What is the best approach to manage a 60-year-old patient with Hypertension (HTN) on triamterene, who also has Obsessive-Compulsive Disorder (OCD), Major Depressive Disorder (MDD), and anxiety?

Management of Hypertension, OCD, MDD, and Anxiety in a 60-Year-Old on Triamterene

Start an SSRI (sertraline 50 mg daily or fluvoxamine 50 mg daily) combined with cognitive behavioral therapy (CBT) with exposure and response prevention (ERP) to address the OCD, MDD, and anxiety simultaneously, while optimizing the hypertension regimen by transitioning from triamterene monotherapy to a RAS-inhibitor (ACE-I or ARB) plus calcium channel blocker (CCB) combination. 1, 2, 3

Psychiatric Management

First-Line Treatment Selection

• Sertraline is the preferred SSRI for this patient with comorbid OCD, MDD, and anxiety because it treats all three conditions simultaneously and has fewer drug interactions compared to other SSRIs, which is critical given the need for antihypertensive polypharmacy. 3, 4

• Start sertraline at 50 mg once daily (morning or evening) and titrate upward over 1-2 weeks to minimize initial anxiety or agitation, which may occur but typically resolves within the first few weeks. 4

• Fluvoxamine is an acceptable alternative if sertraline is not tolerated, as it has demonstrated efficacy for both OCD and MDD, though it requires dose adjustments of certain benzodiazepines (reduce alprazolam/triazolam by 50%) due to CYP1A2 and CYP3A4 inhibition. 2

Dosing and Duration Strategy

• Allow 8-12 weeks at maximum tolerated dose (up to 200 mg/day for sertraline) before declaring treatment failure, as OCD symptoms may take longer to improve than depressive symptoms. 1, 2, 4

• Patients not responding to 50 mg/day may benefit from dose increases up to 200 mg/day, with changes occurring at intervals of no less than 1 week given sertraline's 24-hour elimination half-life. 4

• Plan for 12-24 months of maintenance therapy after achieving remission, as both OCD and MDD have high relapse rates. 2, 3

Combination Therapy Approach

• Initiate CBT with ERP from the outset rather than sequentially, as combination therapy offers superior outcomes for both OCD and MDD compared to either treatment alone. 2, 3, 5

• The combination of SSRI plus CBT/ERP is associated with optimal response compared to each treatment alone or other treatment strategies. 5

Treatment-Resistant Cases

• If inadequate response after 8-12 weeks at maximum tolerated SSRI dose, consider: 1, 3, 5
  • Switching to another SSRI (fluoxetine has longer half-life, advantageous for adherence issues)
  • Augmentation with low-dose aripiprazole or other atypical antipsychotics
  • Intensifying CBT/ERP therapy
  • Clomipramine may be considered only after multiple SSRI trials fail (requires 3 adequate SSRI trials including one with clomipramine per treatment-refractory criteria)

Hypertension Management

Medication Optimization

• Transition from triamterene monotherapy to a RAS-inhibitor (ACE-I or ARB) plus CCB combination, as this is the preferred regimen for patients with hypertension and psychiatric disorders, offering lower rates of pharmacological interactions with antidepressants. 1

• Triamterene as monotherapy is suboptimal; patients with psychiatric disorders should preferentially receive RAS-inhibitors and diuretics, with CCBs as appropriate additions. 1

• Use CCBs and alpha-1 blockers with caution due to risk of orthostatic hypotension, particularly relevant with SSRIs (serotonin reuptake inhibitors). 1

• Beta-blockers (except metoprolol) should be reserved for drug-induced tachycardia from antidepressants or antipsychotics if it develops. 1

Blood Pressure Targets

• Lower BP as in the general population, with target <140/90 mm Hg, recognizing that psychiatric disorders increase cardiovascular risk. 1

• Monitor for pharmacologic interactions, ECG abnormalities, and postural BP changes given the combination of antihypertensive and psychotropic medications. 1

Critical Monitoring and Pitfalls

Assessment Strategy

• Track OCD symptoms (using Yale-Brown Obsessive-Compulsive Scale), depressive symptoms, and anxiety separately, as improvement timelines differ. 2, 3

• Assess quality of life and functional capacity at baseline and throughout treatment. 2

• Monitor for sexual dysfunction, though sertraline has relatively lower rates compared to paroxetine. 2

Common Pitfalls to Avoid

• Never abruptly discontinue SSRIs due to risk of discontinuation syndrome, particularly with shorter-acting agents (though sertraline has lower risk than paroxetine). 3

• Do not declare treatment failure before 8-12 weeks at maximum tolerated dose, as premature switching undermines adequate trial duration. 1, 2

• Avoid declaring treatment resistance without confirming: adequate SSRI dose/duration, medication adherence, and exclusion of substance-induced symptoms. 1

• Do not use MAOIs within 14 days of SSRI discontinuation or initiation due to serotonin syndrome risk. 4

• Be vigilant for suicidal ideation, as patients with mood and adjustment disorders can develop suicidal tendencies, and suicide risk in patients with comorbid conditions is elevated. 1