Pretest self-assessment question (answer at the end of the case)
Which of the following are approved for treating mood swings?
A. Fluoxetine (Prozac)
B. Lamotrigine (Lamictal)
C. Asenapine (Saphris)
D. Alprazolam (Xanax)
E. All of the above
F. None of the above
Patient evaluation on intake
30-year-old identical twins are referred separately for depression and anger problems
Both state that external stressors, e.g., work, family, etc. have driven them to depression and “mood swings”
Psychiatric history
Patient #1 states that he has a long history of mood swings, especially toward anger attacks, but over the last few years has been more “down and out” stressed, and suffering from insomnia
Patient #2 is identical
Patient #1 further admits to full MDD symptoms
– Occasionally experiences passive suicidal thoughts, agitation and restlessness, fatigue, poor concentration, and amotivation
– Does not have evidence of guilt or worthlessness symptoms
Patient #2 is identical
Patient #1 has no history of psychosis, mania, substance misuse, anxiety disorder
Patient #2 is identical
Patient #1 admits to a history of volatile and irritable temperament, difficulty in delaying gratification, poor frustration tolerance, and learning from an early age that aggression is often beneficial
Patient #2 is identical
Social and personal history
Patients #1 and #2 both graduated from high school
Both have been gainfully employed in service industry jobs, but have had difficulty dealing with their supervisors
Both are married with children
Their relationships are generally supportive but with occasional bouts of conflict
Both have a legal history of violent and assaultive behavior
Neither have alcohol or drug addiction histories
Medical history
Patient #1 has HTN, hypercholesterolemia, pre-diabetes, and an atrial cardiac arrhythmia
Patient #2 is identical except for the arrhythmia
Family history
Patient #1 admits distant family members have schizophrenia or bipolar disorder
Patient #2 is identical
Medication history
Patient #1 was started on the SNRI, venlafaxine-XR (Effexor-XR) 75 mg/d, by his PCP over a year ago
Patient #2 is not identical here and had been placed on a stimulant, an NDRI, an SSRI, a BZRA, and an epilepsy medication, topiramate (Topamax), by his previous psychiatrist
– Feels the latter medication was not helping, caused GI distress; he stopped it two weeks ago
Therefore, they are identical at some level of medication non-compliance, but they are very different in that their previous provider engaged in either a slow, limited series of monotherapies or in aggressive polypharmacy
Psychotherapy history
Patients #1 and #2 have been undergoing eclectic, supportive, individual psychotherapy over the last few months
Neither has received formal CBT, IPT, DBT, or PDP
Patient evaluation on initial visit
There is evidence of a gradual onset of MDD symptoms associated with multiple social stressors
Premorbid, Cluster B personality traits are observed as well
– DSM-5 lists several personality disorders, and Cluster B disorders traditionally involve patients who suffer from marked mood swings, inability to control their affect, and are often considered to be dramatic and erratic
– These include histrionic, narcissistic, antisocial, and borderline personality disorders
Both seem to be moderately depressed and suffering
Both seem motivated for medication management
Current medications
Question
Do patients suffering from unstable, affectively labile, insatiable, frustration-inducing, volatile Cluster B moods respond to psychopharmacology?
Yes
No
Maybe
Attending physician’s mental notes: initial evaluation
Both patients are motivated for treatment and have very similar presentations
Both have initial failures with psychotropics
Patient #1 was subtherapeutic on an antidepressant and he discontinued as it was not helping
– He has been undertreated
Patient #2 is the opposite and appears to be on many medications
– Most of which are therapeutic
– He may have been overtreated
Both stopped some of their medications without consulting their individual prescribers, which is troubling
The MDD symptoms should be easy to treat as they are relatively new
The personality disorder symptoms will increase treatment resistance and likely predispose both patients to frequent depressive relapses
Will need to better delineate adjustment disorders (that are numerous) versus state-dependent, full MDEs as well
There will likely be clear interplay between stress adjustments, personality coping styles, and frank MDD
Question
Which of the following would be your next step for both patients?
Use psychotherapy alone as there are no approved drugs for treating personality traits
Use SSRI/SNRI as they are approved for MDD
Use a mood stabilizing antiepileptic medication as some are approved for bipolar mood stabilization and have some data showing effectiveness in personality disorders where mood lability is problematic
Use an atypical antipsychotic as some are approved for bipolar mood stabilization, depression, agitation, and have some nonregulatory data showing effectiveness in personality disorders, especially for cognitive, perceptual, and aggressivity symptoms
Use buspirone or a beta-blocker as they have some off-label data showing effectiveness in treating anger and irritability
Attending physician’s mental notes: initial evaluation (continued)
Further discussion with the treating psychotherapists is needed to better delineate diagnoses
– Their depressive spells seem legitimate and sustained for both patients
– This is felt to be superimposed on top of long-standing Cluster B personality traits
These traits are felt to be further exacerbated by stress and depression
Likely, ongoing psychotherapy will be needed in order to maximize psychopharmacological response and prevent relapses
Using an approved antidepressant makes on-label sense, but the level of mood lability may warrant a mood stabilizing antipsychotic or mood stabilizer, which is not unlike treating a bipolar patient
Further investigation
Is there anything else you would especially like to know about these patients?
What about details concerning the patients’ potential for metabolic disorder?
Both patients are overweight with centralized abdominal obesity
Both patients share HTN and elevated lipids
Discussions with their PCPs suggest these are relatively well controlled with statins and antihypertensives
Both patients have slightly elevated blood glucose levels suggesting pre-diabetes
Both patients have family members who developed full metabolic disorder with age
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
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