What is the best course of action for establishing psychiatric care for a patient with a history of PTSD, depression, ADHD, anxiety disorder, borderline personality disorder, lupus, fibromyalgia, rheumatoid arthritis, endometriosis, cervical cancer, and Raynaud's disease, currently taking Lexapro (escitalopram), Vyvanse (lisdexamfetamine), and hydroxyzine hydrochloride, after relocating to a new state?

Establishing Psychiatric Care After Relocation

Continue the current medication regimen (Lexapro 10 mg daily, Vyvanse 30 mg morning/10 mg afternoon PRN, hydroxyzine 10 mg PRN up to QID) without changes, as the patient is clinically stable, and prioritize immediate establishment of both psychiatric and primary care providers in the new state. 1

Immediate Action Steps

Psychiatric Care Establishment

• Seek a psychiatrist or psychiatric nurse practitioner within 2-4 weeks who can provide continuity of the current stable regimen and has experience managing complex comorbid psychiatric conditions (PTSD, depression, ADHD, anxiety, borderline personality disorder). 2, 3
• Request medical records transfer from the previous psychiatric provider immediately, including documentation of the 2019 hospitalization, medication trials, and response patterns. 4
• Schedule an initial psychiatric evaluation focused on confirming current stability, reviewing medication adherence, and establishing a therapeutic relationship rather than making immediate medication changes. 3

Primary Care Establishment

• Establish primary care within 4 weeks given the multiple autoimmune and rheumatologic conditions (lupus, fibromyalgia, rheumatoid arthritis, Raynaud's disease) that require ongoing monitoring and may interact with psychiatric medications. 2
• The primary care physician should monitor for potential drug interactions, particularly between SSRIs and any NSAIDs or immunosuppressive agents used for autoimmune conditions. 5, 1

Medication Continuation Rationale

Lexapro (Escitalopram) 10 mg Daily

• Continue current dose as the patient reports mood and anxiety control, indicating therapeutic benefit. 1
• Sertraline has been studied more extensively in patients with complex medical conditions and has lower QTc prolongation risk than escitalopram, but switching a stable patient is not warranted without clinical indication. 5
• Monitor for activating side effects (nervousness, insomnia, agitation), though these typically occur at treatment initiation or dose changes, not during stable maintenance therapy. 6, 1
• Antidepressant treatment should continue for 9-12 months after recovery from a depressive episode, and given the patient's complex psychiatric history, indefinite maintenance may be appropriate. 5

Vyvanse (Lisdexamfetamine) 30 mg AM/10 mg Afternoon PRN

• Continue the current split-dosing regimen as it provides adequate ADHD symptom control without sleep disturbance. 5
• The PRN afternoon dose allows flexible coverage for extended work hours without accumulating medication effects that could interfere with sleep. 5
• Monitor blood pressure and heart rate at primary care visits, as stimulants can exacerbate hypertension and interact with Raynaud's disease. 5

Hydroxyzine 10 mg PRN Up to QID

• Continue as-needed use for breakthrough anxiety, as this provides non-benzodiazepine anxiolytic coverage without addiction risk. 5
• Hydroxyzine is appropriate for anxiety management in patients with substance use concerns or borderline personality disorder where benzodiazepines carry higher risk. 5

Critical Monitoring Parameters

Psychiatric Monitoring

• Assess for suicidal ideation at every visit, particularly given the 2019 hospitalization history, even though the patient reports no recent ideations. 1
• Monitor for serotonin syndrome symptoms (agitation, confusion, tremor, tachycardia, hyperthermia) given escitalopram use, especially if any new medications are added. 1
• Screen for discontinuation symptoms if any medication interruptions occur during the transition period (irritability, dizziness, electric shock sensations, anxiety). 1

Medical-Psychiatric Interface

• Coordinate care between psychiatry and primary care to address the complex interaction between autoimmune conditions and psychiatric medications. 2, 3
• SSRIs can increase bleeding risk, particularly relevant given potential NSAID use for rheumatologic conditions and the history of endometriosis/hysterectomy. 5, 1
• Monitor for hypertension from stimulant use, which may be exacerbated by Raynaud's disease and autoimmune conditions. 5

Common Pitfalls to Avoid

• Do not discontinue or change medications during the transition period unless acute safety concerns arise, as stability is the priority. 1
• Do not assume medication adherence—explicitly assess adherence patterns and barriers at the first visit, as collaborative management improves outcomes. 3
• Do not delay primary care establishment—the autoimmune conditions require monitoring that cannot be deferred, and medication interactions must be managed. 2
• Avoid prescribing benzodiazepines for anxiety in this patient with borderline personality disorder and prior suicidal ideation, as hydroxyzine provides safer anxiolytic coverage. 5

Collaborative Care Model

• Implement collaborative management between primary care and psychiatry from the outset, with clear communication channels and shared treatment planning. 3
• The primary care physician should manage medical conditions and monitor for medication side effects, while the psychiatrist manages psychiatric medication optimization. 2, 3
• Schedule follow-up psychiatric visits at 4-6 week intervals initially to ensure stability during the transition, then extend to 3-month intervals if stable. 3