From the Guidelines
To help this 18-year-old psychiatric patient with multiple conditions, I recommend a comprehensive approach including medication adjustments and therapy, prioritizing her overall morbidity, mortality, and quality of life. First, consider increasing Lexapro to 15-20 mg daily since the current 10 mg dose is providing only partial response, as suggested by the American College of Physicians guideline on using second-generation antidepressants to treat depressive disorders 1. For sleep, replace hydroxyzine with trazodone 50-100 mg at bedtime or low-dose mirtazapine 7.5-15 mg, which may also help with appetite regulation for her avoidant restrictive food intake disorder, based on the management of chronic insomnia disorder in adults guideline from the American College of Physicians 1. For anxiety and fibromyalgia pain, duloxetine 30-60 mg daily could be beneficial as it addresses both depression and chronic pain conditions, as discussed in the use and misuse of opioids in chronic pain review 1. Some key points to consider in her treatment plan include:
- Cognitive Behavioral Therapy (CBT) is essential to address her emotional numbness, anxiety, and depression, while Dialectical Behavior Therapy (DBT) can help with emotional regulation.
- For her fibromyalgia and IBS, recommend non-pharmacological approaches including regular gentle exercise, proper sleep hygiene, and dietary modifications, such as a low FODMAP diet, as suggested in the irritable bowel syndrome and mental health comorbidity review 1.
- The emotional numbness (anhedonia) she experiences is likely related to her depression and anxiety, and often responds to a combination of proper medication management and therapy.
- Regular follow-up appointments every 2-4 weeks initially are important to monitor medication response and side effects, particularly when adjusting antidepressants in a young adult.
From the Research
Treatment Options for Adolescent Psychiatric Patient
The patient in question is an 18-year-old with feelings of ennui, numbness, and physical pain, accompanied by anxiety, depression, insomnia, fibromyalgia, irritable bowel syndrome, panic disorder, and avoidant restrictive food intake disorder. She is currently on Lexapro 10 mg with only partial response and hydroxyzine 100 mg per night, which is no longer effective.
- Mindfulness-Based Stress Reduction (MBSR): A study published in JAMA Psychiatry 2 found that MBSR was noninferior to escitalopram in treating anxiety disorders. This suggests that MBSR could be a viable alternative or complementary treatment for the patient's anxiety and depression.
- Escitalopram Dosage: The patient is currently taking Lexapro 10 mg, which is the starting dose for many patients. Studies have shown that escitalopram is effective in treating major depressive disorder and anxiety disorders 3, 4, 5. However, the patient has only had a partial response, which may indicate the need for dose escalation or augmentation.
- Augmentation Strategies: A review of partial response and nonresponse to antidepressant therapy 6 suggests that simultaneous targeting of both the noradrenergic and serotonergic systems is an effective augmentation strategy. This could involve adding a second medication to the patient's treatment regimen.
- Treatment of Comorbid Conditions: The patient's fibromyalgia, irritable bowel syndrome, and panic disorder should also be taken into consideration when developing a treatment plan. A comprehensive approach that addresses all of these conditions may be necessary to achieve optimal outcomes.
Potential Next Steps
Based on the available evidence, potential next steps for the patient's treatment could include:
- Increasing the dose of Lexapro or adding a second medication to augment its effects
- Implementing MBSR or other mindfulness-based interventions to complement pharmacological treatment
- Addressing the patient's comorbid conditions, such as fibromyalgia and irritable bowel syndrome, through targeted therapies or referrals to specialist care
- Continuously monitoring the patient's response to treatment and adjusting the plan as needed to achieve optimal outcomes.