Pretest self-assessment question (answer at the end of the case)
Why might certain atypical antipsychotics interact detrimentally with MAOI antidepressants?
A. Some atypical antipsychotics possess serotonin reuptake inhibitor (SRI) properties
B. Some atypical antipsychotics possess SNRI properties
C. Some atypical antipsychotics are partial agonists at 5-HT1A receptors
D. Some atypical antipsychotics are partial agonists at D3 receptors
E. A, B, and C
F. All of the above
Patient evaluation on intake
57-year-old man with a chief complaint of “horrible depression”
Feels he “made a bad decision” late in his career and is now unemployed after many successful years in equipment sales
Fearful and nervous that, at his age, he is too young to retire and too old to find a new job and be successful again
Psychiatric history
He had been without major mental health issues until he left his gainful employment of 25 years as an equipment salesman
– He left during poor corporate economic times assuming his company would fold
– He left for a second company for a sales position in a different market, and performed poorly on commission and was let go
– Psychiatric symptoms developed after this
Has not been able to go back to work at all due to anxiety and fear about failing again
He admits to full syndromal depressive symptoms
He now worries about everything, all the time, cannot focus, and is tense. He states he was never like this before
Additionally, he can barely “look people in the eye” and talk to them
– He is very concerned about doing and saying the right thing
– After years of remembering many details in sales, he can barely keep any facts straight, and is convinced that he will fail
– Panic attacks have occurred at recent job interviews, and since then is avoiding most situations where he has to speak to superiors
He has relatively few friends as most were colleagues at his previous job
While he is at home more, he is experiencing more conflict with his wife, although states she is supportive
Social and personal history
He graduated high school and served successfully in the military without traumatic experience
He was gainfully employed in sales for many years before changing jobs as noted
His wife is employed now but they are having difficulties financially
He does not use drugs or alcohol
Medical history
He has experienced 10 lbs of weight loss while depressed over last several months and is slightly underweight
He has no acute or chronic medical issues
He has no liver or renal disease
Family history
Denies any known psychiatric illness in any family member
Medication history
Psychotherapy history
Recently, started outpatient CBT with an adept clinician in the local area
Little to no response to these psychotherapeutic interventions, but acknowledges it is early in the course of this intervention and feels comfortable conversing about his problems
Patient evaluation on initial visit
Acute onset of MDD symptoms with associated, or possibly comorbid anxiety disorder roughly six months ago
Suffers immensely with guilt over his decision to leave his successful job for a new job this late in his career
Very compliant with medication management and has started psychotherapy
Good insight into his illness and wants to get better
He has current, fleeting passive suicidal ideation
There is possible guilt-based delusions (current ideation noted) but no other signs of psychosis
Reports no current side effects
Current medications
Question
In your clinical experience, would you expect a patient such as this to recover?
Yes, his premorbid health and functioning were very good
No, sometimes a devastating, late-life event causes chronic, unremitting depression
Attending physician’s mental notes: initial evaluation
This patient has his first MDE now. It is acute and triggered by a psychosocial stressor
It seems more than an adjustment disorder as it is pervasive, lasting over time, and clearly disabling
His initial failure on an SSRI is not alarming and he has recently been given a higher dose of an SNRI and started CBT, fostering a good prognosis
However, his older age of onset, loss of income, status, and some mild marital strife are concerning
Question
Which of the following would be your next step?
Increase the duloxetine (Cymbalta) to the full FDA dose of 120 mg
Increase the alprazolam (Xanax) to a higher, more effective dose
Augment the current medications with a third agent to accelerate response
Do nothing additionally outside waiting for SNRI and CBT effectiveness to occur
Attending physician’s mental notes: initial evaluation (continued)
This patient seems to be on one of the gold standard approaches to treating depression
First, an adequate trial dose/duration of an SSRI
Now started on an adequate dose/duration of an SNRI
Is starting bona fide CBT
Things look good in that the current regimen is a reasonable one
However, there is concern regarding his passive suicidal thoughts, which provoked a discussion about safety planning
He also seems very guilt ridden and ruminative about his failure. Will need to continue to investigate if this is delusional
He does meet criteria for MDD, SAD, and GAD
It is unclear if these are truly comorbid or if his depression is fostering the anxiety symptoms
– The latter seems appropriate as he had no premorbid anxiety prior to the onset of his depression
If comorbid anxiety becomes more evident, his prognosis worsens
Further investigation
Is there anything else you would especially like to know about this patient?
What about details concerning his past medication treatment and his current CBT?
– Has taken paroxetine (Paxil) up to 40 mg/d
He tolerated it well and only had a minimal clinical response, which he states was not meaningful
He has had three sessions so far
He likes his therapist and seems to have good rapport
This therapist is well known in the community and has a good reputation, where many CBT techniques are utilized although in an eclectic manner, over a longer time than the usual manualized 12–20 week duration
Case outcome: first interim follow-up visit four weeks later
Patient now has more CBT and time on his SNRI
He is no better and acknowledges the same symptoms as on his first appointment
He states that he has no side effects, which he appreciates
Question
Would you increase his current medications or change strategies?
Yes, continue both duloxetine and alprazolam at even higher doses
Continue duloxetine at higher doses but keep alprazolam as it is
Continue alprazolam at higher doses but keep duloxetine as it is
No, discontinue both agents as they have failed to allow for a clinical response and start new regimen
Case outcome: second interim follow-up visit at two months
The patient had his duolextine (Cymbalta) increased to 120 mg/d and his alprazolam (Xanax) increased to 1 mg three times a day
He has no side effects, is normotensive, and is reliably using his controlled substance
This approach maximizes his antidepressant and the anxiolytic augmentation increase may help his secondary anxiety symptoms
This approach leaves no doubt that a full trial was given and also allows more time for CBT to become clinically effective
The patient shows moderately better affective ranges, less psychomotor symptoms, and states an absence of suicidal thoughts as a result
He is felt to be 20%–30% better
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