What is the best course of treatment for a 52-year-old female patient with depression, anxiety, and a history of substance abuse, currently taking aripiprazole (Abilify) 2mg, escitalopram (Lexapro), lisinopril (Zestril) 10mg, and naltrexone (ReVia) 50mg, and experiencing withdrawal symptoms, bilateral hand numbness/tingling, and stress incontinence?

Management of Depression and Anxiety in a Patient with Alcohol Use Disorder

For this 52-year-old female patient with depression, anxiety, and alcohol use disorder, the most appropriate treatment approach is to continue escitalopram for depression/anxiety, maintain naltrexone for alcohol use disorder, and adjust aripiprazole dosage to 5-10mg for augmentation therapy while monitoring for side effects and ordering vitamin B12 levels to evaluate the bilateral hand numbness.

Current Clinical Presentation

• 52-year-old female with depression and anxiety
• History of alcohol use disorder (AUD) with 55 days of sobriety
• Previous withdrawal symptoms: tremors, nausea, vomiting, headaches, visual disturbances
• History of 4 detox programs, most recent in June 2023
• Active in AA for 10 years, attending weekly meetings
• Bilateral hand numbness/tingling in fingertips (worse in mornings)
• Easy bruising and stress incontinence
• Current medications:
  • Escitalopram (Lexapro)
  • Aripiprazole 2mg
  • Naltrexone 50mg
  • Lisinopril 10mg
  • Albuterol sulfate HFA inhaler
  • Flovent HFA
  • B complex vitamin
  • Denavir 1% topical cream
  • Valtrex as needed

Assessment and Treatment Plan

1. Depression and Anxiety Management

• Continue escitalopram as first-line treatment for depression and anxiety 1

  • Escitalopram is one of the preferred agents for depression with favorable adverse effect profile 1
  • Has demonstrated efficacy in both depression and anxiety disorders 2

• Adjust aripiprazole dosage:

  • Current 2mg dose is lower than typically effective range
  • Increase to 5-10mg as augmentation therapy for treatment-resistant depression/anxiety 3
  • Aripiprazole has shown efficacy as an SSRI augmentation agent in patients with incomplete response to SSRIs alone 3
  • 59% of patients with depression and anxiety showed significant improvement with aripiprazole augmentation 3

2. Alcohol Use Disorder Management

• Continue naltrexone 50mg daily

  • FDA-approved dose for alcohol dependence 4
  • Reduces alcohol cravings and helps maintain abstinence
  • Current 55-day sobriety suggests effectiveness of current regimen

• Support continued AA participation

  • Encourage obtaining a sponsor and completing the 12 steps
  • Medication compliance should be considered only one factor in successful treatment 4

3. Neurological Symptoms Evaluation

• Order vitamin B12 level to evaluate bilateral hand numbness/tingling
  • Morning paresthesias suggest possible peripheral neuropathy
  • Could be related to prior alcohol use or nutritional deficiency
  • Consider gabapentin or pregabalin if neuropathic pain is confirmed 1

4. Monitoring and Follow-up

• Monitor for medication side effects:

  • Escitalopram: risk of serotonin syndrome, discontinuation syndrome if missed doses 5
  • Aripiprazole: monitor for extrapyramidal symptoms, metabolic effects
  • Naltrexone: ensure continued opioid abstinence to prevent precipitated withdrawal 4

• Schedule follow-up in 4 weeks to assess:

  • Response to adjusted aripiprazole dose
  • Continued sobriety
  • B12 test results and neurological symptoms
  • Stress incontinence symptoms (consider referral to urology/gynecology if persistent)

Important Considerations and Pitfalls

Medication Interactions and Precautions

• Avoid abrupt discontinuation of escitalopram due to risk of discontinuation syndrome 5
• Monitor for serotonin syndrome with the combination of psychiatric medications 5
• Ensure patient understands the importance of avoiding opioids while on naltrexone 4

Addressing Comorbidities

• Easy bruising: May be related to nutritional deficiencies from prior alcohol use
• Stress incontinence: Consider pelvic floor exercises and possible referral if symptoms are bothersome

Common Pitfalls to Avoid

• Undertreatment of depression/anxiety: The current aripiprazole dose of 2mg may be subtherapeutic for augmentation
• Focusing only on medications: Ensure continued psychosocial support through AA and consider additional counseling
• Missing vitamin deficiencies: Alcohol use disorder commonly leads to B vitamin deficiencies that can cause neurological symptoms

This treatment plan addresses both the psychiatric and substance use aspects of the patient's presentation while investigating potential underlying causes of her neurological symptoms.