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

This is problematic. He did not become hypomanic using the relatively safer NDRI antidepressant approach, but it has failed to help

He is a student with no insurance and will not agree to have psychotherapy

Adding another antidepressant likely means stepping back into the SSRI class, where he became hypomanic twice before when he was not mood stabilized in advance

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

The patient moves away and takes classes two hours away at a new school, thus will come for visits every 90 days but with phone contact throughout

As he is mood stabilized on lamotrigine, he is next titrated onto the NDRI bupropion-XL (Wellbutrin-XL) to the maximum dose of 450 mg/d while continuing lamotrigine

This approach maximizes the antidepressant and the mood stabilizer dose

Continues to be very depressed and anxious

There is no clear change in symptoms

There are no side effects and no activation to hypomania

Question

What would you do next?

Insist he be referred for psychotherapy; continue the lamotrigine and bupropion-XL

Increase lamotrigine in the hope that it will treat the depression and anxiety

Add an SSRI antidepressant in the hope that the MDD and SAD will improve while minimizing hypomania escalation risk, and while he is mood stabilized

Add a bipolar depression-approved agent such as olanzapine–fluoxetine combination (Symbyax), quetiapine(Seroquel-XR), or lurasidone(Latuda)

Add another mood stabilizer such as lithium

Case outcome: interim follow-up visits through nine months

Gradually, the SSRI escitalopram (Lexapro) is started at the low 5 mg/d dose as samples were available

• – The patient had no income and no insurance

The ineffective bupropion-XL was discontinued while maintenance lamotrigine (Lamictal) is continued

He and his family were alerted to watch specifically for hypomania onset symptoms

Eventually at 15 mg/d of escitalopram

• – Is still depressed and anxious

• – Develops weight gain

  • To which he admits he is very sensitive

  • Develops mild sexual side effects too

• – Asks promptly for non-SSRI options and elects to increase the lamotrigine to 300 mg/d in the hope that it will alleviate depression without adverse effects

At the next visit, he is free of depression

• – There are moderate reductions in SAD symptoms

• – There is no evidence of hypomania on higher dose lamotrigine (Lamictal) monotherapy

Question

What would you do next?

As the lamotrigine (Lamictal) 300 mg/d dose seems to have allowed depressive remission, the SSRI should be discontinued

It is unclear if the lamotrigine worked alone to gain depressive remission, or if it worked in combination with the SSRI escitalopram (Lexapro); therefore, both should be continued

The lamotrigine should be increased again to see if the SAD will remit as well

Increase the escitalopram despite side effects to see if the SAD will remit

Switch the SSRI to a novel class of antidepressants such as mirtazapine (Remeron), trazodone-ER (Oleptro), or vilazodone (Viibryd)

Add a BZ anxiolytic to remit the SAD symptoms

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

Patient seems to be mood stabilized and is solidly euthymic now

His SAD is 50% better and it seems that he is able to control these symptoms, which he admits are not interfering with his life at this time

He is concerned about weight gain and sexual side effects but seems to accept the benefits of his medications

He asks to keep his medications as they are and agrees to continue the SSRI escitalopram (Lexapro)