What is the best mood stabilizer for a 21-year-old male with Obsessive-Compulsive Disorder (OCD), Major Depressive Disorder (MDD), Attention Deficit Hyperactivity Disorder (ADHD), anxiety, and Post-Traumatic Stress Disorder (PTSD) currently taking Lexapro (escitalopram) and Wellbutrin (bupropion)?

Mood Stabilizer Selection for a 21-Year-Old Male with Multiple Psychiatric Disorders

For a 21-year-old male with OCD, MDD, ADHD, anxiety, and PTSD currently taking Lexapro and Wellbutrin, a mood stabilizer is not the first-line approach; instead, optimizing current medications and considering lamotrigine if truly needed would be most appropriate.

Current Medication Assessment

The patient is currently on:

• Lexapro (escitalopram) - an SSRI effective for OCD, MDD, anxiety disorders, and PTSD 1, 2, 3
• Wellbutrin (bupropion) - effective for MDD and ADHD, often used as an augmentation strategy 4, 5

This combination is actually quite appropriate for the patient's constellation of disorders:

• Escitalopram is a first-line treatment for OCD, anxiety disorders, and MDD 6, 2
• Bupropion augmentation to an SSRI is an evidence-based approach for treatment-resistant depression 7
• The combination targets different neurotransmitter systems (serotonin via escitalopram and dopamine/norepinephrine via bupropion)

Evaluation Before Adding a Mood Stabilizer

Before adding a mood stabilizer, consider:

1. Dose optimization of current medications:

   • Ensure escitalopram is at an adequate dose (up to 20mg daily) 7, 2
   • Verify bupropion is optimized (up to 100mg three times daily) 7
   • Higher doses of SSRIs are often needed for OCD than for other anxiety disorders 6

2. Response assessment:

   • Determine if the patient has had an adequate trial (8-12 weeks) at optimal doses 6, 7
   • Evaluate which specific symptoms remain problematic

3. Rule out bipolar disorder:

   • Adding a mood stabilizer without bipolar disorder may not be indicated
   • Assess for history of manic/hypomanic episodes

Mood Stabilizer Selection (If Truly Needed)

If a mood stabilizer is deemed necessary after optimization of current therapy:

First Choice: Lamotrigine

• Best tolerated mood stabilizer with least cognitive side effects
• Particularly effective for depressive symptoms
• Can be safely combined with escitalopram and bupropion
• Gradual titration required to minimize risk of Stevens-Johnson syndrome

Second Choice: Valproic Acid

• Consider if more acute stabilization is needed
• Effective for impulsivity and emotional dysregulation
• Requires blood level monitoring and liver function tests

Third Choice: Lithium

• Classic mood stabilizer with anti-suicidal properties
• Requires regular blood level monitoring
• More side effects and narrow therapeutic window

Important Cautions

• Avoid antipsychotics as mood stabilizers in this young patient if possible due to metabolic side effects and risk of tardive dyskinesia
• Avoid carbamazepine due to potential interactions with escitalopram and bupropion
• The presence of comorbid conditions may change the treatment algorithm (focus on mood stabilizers plus CBT in the presence of bipolar disorder) 6

Alternative Approaches Before Adding Mood Stabilizer

1. Consider CBT augmentation:

   • CBT is a first-line treatment for OCD 6
   • Exposure and Response Prevention (ERP) specifically for OCD
   • Trauma-focused therapy for PTSD

2. Consider SSRI switch if escitalopram is inadequate:

   • Sertraline has shown efficacy for both depression and anxiety symptoms 7
   • Fluoxetine may be beneficial for ADHD symptoms as well

3. Consider SNRI switch/addition:

   • Venlafaxine or duloxetine may help with anxiety and depression 7
   • Duloxetine particularly beneficial if pain symptoms are present

Monitoring and Follow-up

• Reassess symptoms every 2-4 weeks during medication changes 7
• Monitor for emergence of suicidal ideation, especially during transitions
• Evaluate for side effects regularly

Remember that true mood stabilizers are primarily indicated for bipolar disorder, and this patient's presentation may be better addressed through optimization of current medications or alternative strategies before adding a mood stabilizer.