Current medications

Fluoxetine (Prozac) 40 mg/d (SSRI)

Quetiapine (Seroquel) 300 mg/d (atypical antipsychotic)

Question

In your clinical experience, would you consider her current medication regimen a therapeutically dosed one?

Yes

No

Attending physician’s mental notes: initial evaluation

This patient seems to have recovered from her index episode of postpartum MDD, but often relapses

There is some corroborative evidence to suggest hypomania episodes

Has comorbid OCD that has never fully remitted

Seems content to be at home and not working but clearly is distressed by some symptoms

Presents with a supportive spouse, which will help prognosis and treatment adherence

Has been on many psychotropics over the last 30 years

• – It is unclear if these have been therapeutically dosed, but regardless, is likely fairly treatment resistant

Current regimen’s SSRI is too low a dose to be effective in treating OCD

The combination of the SSRI and this particular atypical antipsychotic would be considered adequate for treating MDD

Question

Which of the following would be your next step?

Increase the fluoxetine (Prozac) to the full FDA dose toward 80 mg/d for OCD

Increase the quetiapine (Seroquel) to a higher, possibly more effective dose, toward 600 mg/d

Increase both agents simultaneously

Augment the current two medications with a third agent to improve response

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

This patient seems to be on a standard approach for treating MDD

• – Good dose/duration of therapeutic SSRI

• – A therapeutic dose of her quetiapine (Seroquel) is being utilized now

  • The original quetiapine (Seroquel) immediate release is not approved as adjunctive treatment for unipolar MDD

    • Its longer-acting preparation, quetiapine-XR (Seroquel-XR), is at doses of 150–300 mg/d

  • The immediate-release preparation is approved for treating bipolar depression as a monotherapy at doses 300–600 mg/d

  • Suspect either preparation could be helpful in her case

The atypical antipsychotics are often used clinically to treat resistant OCD, but the current SSRI is likely at too low a dose to be helpful

• – SSRIs typically need much higher doses in place for longer durations than those usually needed for treating other types of anxiety disorder

Care may be complicated in that she has elevated cholesterol and blood pressure and the atypical antipsychotics are associated with escalation of metabolic disorder

Quetiapine (Seroquel) seems to have a dose-related escalation in metabolic disorder

• – These adverse effects may increase remarkably at doses greater than 150 mg/d, according to MDD studies utilizing the XR preparation

Developing better insight into her contamination fears and a referral for a bona fide CBT/ERP course may be warranted

Further investigation

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

What about details concerning her current HTN and hyperlipidemia?

• – Takes verapamil (Calan) 120 mg/d for HTN and is stable and routinely normotensive

• – Takes simvastatin (Zocor) 40 mg/d for hyperlipidemia and is well controlled

  • Cholesterol is 221 mg/dL, but HDL is 78 mg/dL, and triglycerides 75 mg/dL

  • Blood glucose is 86 mg/dL

What about details regarding her longitudinal disability and family support?

• – Her illness struck while she decided to be a homemaker and raise children

• – Did not leave work due to her psychiatric symptoms

• – Was able to raise children without difficulty

• – Spouse is currently very supportive but reports that the patient only really functions well within the immediate family

• – Over time they have not challenged her idiosyncratic OCD symptoms, but do feel she suffers more when concomitantly depressed and agitated