What should be addressed at a follow-up appointment for a 38-year-old male with a history of major depressive disorder, generalized anxiety disorder (GAD), and opioid use disorder, recently hospitalized for suicidal ideation and discharged with an increased dose of gabapentin, newly initiated duloxetine, and discontinued escitalopram (Lexapro)?

From the Guidelines

At the follow-up appointment for this 38-year-old male patient, the provider should focus on assessing the patient's current mental status, particularly suicidal ideation, and evaluating his response to medication changes, with a strong emphasis on monitoring for potential side effects of the newly initiated duloxetine and higher dose of gabapentin, as well as the discontinuation of Lexapro, as recommended by the American College of Physicians 1. The appointment should begin with a thorough assessment of any ongoing suicidal thoughts, plans, or intent, using standardized screening tools if appropriate.

• The provider should evaluate how the patient is tolerating the higher dose of gabapentin and the newly initiated duloxetine, looking for both therapeutic effects and potential side effects, such as nausea, dizziness, and sedation, which are common side effects of these medications 1.
• It's essential to confirm that the discontinuation of Lexapro hasn't caused withdrawal symptoms or worsening of depression, as this can be a critical factor in the patient's mental status.
• The provider should assess the patient's engagement with the partial hospitalization program, including attendance and perceived benefit, as well as the patient's opioid use disorder status, including any cravings, potential relapse, or need for medication-assisted treatment.
• The provider should review the patient's short-term disability application status and determine if additional documentation or support is needed, and evaluate the patient's support system and ensure safety planning is in place, including emergency contacts and crisis resources, as recommended by the U.S. Department of Veterans Affairs and U.S. Department of Defense clinical practice guidelines 1.
• Laboratory monitoring may be necessary depending on the medication regimen, and a clear follow-up plan should be established with appropriate timing based on the patient's clinical stability.
• The provider should also consider the use of nonpharmacologic interventions, such as cognitive behavioral therapy (CBT) or dialectical behavior therapy (DBT), which have been shown to be effective in reducing suicidal ideation and behavior, as well as improving overall mental health outcomes 1.

From the FDA Drug Label

1. Warnings and Precautions 5. 1 Suicidal Thoughts and Behaviors in Children, Adolescents, and Young Adults Patients with major depressive disorder (MDD), both adult and pediatric, may experience worsening of their depression and/or the emergence of suicidal ideation and behavior (suicidality) or unusual changes in behavior, whether or not they are taking antidepressant medications, and this risk may persist until significant remission occurs. All patients being treated with antidepressants for any indication should be monitored appropriately and observed closely for clinical worsening, suicidality, and unusual changes in behavior, especially during the initial few months of a course of drug therapy, or at times of dose changes, either increases or decreases

The patient should be monitored for suicidal thoughts and behaviors, as well as clinical worsening and unusual changes in behavior, especially since the dose of gabapentin was increased and duloxetine was recently started.

• The patient's mood, behavior, and symptoms should be closely observed, especially during the initial few months of treatment or at times of dose changes.
• The patient should be educated on the importance of reporting any changes in mood, behavior, or symptoms to their healthcare provider.
• The healthcare provider should closely monitor the patient's response to treatment and adjust the treatment plan as needed.
• The patient's treatment plan should be reassessed at the follow-up appointment to ensure that it is effective and safe 2.
• The patient's partial hospitalization program and short-term disability leave should also be discussed at the follow-up appointment to ensure that the patient is receiving adequate support and care 2.

From the Research

Follow-up Appointment Considerations

At the follow-up appointment for a 38-year-old male with a history of depression, GAD, and opioid use disorder, several factors should be addressed:

• The patient's recent hospitalization for suicidal ideation and the subsequent changes to his medication regimen, including the increased dose of gabapentin and the introduction of duloxetine, as well as the discontinuation of Lexapro 3, 4, 5.
• The potential risks associated with gabapentin, including its possible contribution to depression, aggressive behavior, and suicidal ideation, particularly in patients with underlying psychiatric disorders 3.
• The patient's participation in a partial hospitalization program and his application for short-term disability leave, which may impact his mental health treatment and overall well-being.
• The importance of monitoring the patient's suicidal ideation and behavior, given the increased risk associated with antidepressant treatment, particularly in the first month after starting treatment 4, 6, 7.

Medication Management

The patient's medication regimen should be carefully evaluated, considering the potential risks and benefits of each medication:

• Gabapentin: its potential to contribute to depression, aggressive behavior, and suicidal ideation, and the need for close monitoring 3.
• Duloxetine: its potential to improve symptoms of depression and reduce suicidal ideation, as well as its relatively low risk of suicidal behaviors compared to other antidepressants 5, 6.
• Discontinuation of Lexapro: the potential impact on the patient's mental health treatment and the need for alternative therapies.

Risk Assessment and Monitoring

The patient's risk of suicidal behavior should be continuously assessed and monitored:

• Regular evaluations of the patient's mental health status, including his symptoms of depression, anxiety, and suicidal ideation.
• Close monitoring of the patient's response to medication changes and adjustments to the treatment plan as needed.
• Collaboration with the patient's healthcare team, including his partial hospitalization program and primary care physician, to ensure comprehensive care and support 4, 6, 7.