From the Guidelines
The best course of action for this 52-year-old patient is to provide a limited refill of their current medications (Hydroxyzine 50mg BID, Trazodone 100mg 2 tablets QD, and Lexapro 20mg QD) while simultaneously referring them to a psychiatrist for proper evaluation and ongoing care. The patient should be given a 30-day supply of medications to prevent withdrawal and maintain stability, but continued refills without psychiatric oversight is not appropriate. The primary care provider should help facilitate a prompt psychiatric appointment, ideally within those 30 days. This approach is necessary because these medications require regular monitoring for efficacy and side effects, particularly for a patient with anxiety and depression. While the patient is currently stable, psychiatric conditions can change over time, requiring dosage adjustments or medication changes. Additionally, Lexapro (an SSRI) and Trazodone both affect serotonin levels and require professional oversight to prevent potential complications like serotonin syndrome. The combination of these three medications represents a complex regimen that should be managed by a specialist who can provide comprehensive mental health care beyond medication management, as recommended by guidelines such as those from the American College of Physicians 1. Moreover, recent guidelines also emphasize the importance of regular assessment and monitoring of patients with anxiety and depression, including those on medications like SSRIs and anxiolytics 1. Given the complexity of the patient's medication regimen and the need for ongoing monitoring and potential adjustments, referral to a psychiatrist is the most appropriate course of action to ensure the patient's safety and optimal management of their condition.
From the FDA Drug Label
The pooled analyses of placebo-controlled trials in children and adolescents with MDD, obsessive compulsive disorder (OCD), or other psychiatric disorders included a total of 24 short-term trials of 9 antidepressant drugs in over 4400 patients The pooled analyses of placebo-controlled trials in adults with MDD or other psychiatric disorders included a total of 295 short-term trials (median duration of 2 months) of 11 antidepressant drugs in over 77,000 patients.
The best course of action for a 52-year-old patient with anxiety and depression, currently stable on Hydroxyzine 50mg BID, Trazodone 100mg 2 tablets QD, and Lexapro 20mg QD, who is no longer under psychiatric care and is requesting a medication refill is to:
- Monitor the patient for any indication of clinical worsening and emergence of suicidal thoughts and behaviors, especially during the initial few months of drug therapy, and at times of dosage changes.
- Counsel family members or caregivers of patients to monitor for changes in behavior and to alert the healthcare provider.
- Consider changing the therapeutic regimen, including possibly discontinuing the medication, in patients whose depression is persistently worse, or who are experiencing emergent suicidality or symptoms that might be precursors to worsening depression or suicidality.
- Prescribe the smallest quantity of tablets consistent with good patient management, in order to reduce the risk of overdose.
- Screen patients for bipolar disorder before initiating treatment with an antidepressant. The patient should be closely monitored, as antidepressant drugs have been associated with the occurrence of cardiac arrhythmias 2.
From the Research
Patient Assessment
The patient is a 52-year-old individual with a history of anxiety and depression, currently stable on a regimen of Hydroxyzine 50mg BID, Trazodone 100mg 2 tablets QD, and Lexapro 20mg QD. The patient has been on these medications for several years and is requesting a refill, denying any suicidal ideation or homicidal ideation.
Medication Review
- Hydroxyzine: Studies have shown that Hydroxyzine is effective in alleviating symptoms of generalized anxiety disorder (GAD) 3, 4. However, the evidence also suggests that Hydroxyzine may be associated with a higher rate of sleepiness/drowsiness compared to other anxiolytic agents 3.
- Trazodone: Trazodone has been found to be an effective antidepressant with a low incidence of serious adverse effects 5, 6. It is also commonly used off-label for the treatment of insomnia, GAD, and other conditions 7. The recommended dosing regimen for Trazodone is 150-400 mg given in two divided doses, with the option to increase the dose as needed 5, 6.
- Lexapro: While there is no direct evidence provided for Lexapro in the given studies, it is a commonly used selective serotonin reuptake inhibitor (SSRI) for the treatment of depression and anxiety disorders.
Considerations for Refill
Given the patient's stability on the current medication regimen and the lack of reported side effects or concerns, a refill may be considered. However, it is essential to monitor the patient's response to the medications and adjust the dosages or regimen as needed to minimize potential side effects and optimize therapeutic benefits. Regular follow-up appointments should be scheduled to assess the patient's mental health status and adjust the treatment plan accordingly. The patient's denial of suicidal ideation or homicidal ideation is also an important consideration, and ongoing monitoring for these risks is crucial 3, 5, 6, 7, 4.