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

Patient #1 agrees at initial evaluation to continue the BZ alprazolam (Xanax) and agrees to restart the SNRI, venlafaxine-ER(Effexor-XR), at 75 mg/d, knowing that it will need to be dosed higher to become more effective and maximized

• – Returns later minimally better but now refuses to escalate the SNRI as it may be associated with worsening blood pressure at higher doses

• – Reports that his PCP had to add another antihypertensive and that radio-ablation for his cardiac arrhythmia has failed

Patient #2, at initial evaluation, stated that he liked his current medications and that each one added had some specific benefit

• – States he was partially better and is not comfortable making changes

• – However, does admit that the BZRA zolpidem is failing to maintain his sleep, thus a switch is made to zolpidem-ER (Ambien-CR) 12.5 mg at bedtime for better sleep maintenance

• – He returns later and states that he developed profuse diarrhea

• – He discontinued all of his psychotropics

• – The diarrhea resolved and he did not restart them

Question

What would you do next?

For both patients, choosing a new monotherapy antidepressant is warranted

For both patients, choosing a mood stabilizing atypical antipsychotic is warranted

For both patients, choosing a mood stabilizer is warranted

Attending physician’s mental notes: second interim follow-up visit at three months

Both patients are not responding fully to SSRI treatment with anxiolytic and hypnotic augmentations

Both now at least have full therapeutic SSRI trials, which they have tolerated well

Both patients clearly state they are unwilling to titrate any higher as they have lost faith that these current SSRIs “will work”

Case outcome: second interim follow-up visit at three months

Patient #1 starts the SSRI fluoxetine (Prozac) at 20 mg/d while the alprazolam is continued

• – Calls between visits feeling no effect and fluoxetine is increased to 40 mg/d

• – Returns stating that the MDD is a bit better, but during the session it is clear that the personality traits are still present and without change

Patient #2 starts the SSRI paroxetine (Paxil) 20 mg/d

• – Reports that his mother was on this with good results

• – This patient also had a chief complaint of insomnia and was simultaneously started on an SARI, trazodone (Desyrel) 50 mg at bedtime

• – Between sessions he requests more paroxetine and it is titrated to 40 mg/d

• – Returns stating he is not better on any account

Question

What would you do next?

For both patients, try another SSRI

For both patients, try an SNRI

For both patients, try an atypical antipsychotic

For both patients, try a mood stabilizer

Attending physician’s mental notes: second interim follow-up visit at three months (continued)

Both patients like the fact that they have been relatively side-effect free on SSRI and are agreeable to trying another

• – Patient #1 is titrated to sertraline (Zoloft) 100 mg/d

• – Patient #2 is titrated to fluoxetine (Prozac) 40 mg/d

This approach allows at least some more SSRI activity to be in place longer for each patient, and ongoing psychotherapy has more time to become effective

This approach also allows further avoidance of side effects and helps to avoid the pattern of overmedicating using irrational polypharmacy, while trying to treat ongoing personality/Cluster B symptoms