What is the best course of action for a patient with depression, anxiety, and disturbed sleep, currently taking lamotrigine, guanfacine, buspirone, and aripiprazole?

Management of Depression with Anxiety and Disturbed Sleep in a Patient on Multiple Psychiatric Medications

The best course of action for this patient is to initiate SSRI therapy (such as sertraline or escitalopram) while referring for Cognitive Behavioral Therapy (CBT), as these are first-line treatments for depression with anxiety per guidelines. 1

Current Medication Assessment

The patient is currently taking:

• Lamotrigine 200 mg daily
• Guanfacine 2 mg ER daily (recently increased to 3 mg)
• Buspirone 15 mg twice daily
• Aripiprazole 10 mg daily

Medication Concerns

1. Aripiprazole and Lamotrigine Combination

   • This combination may be contributing to the patient's worsening anxiety and passive suicidal thoughts
   • Research shows this combination can increase risk of akathisia, anxiety, and suicidal ideation 2
   • Consider discontinuing aripiprazole or reducing the dose under close monitoring

2. Buspirone Evaluation

   • While buspirone can be effective for anxiety 3, the patient's anxiety has worsened despite this medication
   • Current dosing may be inadequate or ineffective for this patient

3. Guanfacine Effectiveness

   • Patient reports no significant changes since starting guanfacine
   • Limited evidence supports guanfacine for anxiety disorders in adults 4

Recommended Treatment Algorithm

Step 1: Medication Adjustments

1. Add SSRI therapy (first-line for anxiety and depression) 1

   • Start with sertraline 25-50mg daily for 1 week
   • Increase to 50-100mg daily in week 2
   • Target dose 50-200mg daily for 4-6 weeks

2. Consider aripiprazole modification

   • Either reduce dose or discontinue due to potential interaction with lamotrigine causing increased anxiety and suicidal thoughts 2

3. Maintain lamotrigine as it may be helpful for mood stabilization

4. Re-evaluate buspirone effectiveness

   • Consider dose adjustment if continuing

Step 2: Psychotherapy Referral

• Initiate Cognitive Behavioral Therapy (CBT) - recommended as first-line psychotherapeutic treatment for anxiety and depression 1
• Individual sessions are preferred over group sessions for superior clinical efficacy

Step 3: Sleep Management

• Consider adding a non-benzodiazepine sleep aid temporarily if sleep disturbance persists
• Address sleep hygiene practices

Step 4: Follow-up Schedule

• Schedule follow-up within 2 weeks to assess medication response and side effects 1
• Minimum of 3 follow-up visits within the first 3 months to improve medication adherence 5
• Use standardized measures (GAD-7 for anxiety, PHQ-9 for depression) to track progress 1

Important Clinical Considerations

• Explicitly discuss treatment duration with the patient - recommend continuing treatment for at least 9-12 months after symptom remission 1
• Document this discussion as research shows discrepancies between physician instructions and patient recall about treatment duration 5
• Discuss potential medication side effects thoroughly, as this improves medication adherence 5
• Monitor closely for suicidal ideation, particularly in the first weeks of treatment and with any medication changes 1
• Limit medication quantities during initial treatment phase due to passive suicidal thoughts 1

Treatment Monitoring

• Evaluate response to SSRI therapy after 6-8 weeks at adequate dose 1
• If inadequate response, consider switching to alternative SSRI or SNRI (venlafaxine or duloxetine) 1
• Assess for emergence of manic symptoms, which would necessitate discontinuation of antidepressants and psychiatric consultation 1

This approach prioritizes evidence-based interventions for depression with anxiety while addressing the patient's current medication regimen and reported symptoms.