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

Patient was given the choice to escalate the SSRI or the atypical antipsychotic, as both were felt to still have room to therapeutically increase dosing

Patient suggested that the atypical had allowed better sleep and more calming effects

• – Quetiapine was raised to 400 mg at bedtime

• – This escalation was also warranted in that there is a potential history for bipolar II symptoms, and as she has fair insight at best into the OCD

• – Was converted to the once-daily quetiapine-XR in case symptoms were more representative of a bipolar disorder and would require even higher dosing in the future to prevent onset of mania, while treating the OCD with higher-dose SSRI therapy

• – This preparation is approved officially for depression adjunctive treatment as well, but at the lower doses already used. Up to 600 mg/d is approved for bipolar depression

After this, husband reported that this is the “best she has done in years” and asks how long the effect will last?

• – Patient agrees in that the MDD and agitation are completely gone

• – Is spending less time in her car and seems less concerned with regard to contamination fears

No side effects reported

Question

How would you answer the husband’s question about longevity of response?

She will stay in remission for many years

She will likely relapse within the year

She will likely do well, but requires ongoing minor medication changes to maintain her response

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

Despite being a little better clinically, now the patient is resistant to higher dose (fluoxetine 60 mg/d) and atypical antipsychotic (quetiapine-XR 500 mg/d) trials

She has a clinically meaningful response in that she is less agitated, sleeping well, but she is not even a 50% responder

She is side effect free, which is positive

Case outcome: interim follow-up visits through six months

Patient calls between appointments stating that she and her spouse feel she is more depressed and agitated again despite there being no clear stress-related events

Quetiapine-XR (Seroquel-XR) is increased to 500 mg/d without improvement

At an office visit with apparent clinical decline noted, agrees to increase the SSRI, fluoxetine (Prozac), to 60 mg/d

• – This approach begins to maximize both medications toward a full-dosing strategy

Mild improvement is noted but not to the same degree as the first medication adjustment

• – Compared to baseline, she is perhaps

  • 30% better with regards to MDD symptoms

  • 15% better with regard to OCD

Question

Do you consider her to be on optimal medication doses?

Yes, both agents are dosed above the moderate approved range and should be considered therapeutic failures

No, neither agent is dosed high enough to be considered a full trial, especially if her differential diagnosis includes OCD with potential bipolar or psychotic illness

Attending physician’s mental notes: interim follow-up visit through six months (continued)

Symptoms continue to fluctuate despite increasing medications

There is an element of patient and family pessimism as she was robustly better, perhaps at her baseline best ever, only to decline again

From a unipolar MDD point of view, quetiapine-XR (500 mg) and fluoxetine (60 mg) are maximized

If there is a psychotic element to the depression, then the quetiapine-XR could be increased further

From an OCD point of view, the fluoxetine or quetiapine-XR could be escalated for better effectiveness

If the atypical antipsychotic is continued, laboratory values likely need to be obtained from the PCP to make sure there is no metabolic worsening