What To Try Next?

[187502]

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My resident told me to do some research and suggest the next course of treatment for the patient below:

Patient is a 31 y/o SWM. C/C - Current antidepressant providing insufficient resolution of Dysthymia & GAD

History of MDD, Panic Disorder, Dysthymia, & GAD.

Previous meds:

Venlafaxine XR - 150 mg - Experienced no remission of MDD & dysthymia, resolution of GAD. 300 mg - Complete resolution of depression and anxiety but patient developed agoraphobia. Discontinuation of medication promptly resolved agoraphobia.

Paroxetine - 20 mg - Incomplete resolution of depression and anxiety. 40 mg- Complete resolution of anxiety and depression, apparently well tolerated. Subsequent bloodwork indicated AST/ALT 3x baseline. 12 months previous AST/ALT were within the "normal" range. No other change in meds, Hep panel was negative. Discontinuation of meds and subsequent bloodwork indicate AST/ALT returned to baseline levels.

Current Medication:

Citalopram - 20 mg - Poor control over depression and anxiety. 40 mg - No improvement over 20 mg dose after 90 days.

Considering the patients poor response to a lower dose of an SSNRI and troubling response to a higher dose I don't think any medications in that class would be an appropriate choice.

Some SSRI's appear to be effective, so I'm thinking Serataline 50 mg QD to start and moving up to 100 mg QD if necessary.

What do you think? Any feedback/insight would be appreciated.

 

[sunlioness]

Therapy.
​

 

[TheWowEffect]

Obviously, this is a complicated patient and thus, you have think on multilple levels.

1. I am surprised that LFTs increased by that much with just Paroxetine. Are you sure that was the sole cause?

2. Why was Venlafaxine discontinued when pt developed Agoraphobia? As you said, depression and anxiety completetly resolved on Venlafaxine. May be you should have added a PRN benzodiazepine for Agoraphobia, and kept her on venlafaxine.

3. It might be a helpful to think about augmenting with other agents like anti-psychotics or may be lithium.

4. While therapy should be part of the treatment plan for this patient as suggested by another poster, just doing therapy would be plain malpractice. Medications would be the first line treatment for this patient with therapy offering additional benefits.

5. Another rule of thumb- when things are not going as planned, re-visit the diagnosis.

 

[sunlioness]

4. While therapy should be part of the treatment plan for this patient as suggested by another poster, just doing therapy would be plain malpractice. Medications would be the first line treatment for this patient with therapy offering additional benefits.

I would consider meds and therapy together to be first line and that not at least recommending therapy (patients can always refuse and often do) would be plain malpractice as well.

 

[Anasazi23]

this seems relatively straight-forward to me. You've got at least partial clinical response to two different antidepressant classes. No reason why you can't try zoloft, prozac, another ssri. Lexapro perhaps.

Personally, I'd go with duloxetine, since the response from effexor was so good except for the somewhat odd "side effect" of the agoraphobia, which sounds fishy to me.

 

[OldPsychDoc]

this seems relatively straight-forward to me. You've got at least partial clinical response to two different antidepressant classes. No reason why you can't try zoloft, prozac, another ssri. Lexapro perhaps.

Personally, I'd go with duloxetine, since the response from effexor was so good except for the somewhat odd "side effect" of the agoraphobia, which sounds fishy to me.

Reasonable ideas.

First, why are you holding citalopram at 40? Ninety days is too long to not change the dose. Don't give up before you've tried 60, and 80's not out of the question.

Or if the dysthymia is predominating and the panics are under control, give a longer-acting bupropion a try for energy, & alertness. Titrate up gently to avoid precipitating anxiety attacks. And if they're anxious about finances, a month of the celexa/wellbutrin combo can be done for about the cost of 2 days work of Cymbalta!

 

[187502]

Obviously, this is a complicated patient and thus, you have think on multilple levels.

1. I am surprised that LFTs increased by that much with just Paroxetine. Are you sure that was the sole cause?

2. Why was Venlafaxine discontinued when pt developed Agoraphobia? As you said, depression and anxiety completetly resolved on Venlafaxine. May be you should have added a PRN benzodiazepine for Agoraphobia, and kept her on venlafaxine.

