoms between her doses

• – Assumption is made that this is tachyphylaxis with breakthrough anxiogenic withdrawal symptoms

• – She is converted to the slow-release preparation of alprazolam-ER (Xanax-XR) at 2 mg three times per day

Attending physician mental notes

Finally have been able to work through and maximize a bona fide antidepressant treatment and troubleshoot her breakthrough anxiety spells

The patient’s depressive vegetative symptoms begin to respond and she is also less anxious

Plan on every four to six weeks increasing her SNRI for better effect, and hopefully, remission

DBT should also help navigate personality- and adjustment-based mood exacerbations

Case outcome: interim follow-up visits through 15 months

The patient becomes critically ill, is hospitalized and undergoes major surgery for bowel infarction, which appears idiopathic and unrelated to any of her medications

Delirium develops in the intensive care unit, likely due to

• – The pain medications that are administered

• – Serotonin discontinuation syndrome and sedative withdrawal while being off all of her psychotropics, as she was on bowel rest and unable to take oral medicines

Upon consultation, she was given

• – Intravenous lorazepam (Ativan) to cover her sedative withdrawal

• – The typical antipsychotic perphenazine (Trilafon) for her medical delirium, with good resolution of her symptoms

During surgery, she was given an ostomy and had a shortened gastrointestinal tract (GIT)

Once she was able to eat and back in the outpatient setting

• – The usual alprazolam-ER (Xanax-XR) 2 mg three times a day is restarted

• – The antidepressant desvenlafaxine (Pristiq) was not restarted as she was denying depression symptoms

She appeared to have better mood control on her low-dose typical antipsychotic perphenazine (Trilafon) and it was continued

The patient later reported an acute increase in anxiety again a few days after the transition to her oral BZ anxiolytic

• – She transitioned from approximately 4 mg/d of intravenous lorazepam (Ativan)

  • This is equivalent to 8 mg of oral dosing

• – Regarding her current alprazolam-ER (Xanax-XR) 6 mg/d use, it is clearly a higher equivalent dose, hence withdrawal rebound anxiety was initially ruled out

Patient next reported seeing medication tablets in her ostomy bag

• – These were identified as her slow-release preparation alprazolam-XR (Xanax-XR)

• – With her shortened GI tract, she was not absorbing these types of tablets

• – She appeared to be in mild BZ sedative withdrawal