Sorta hoping someone here can offer up a suggestion or two as on how to proceed with a patient I am currently seeing. I will be seeing him this week and have already spoken with about his situation and honestly I have not one clue on where to proceed.
Firstly, let me say we have absolutely no access locally to a psychiatrist. The nearest psychiatrist is over two hours away. The patient has been seeing a psychologist locally for cognitive behavioral therapy and has made some progress with his anxiety but still has a ways to go.
Current medications are:
Effexor XR 225mg qd
Klonopin .5mg qam
Toprol XL 200 qd (For tachycardia and essential HTN)
(Betablocker could obviously be contributing to his depression however this medication was selected by a highly regarded cardiologist who felt some cardiac issues were being caused by the ACE I and ACE II drugs he had tried and subsequently his symptoms resolved on this medicine).
Patient has a long history of trying other psych medications including Depakote, Lithium, Topamax and Zyprexa for mood stabilization. At one point he was traveling to a psychiatrist and she was working on a dx of Cyclothymia. He has no symptoms of Cyclothymia or any other BP type illness when maintained on Effexor XR. Any other SSRI/SNRI and the symptoms represent.
The issue we're dealing with is a seasonal depression which occurs this time every year. I've been managing this with him and this will be the fifth year it occurs. Usually see it starting in early October and it subsequently resolves in January. Psyc consults in the past have ruled out any SAD, PTSD. The patient cannot provide any explanation as to what may have happened in his life at this time of year to account for any worsening of depression.
Last year I convinced him to return to a psychiatrist in September in hopes of starting some sort of proactive treatment which might avert the "October blues". The psychiatrist started him on Adderall 15mg bid and continued him on that for six months. (And no, I have no idea her logic on that one). This did delay the problem but within a month of stopping the Adderall he complained of worsening depression (which I can't determine if it was simply a delay of his usual problems or was percipitated by the withdrawal of the amphetamine).
So... does anyone or can anyone make any suggestions here? My thinking is to perhaps increase the Effexor XR or start a mood stabilizer? The only thing I can find anywhere on a case like this is using LiCO3 however in that text Lithium was used long term. This patient really just needs a short course of something 1/4 of the year.
Any direction you could provide would be greatly appreciated.
Kinda lost of for a sense of direction at the moment.
Cosmo
Firstly, let me say we have absolutely no access locally to a psychiatrist. The nearest psychiatrist is over two hours away. The patient has been seeing a psychologist locally for cognitive behavioral therapy and has made some progress with his anxiety but still has a ways to go.
Current medications are:
Effexor XR 225mg qd
Klonopin .5mg qam
Toprol XL 200 qd (For tachycardia and essential HTN)
(Betablocker could obviously be contributing to his depression however this medication was selected by a highly regarded cardiologist who felt some cardiac issues were being caused by the ACE I and ACE II drugs he had tried and subsequently his symptoms resolved on this medicine).
Patient has a long history of trying other psych medications including Depakote, Lithium, Topamax and Zyprexa for mood stabilization. At one point he was traveling to a psychiatrist and she was working on a dx of Cyclothymia. He has no symptoms of Cyclothymia or any other BP type illness when maintained on Effexor XR. Any other SSRI/SNRI and the symptoms represent.
The issue we're dealing with is a seasonal depression which occurs this time every year. I've been managing this with him and this will be the fifth year it occurs. Usually see it starting in early October and it subsequently resolves in January. Psyc consults in the past have ruled out any SAD, PTSD. The patient cannot provide any explanation as to what may have happened in his life at this time of year to account for any worsening of depression.
Last year I convinced him to return to a psychiatrist in September in hopes of starting some sort of proactive treatment which might avert the "October blues". The psychiatrist started him on Adderall 15mg bid and continued him on that for six months. (And no, I have no idea her logic on that one). This did delay the problem but within a month of stopping the Adderall he complained of worsening depression (which I can't determine if it was simply a delay of his usual problems or was percipitated by the withdrawal of the amphetamine).
So... does anyone or can anyone make any suggestions here? My thinking is to perhaps increase the Effexor XR or start a mood stabilizer? The only thing I can find anywhere on a case like this is using LiCO3 however in that text Lithium was used long term. This patient really just needs a short course of something 1/4 of the year.
Any direction you could provide would be greatly appreciated.
Kinda lost of for a sense of direction at the moment.
Cosmo
