Question

What would you do next?

Request a home visiting nurse and restart intravenous or intramuscular lorazepam (Ativan), as these are parenteral routes and were effective in the hospital

Convert this patient to a longer half-life BZ sedative, such as diazepam (Valium), assuming she can absorb some of this immediate-release drug and avoid withdrawal due to its extensively long half-life and metabolites

Convert this patient back to the immediate-release alprazolam at an equivalent dose as it should be absorbed better without the slow-release mechanism in place

Case debrief

This is a complex patient with many psychiatric comorbidities, psychosomatic conditions, and now a surgical emergency

She was making consistent progress in rapport, trust, and an adequate and aggressively dosed antidepressant was administered

However, she had to work through many ambivalences and anxieties regarding her medications to get to this point

Her progress was thwarted by her bowel infarction and poor ability to absorb medications

• – Parenteral substitute medications were chosen and found to be effective acutely

• – Upon conversion back to oral tablets in the outpatient setting, it became clear she could not absorb some of her oral slow-release medications

• – She was placed back on immediate-release preparations with good anxiolysis, and continued on her perphenazine (Trilafon) longer term as a mood elevator and stabilizer as well as antipsychotic

  • At low doses, this typical antipsychotic possesses atypical properties of 5-HT2A receptor antagonism, and has been used to treat depression in an off-label manner. It had been FDA approved as a combination antidepressant, when it is commercially combined with the TCA amitriptyline

  • She should be monitored for TD and EPS

  • She could be switched to an atypical antipsychotic as an alternative

  • The patient opted to keep this medication as it is because it is helpful and well tolerated

The patient remains on this combination (alprazolam plus perphenazine)

She had to stop DBT while hospitalized but restarted psychotherapy with a dynamically oriented couples’ therapist and is seeing gradual improvements in her personality traits

She remains sober and shows no misuse of her controlled medications

Take-home points

Treating this patient involved using many psychotherapeutic skills in order to maintain compliance and achieve therapeutic doses

A 12-minute rapid medication management session approach likely would have backfired and allowed for a continuation of many subtherapeutic, side-effect riddled medication trials

Spending more time with this patient, processing ambivalence about medications, increasing her ability to tolerate side effects, and gaining her trust by titrating slowly with one agent at a time appeared to be helpful in promoting symptom relief, until her surgical emergency warranted medication changes

Steering away from the urge to treat patients with many symptoms of differing etiologies with a myriad of low-dose medications, given her personality traits, it made clinical sense to attempt solid monotherapy adjustments when possible

This approach also allows more time for psychotherapeutic approaches to become effective

This lowers the risk of excessive, unwarranted polypharmacy and the excessive collection of adverse effects