Pretest self-assessment question (answer at the end of the case)
Which of the following are most accurate about gabapentin and its ability to treat psychiatric symptoms?
A. It alleviates mania
B. It alleviates panic attacks
C. It alleviates obsessive compulsive symptoms
D. It reduces alcohol consumption
E. A and C
F. B and D
G. All of the above
Patient evaluation on intake
27-year-old man states he is in between graduate school assignments and “has some concerns”
Has been depressed and anxious but is most concerned about his alcohol use
Psychiatric history
Became increasingly anxious two years ago and was placed on the SSRI sertraline (Zoloft)
– Was experiencing bouts of generalized worries but these episodes would last weeks but never more than a few months
– Would have minor panic attacks, but not major disabling ones. Sometimes these are triggered by stressors but many happen unexpectedly
– He states he is socially anxious at times, but this occurs more often in academic circles compared to social circles
– As a teenager, he had obsessive needs to have symmetry and to wash his hands, but has not had these symptoms since his late teens
– He denies PTSD
Alludes to being depressed at times
Will have bouts of increased activity and less need for sleep
– Denies mood elevation at these times, and these episodes usually begin when he takes on new tasks, jobs, interpersonal situations
– He does feel more capable but denies any grandiosity or invincibility feelings at these times
– These last from days to weeks depending upon his life events
The alcohol use increased over the last few weeks to the point of four- to five- day binges of excessive alcohol drinking where, for the first time, he started drinking in the morning
– Never has been a daily drinker but admits to binges on weekends
Has had no legal, medical, or social consequences as a result
Does admit that once he has four to five drinks he often drinks several more and loses control of his ability to stop drinking
– Admits that he has tried to cut back on drinking, would get annoyed if asked to stop, feels guilt now about his excessive use, and on his last binge he drank an “eye-opener” drink in the morning
After he tried to quit, he felt compelled to start drinking on the first morning of attempted sobriety
– Increased tolerance over the years is noted but has never experienced alcohol withdrawal
– Suicidal thinking escalates now when heavily intoxicated and the most recent alcohol binge scared him and convinced him to seek help
Social and personal history
Graduated from college and is working on a doctorate in the humanities
Has a girlfriend and has sustained meaningful relationships without difficulty
Drinks coffee in the morning, and only smokes cigarettes when drinking alcohol
Medical history
Denies medical problems
Family history
Thinks one of his grandmothers suffered from MDD
Mother takes an SSRI but he cannot recollect which one, and he is unclear if she is depressed, anxious, or both
He has no family members with schizophrenia or bipolar disorder
Medication history
Has been treated with two SSRIs by his PCP
– In college he took paroxetine (Paxil) 20 mg/d but was drinking and smoking most of the time so is unclear if it helped, or not
– Sertraline (Zoloft) has been used over the last year, ranging from 50 mg/d to 100 mg/d
50 mg/d is partially ameliorative of his symptoms at best
100 mg/d made him anxious and agitated
– The BZRA zolpidem (Ambien) 10 mg at bedtime has been used for insomnia but became ineffective due to tolerance
– Zolpidem-CR (Ambien-CR) was next used and is effective now
– Alprazolam (Xanax) 1 mg/d has been used as needed for anxiety
Psychotherapy history
Has not had psychotherapy outside visiting a counselor a few times in college
Patient evaluation on initial visit
The patient presents with a mixture of subsyndromal depression and anxiety
Has brief, discrete periods of activity elevation that seem driven by anxiety in new situations
– Possibly hypomania
Now has a problematic, acute escalation in his drinking pattern, which left him temporarily more depressed and even suicidal
Seems motivated to change his drinking pattern, but would like to address his depression and anxiety symptoms as well
Current psychiatric medications
Question
Do any of these medications concern you regarding this patient’s comorbidities?
Yes, given his alcohol misuse, his BZRA (zolpidem-CR) should be tapered off
Yes, given his alcohol misuse, his sedative–anxiolytic (alprazolam) should be tapered off
Yes, his SSRI (sertraline) should be discontinued due to history of possible mood elevations and hypomania
No, he seems to be partially treated and some patients may require dose escalation for better symptom control
Attending physician’s mental notes: initial evaluation
Seems to have minor depression and minor anxiety symptoms but does not meet a full DSM-5 categorical diagnosis for any disorder
Has bouts of increased goal-directed activity that seem to be driven more by anxiety in new social situations, but hypomania must be considered as he may underreport the severity and duration of these episodes
He appears to be binge drinking and is starting to gain consequences and repercussions from his drinking. He has a few DSM-5 AUD symptoms, perhaps placing him in the mild to moderate category of severity
Will have to have three or four subsyndromal DSM-5 symptom clusters, but they have added up to cause enough psychological distress that he wants to be treated now
Question
Which of the following would be your next step?
Discuss with the patient which target symptoms (anxiety, depression, insomnia, hypomania, alcohol use) are most impairing and select a medication based upon this rationale
Focus on alcohol sobriety as this has the highest risk for causing suicide in this patient
Focus on mood stability as he might be a bipolar II or cyclothymic disorder patient
As he has no definitive categorical disorder, refer for psychotherapy to address his long-term dynamic issues, anxiety and depression symptoms
Refer for psychological testing to better delineate his symptoms
Attending physician’s mental notes: initial evaluation (continued)
He is distressed and now motivated for active change
Views his alcohol use as a problem and being “out of control” and relates some of it to self-medicating his stress, anxiety, and depressive symptoms
Bouts of increased energy seem to be driven by novelty in new social situations and tasks, which may be a personality trait, a response to anxiety, but differentially do not seem to be a sustained mood elevation or bipolar disorder phenomenon
Sees the alcohol use as the main issue and insomnia as the second most impairing target symptom
The use of excessive alcohol, a BZ, and a BZRA hypnotic are troubling
– There is no evidence of misusing these controlled medications, but he is at higher risk for becoming addicted to them or accidentally overdosing
– They are marginally effective now anyhow
Case outcome: initial visit
Patient is educated about his working diagnosis being complicated due to his minor levels of several symptom clusters, his clear AUD, and that picking an approved monotherapy may be difficult
He is educated about the conflict of interest in that he presents being worried about alcohol misuse and is also on two addictive sedative-type medications
Admits he has used them concurrently with alcohol in the past, but has not dose-escalated his prescription medications on his own
Feels his lower-dose SSRI, sertraline (Zoloft), is partially effective and asks to keep it as it is and not to “give up on it”
Agrees to taper off his potentially addictive zolpidem-CR and alprazolam with minimal resistance, assuming that his insomnia can be controlled by another regimen
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
