Current medications

Divalproex sodium (Depakote) 1000 mg/d (mood stabilizer)

Mirtazapine (Remeron) 30 mg/d (NaSSA)

Alprazolam (Xanax) 3 mg/d as needed (BZ)

Question

Based on your geographic location, is Lyme disease a reasonable differential diagnosis?

No, there is a very small deer population in my area and chances of deer tick bites are very low

Maybe – I live in a geographic area where more cases are being reported every year

Yes, most cases of Lyme disease are concentrated in a few areas, and most infections occur in the northeast, in the Great Lakes region, and along the Pacific coast of the United States. I live in one of these areas

Attending physician’s mental notes: initial evaluation

This patient has chronic and recurrent MDD

Likely has comorbid GAD and PTSD, or these are at least present in a subsyndromal aspect

There is a possibility that she has an infectious etiology as well

These comorbidities and chronicity of her illness make her prognosis fair at best

She has had several recent therapeutic polypharmacy trials, albeit not always dosed at maximum levels, and has had many monotherapy trials over the years

• – This also worsens her prognosis with regard to achieving remission

She does have positive family support and initial indications suggest that she is compliant with treatment, both of which improve her prognosis

Question

Which of the following would be your next step?

Increase the NaSSA antidepressant mirtazapine (Remeron) to the full FDA dose of 45 mg/d to maximize its potential

Increase the BZ alprazolam (Xanax) to a higher dose to treat her agitation and anxiety

Check divalproex (Depakote) levels, and if warranted, increase to make this therapeutic despite the patient not having bipolar disorder

Augment the current medications with yet another agent to enhance antidepressant response

Refer for formal CBT or IPT manualized psychotherapy

Confer with outside clinicians regarding Lyme disease workup and findings

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

This patient seems to be taking standard treatment for resistant MDD

• – Good use of multiple antidepressant classes and augmentations with evidence-based agents

• – Now is on a moderate dose of an antidepressant

However, there is concern about the use of divalproex (Depakote) as she does not appear to have a bipolar history

• – Perhaps it was prescribed for anxiolysis as she is quite agitated at times and failing to respond to BZ

She seems very guilt-ridden and ruminative about her perceived inadequacy

• – Will need to continue to investigate if this is delusional

Further investigation

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

What about details concerning her past medication treatment?

• – Her doses of medications appear to be therapeutic (moderate to high dosages)

• – The divalproex is confirmed as being used for anxiety, not bipolar disorder

• – She has never misused controlled prescriptions

What about details concerning her possible Lyme disease exposure?

• – Has lived most of her life in areas that are prevalent for Lyme disease

• – Does not recollect a tick bite

• – Does not recollect the typical “bull’s eye” rash

• – States multiple family members have developed Lyme disease without known bites/rashes

• – Her local internist does not feel this is Lyme disease, which has angered family members who have arranged a visit to a Lyme disease expert in another state for a second opinion, as they feel strongly that it is

• – Her present MDE is chronic and has similar features compared to her previous MDEs, which would predate her possible Lyme exposure

  • The current MDE does not appear different symptomatically from her prior MDEs