3. It might be a helpful to think about augmenting with other agents like anti-psychotics or may be lithium.

4. While therapy should be part of the treatment plan for this patient as suggested by another poster, just doing therapy would be plain malpractice. Medications would be the first line treatment for this patient with therapy offering additional benefits.

5. Another rule of thumb- when things are not going as planned, re-visit the diagnosis.

1. Hep panel for A & C was negative for recent or past exposure, patient was immunized for Hep B. Negative for EBV and CMV. No significant alcohol or illicit drug use during that time according to the chart (but who really knows).

The only other potential factor was hepatic steatosis, patient has gained 40 pounds since starting antidepressant therapy (hard to say how much of a part the antidepressants played in that) and BMI was 23+ before that. However, since levels returned to baseline within 60 days of discontinuing paroxetine I'm inclined to believe it was indeed that.

2. According to the chart Venlafaxine was discontinued because the patient refused to continue treatment with that medication saying that the fear associated with going outside was so severe that he was unable to leave his apartment at 300 mg.

3. I hadn't thought of polytherapy, I'll have to approach my resident and see if he wants to go that route or stick with monotherapy.

4. Chart indicates that insurance has refused recommendations for therapy a number of times. The insurance company asserts that with the patients history of depression that "pharmacotherapeutic solutions are deemed to be optimal"🙂rolleyes🙂

Reasonable ideas.

First, why are you holding citalopram at 40? Ninety days is too longto not change the dose. Don't give up before you've tried 60, and 80'snot out of the question.

Ah, I wasn't aware of that. The white paper I read for Citalopram indicated that doses of 60+ hadn't shown any clinical benefits over 40 mg QD.

Or if the dysthymia is predominating and the panics are undercontrol, give a longer-acting bupropion a try for energy, &alertness. Titrate up gently to avoid precipitating anxiety attacks.And if they're anxious about finances, a month of the celexa/wellbutrincombo can be done for about the cost of 2 days work of Cymbalta!

Dysthymia definitely appears to be predominant. Money seems to be of significant concern to the patient, has indicated that insurance has excellent generic coverage, but poor non-generic formulary.

 

[sunlioness]

4. Chart indicates that insurance has refused recommendations for therapy a number of times. The insurance company asserts that with the patients history of depression that "pharmacotherapeutic solutions are deemed to be optimal"🙂rolleyes🙂

🙄 is right. Gosh that stuff just makes me mad. But that's a rant for another day.

 

[TheWowEffect]

I would consider meds and therapy together to be first line and that not at least recommending therapy (patients can always refuse and often do) would be plain malpractice as well.

Absolutely. It is essential to make both recommendations, but I am sure you know the answer if a choice has to be made. At least in this case, pt actually had no choice, unless she had the money to warm a cushy couch in an office in (insert name of a rich suburban area).

 

[whopper]

Venlafaxine XR - 150 mg - Experienced no remission of MDD & dysthymia, resolution of GAD. 300 mg - Complete resolution of depression and anxiety but patient developed agoraphobia. Discontinuation of medication promptly resolved agoraphobia.

I've never heard of a case of agoraphobia occurring due to Venlafaxine. Are you sure it was because of Venlafaxine? You could've had a published case here!

Citalopram - 20 mg - Poor control over depression and anxiety. 40 mg - No improvement over 20 mg dose after 90 days.

IMHO there is no reason to keep a patient on a med for 90s days if there's no improvement. It takes 4-6 weeks to see if the med at the current dosage is having any benefit. No reason to wait longer & keep the patient in therapeutic limbo. If no improvement, then either the med's not working at the current dose or the patient is not compliant.

My reccomendation:

Stick with 1 med, base that med on whether or not it best suits the patient's profile-e.g. cost, side effects, benefits, etc.
Also start psychotherapy. IF the patient has MDD & GAD, my choice would be CBT all things being equal. Start the patient on a triple column diary and work on that with the patient.

