From the Guidelines
For this 18-year-old psychiatric patient with multiple conditions, I strongly recommend a comprehensive treatment approach that prioritizes cognitive behavioral therapy (CBT) and medication adjustments to address depression, anxiety, and disordered eating, while also considering the patient's irritable bowel syndrome (IBS) and fibromyalgia. The patient's current Lexapro dose of 10 mg is providing only partial response, so increasing it to 20 mg daily may be beneficial 1. For sleep, replacing hydroxyzine with trazodone 50-100 mg at bedtime could address both insomnia and potentially augment antidepressant effects. Anxiety management could be improved by considering scheduled buspirone 7.5-15 mg twice daily rather than as-needed Xanax to avoid dependence issues. Duloxetine 30-60 mg daily could be beneficial as it targets both depression and fibromyalgia pain, and its effects on IBS symptoms should also be considered 1. Nutritional counseling with a specialized dietitian is essential for the avoidant restrictive food intake disorder, and a gentle FODMAP diet approach might be appropriate, particularly in people with mild to moderate gastrointestinal symptoms 1. CBT should be implemented for depression, anxiety, and eating behaviors, with dialectical behavior therapy (DBT) skills to address emotional numbness, and brain–gut behavior therapy (BGBT) could also be beneficial in remediating psychological and cognitive factors that impact gastrointestinal symptom perception 1. Regular exercise, sleep hygiene practices, and mindfulness techniques should also be recommended. These recommendations target multiple symptoms simultaneously, and regular monitoring for medication effectiveness and side effects is crucial, with adjustments as needed. Key considerations include:
- Medication adjustments to optimize treatment of depression, anxiety, and fibromyalgia
- Implementation of CBT and BGBT to address psychological and cognitive factors contributing to symptoms
- Nutritional counseling and gentle FODMAP diet approach for IBS management
- Regular exercise, sleep hygiene practices, and mindfulness techniques to promote overall well-being.
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
- A study published in 2023 2 compared Mindfulness-Based Stress Reduction (MBSR) to escitalopram for the treatment of adults with anxiety disorders, finding that MBSR was noninferior to escitalopram.
- This suggests that MBSR could be a viable alternative or complementary treatment for the patient's anxiety and depression.
Escitalopram Therapy
- Research from 2008 3 and 2007 4 indicates that escitalopram is an effective and well-tolerated treatment for major depression and anxiety disorders.
- A 2021 systematic review and network meta-analysis 5 found that escitalopram had greater efficacy and acceptability than placebo for the treatment of panic disorder.
- A 2004 study 6 demonstrated the efficacy and tolerability of escitalopram in the treatment of generalized anxiety disorder.
Considerations for Treatment Adjustment
- Given the patient's partial response to Lexapro 10 mg, it may be worth considering an adjustment to her medication regimen, potentially increasing the dose or adding a complementary treatment like MBSR.
- The patient's use of hydroxyzine 100 mg per night, which is no longer effective, may need to be reevaluated, and alternative treatments for insomnia could be explored.
- The patient's fibromyalgia, irritable bowel syndrome, and avoidant restrictive food intake disorder should also be taken into account when adjusting her treatment plan.