What is the best course of treatment for a patient with depression, anxiety, and sleep disturbances, taking Wellbutrin XL (bupropion), Zoloft (sertraline), Buspar (buspirone), and hydroxyzine, with a positive MDQ result?

Management of Depression, Anxiety, and Sleep Disturbances in a Patient with Positive MDQ

Based on the positive MDQ screening result, this patient should be evaluated for bipolar disorder and treated with a mood stabilizer as the primary intervention rather than continuing the current antidepressant regimen.

Assessment of Current Situation

• The patient is a 41-year-old male with depression, anxiety, sleep disturbances, and cannabis use
• Current medications include:
  • Wellbutrin XL (bupropion) 300 mg daily
  • Zoloft (sertraline) 100 mg daily
  • Buspar (buspirone) 5 mg twice daily
  • Hydroxyzine 25 mg PRN for sleep
• Sleep is limited to 5-6 hours per night
• Critical finding: Positive MDQ (Mood Disorder Questionnaire) result, suggesting possible bipolar disorder 1

Immediate Treatment Considerations

Step 1: Address Potential Bipolar Disorder

• The positive MDQ result indicates a high probability of bipolar spectrum disorder, which fundamentally changes the treatment approach 1
• Current regimen with multiple antidepressants (bupropion and sertraline) without mood stabilization poses risk of mood destabilization or cycling in bipolar patients 2
• Bupropion can cause agitation, anxiety, and insomnia which may worsen symptoms in bipolar patients 2

Step 2: Medication Adjustments

1. Add a mood stabilizer:

   • Lamotrigine is recommended as first-line for bipolar depression with less sedation than other mood stabilizers 3
   • Start at low dose (25mg daily) and titrate slowly to reduce risk of serious rash

2. Antidepressant management:

   • Consider tapering and discontinuing bupropion first, as it can be activating and worsen anxiety and sleep issues 1, 2
   • Maintain sertraline temporarily as it has better evidence for anxiety symptoms than other SSRIs 1
   • Plan for eventual tapering of sertraline after mood stabilizer is established

3. Sleep management:

   • Replace hydroxyzine with mirtazapine 7.5-15mg at bedtime for more effective sleep management 1
   • Mirtazapine promotes sleep, appetite, and weight gain, which may benefit this patient 1
   • Avoid benzodiazepines and z-drugs (zolpidem) due to risk of dependence and cognitive impairment 1

4. Anxiety management:

   • Continue buspirone temporarily but monitor for serotonin syndrome with sertraline 4
   • Consider discontinuing buspirone after mood stabilization is achieved

Monitoring and Follow-up

• Reassess symptoms every 2 weeks during medication adjustments 1
• Monitor for emergence of hypomania/mania, especially during antidepressant taper 2
• Evaluate cannabis use and its impact on mood and sleep; consider recommending reduction or cessation 1
• Assess for side effects of new medications, particularly rash with lamotrigine 3

Additional Interventions

• Cognitive Behavioral Therapy for Insomnia (CBT-I) should be initiated as first-line treatment for sleep disturbances 1
• Regular sleep schedule with consistent wake time, even on weekends 5
• Limit cannabis use, especially before bedtime, as it can disrupt sleep architecture despite subjective improvement 1

Common Pitfalls to Avoid

• Continuing multiple antidepressants in a patient with bipolar disorder can worsen cycling and potentially trigger manic episodes 2
• Overlooking the significance of a positive MDQ - this fundamentally changes the diagnosis from unipolar to bipolar spectrum disorder 1
• Relying solely on PRN medications for sleep without addressing the underlying mood disorder 1
• Adding benzodiazepines for anxiety which can lead to dependence and worsen overall outcomes 1

Treatment Algorithm

1. Week 1-2: Start lamotrigine 25mg daily while maintaining current medications
2. Week 3-4: Increase lamotrigine to 50mg daily; start mirtazapine 7.5mg at bedtime; begin tapering bupropion
3. Week 5-6: Increase lamotrigine to 100mg daily; discontinue bupropion; maintain mirtazapine and sertraline
4. Week 7-8: Increase lamotrigine to 200mg daily if tolerated; begin tapering sertraline if mood is stable
5. Week 9-12: Consider discontinuing buspirone if anxiety is controlled; adjust mirtazapine dose based on sleep response

This approach prioritizes mood stabilization while addressing sleep disturbances and anxiety, with the goal of simplifying the medication regimen once the patient is stabilized 1, 3.