Start the patient on the med-give the patient 1-4 weeks of medication therapy, then taper up the dose (based on severity of sx, if severe, taper up more quickly. I'm basing this based on my own interpretation of STAR*D). Remind the patient the meds take 4-6 weeks to work & the patient must maintain compliance.

Then at 4-6 weeks, continue to taper up unless its working at its current dose to the patient's satisfaction. Continue to taper up until the maximum dose is reached, giving 2-4 weeks between each increase of dosage, again speed depends on severity of sx.

If by the time the patient has been on the maximum dose for over 4-6 weeks without a benefit--either switch to a different med of add augmentation therapy.

With an anxiety DO, I'd go with Buspirone-only 4 dollars a month at Target or Wal-Mart.

I'd also reccomend that the patient also get a good dose of omega-3 fatty acids since there is some data indicating that Omega Fatty acids can decrease depression & anxiety.

And as always, educate the patient on the pros & cons, benefits & side effects of antidepressant treatment.

 

[TheWowEffect]

With an anxiety DO, I'd go with Buspirone-only 4 dollars a month at Target or Wal-Mart.

Good points but I am not sure if this pt's anxiety would be amenable to treatment with buspirone. Like one of my attendings used to say when buspirone was still under patent, "it's a expensive placebo."

 

[whopper]

To clarify, I meant use the buspirone for augmentation therapy of the SSRI already being used--if that SSRI is not doing the job for the patient. I didn't mean to use buspirone as a med by itself to tx GAD.

I am very open to adding buspirone augmentation given its cheap price, small amount of side effects & strong evidence of added benefit in STAR*D. I also try to reccomend to all depressed & anxious patients to get a good dose of Omega 3's since even if it doesn't work so much for their psychiatric sx, its at the very least a good thing to ingest for general health & not expensive.

of add augmentation therapy.

With an anxiety DO, I'd go with Buspirone-only 4 dollars a month at Target or Wal-Mart.

I should've typed
"OR ADD AUGMENTATION THERAPY, CONSIDER BUSPIRONE"
A mistype on my part.

 

[billypilgrim37]

"it's a expensive placebo."

"...with all of the properties you'd want in an anxiolytic, except for efficacy."

 

[Ritz]

give paxil after talking to the patient with frequent monitoring. 3-4 times LFTs, it is not an absolute CI unless the pt has other complicating factors. Get GI consult, will treat your anxiety. 🙂 Just kiddin.

 

[DrIng]

Firstly let me say, thank God I live in a country with a socialised medicial and pharmaceutical system where any antidepressant is going to cost someone on a low income $4 a month and many of these considerations are irrelevant.

However, therapy is not always covered by the government but our national psychiatry training program requires every resident to do some therapy (both psychodynamic and CBT) so there is a steady supply of willing if not skilled doctors ready to do some therapy. Could your patient look at something like that to help. Really if they're dysthymic then meds alone aren't going to help too much!

 

[FURY 161]

Venlafaxine XR - 150 mg - Experienced no remission of MDD & dysthymia, resolution of GAD. 300 mg - Complete resolution of depression and anxiety but patient developed agoraphobia. Discontinuation of medication promptly resolved agoraphobia.

2. According to the chart Venlafaxine was discontinued because the patient refused to continue treatment with that medication saying that the fear associated with going outside was so severe that he was unable to leave his apartment at 300 mg.

Agoraphobia cannot result from meds. The whole story is very fishy. The pt might be prodromal (even at 30-ties), Effexor making him frankly psychotic, that's why he is not getting out of the house. This so called disthymia and depression with anxiety, agoraphobia, might be smth more serious. One of the differential diagnostic considerations for agoraphobia is schizophrenia. What is his functioning, relationships, work history, family hx etc?
If there is no psychosis there, personality disorder should be strongly considered.
Anyway, if there is prominent anxiety, you can give him Neurontin.

 

[michaelrack]

I agree with the suggestion to try cymbalta. If the patient failed cymbalta, would try imipramine.