How to manage psychiatric symptoms, including paranoia, hallucinations, low mood, and demoralization, in a 75-year-old male with a history of heart failure, cardiomyopathy, coronary artery disease, and diabetes, who has suffered 12% total body surface area burns and was initially treated with Seroquel (quetiapine) for delirium?

From the Guidelines

I strongly recommend continuing quetiapine (Seroquel) at 25-50mg at bedtime for sleep and to address residual paranoia/hallucinations, with potential daytime dosing of 25mg BID if symptoms persist during the day, as it is a well-established treatment for delirium and has a favorable side effect profile in older adults 1.

Management of Psychiatric Symptoms

The patient's presentation suggests possible post-ICU syndrome with elements of delirium transitioning to depression, and a comprehensive psychiatric approach is necessary to address the emerging psychiatric symptoms.

• Continue quetiapine (Seroquel) at 25-50mg at bedtime for sleep and to address residual paranoia/hallucinations, with potential daytime dosing of 25mg BID if symptoms persist during the day.
• Add escitalopram 5mg daily (lower dose given age and medical comorbidities) to address the depressive symptoms, which can be titrated to 10mg after 1-2 weeks if tolerated, as escitalopram has minimal cardiac effects and is a suitable choice for patients with heart failure, cardiomyopathy, coronary artery disease, and diabetes.

Additional Interventions

• Implement a structured sleep hygiene protocol including consistent sleep/wake times, minimizing nighttime interruptions when possible, and maintaining daytime light exposure.
• Consult psychiatry for a formal evaluation to distinguish between resolving delirium, depression, or adjustment disorder.

Rationale

The patient's medical comorbidities, including heart failure, cardiomyopathy, coronary artery disease, and diabetes, should be taken into consideration when selecting medications, and quetiapine and escitalopram are suitable choices due to their favorable side effect profiles in older adults with medical comorbidities 1.

• A multidisciplinary approach including psychiatric consultation, medication management, and environmental modifications will likely improve his engagement with rehabilitation and overall recovery.
• Depression following critical illness is common and can significantly impair rehabilitation engagement, and addressing depressive symptoms with escitalopram can help improve the patient's quality of life and rehabilitation outcomes.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Managing Psychiatric Symptoms

The patient in question has a complex medical history, including heart failure, cardiomyopathy, coronary artery disease, and diabetes, and has suffered 12% total body surface area burns. Initially treated with Seroquel (quetiapine) for delirium, the management of psychiatric symptoms such as paranoia, hallucinations, low mood, and demoralization is crucial.

• Quetiapine: Studies have shown that quetiapine is effective in treating bipolar depression 2, 3. It has been found to be generally well tolerated, with most treatment-emergent adverse events being of mild to moderate severity. However, it is essential to monitor for potential side effects, such as dry mouth, sedation, somnolence, dizziness, and weight gain.
• Combination Therapy: Combination therapy with an antidepressant and an antipsychotic, such as quetiapine, may be considered for treating psychotic depression 4. The combination of an SNRI (venlafaxine) and quetiapine has shown good results.
• Serotonin Syndrome: When increasing the dose of quetiapine or combining it with serotonergic agents, there is a risk of serotonin syndrome 5. Physicians should be aware of this potential risk and monitor patients closely.
• Alternative Treatments: Sertraline, a selective serotonin reuptake inhibitor, has been found to be safe and effective in treating depressive and anxiety disorders, including in patients with medical comorbidities 6. However, its use in combination with quetiapine should be approached with caution due to the risk of serotonin syndrome.

Considerations for Treatment

When managing psychiatric symptoms in this patient, it is essential to consider the following:

• Monitor for potential side effects of quetiapine, such as dry mouth, sedation, somnolence, dizziness, and weight gain.
• Be aware of the risk of serotonin syndrome when increasing the dose of quetiapine or combining it with serotonergic agents.
• Consider combination therapy with an antidepressant and an antipsychotic, such as quetiapine, for treating psychotic depression.
• Alternative treatments, such as sertraline, may be considered, but their use should be approached with caution due to potential interactions with quetiapine.