From the Guidelines
For a 19-year-old female with MDD, GAD, ARFID, and symptoms suggesting possible bipolar spectrum disorder, I strongly recommend a psychiatric evaluation for bipolar II disorder and medication adjustment, prioritizing mood stabilization and sleep management to improve morbidity, mortality, and quality of life. The patient's decreased need for sleep, increased sociability, and talkativeness while still depressed suggest a possible bipolar spectrum disorder, which may explain the minimal response to several months on lexapro 10mg qd 1. Considering the patient's long-standing history of chronic insomnia, non-responsive to various treatments, including gabapentin, trazodone, hydroxyzine, melatonin, or magnesium, and the fact that quetiapine 50mg enabled her to get a few hours of broken sleep, increasing quetiapine to 100-300mg at bedtime for both mood stabilization and sleep is a reasonable approach.
The American College of Physicians guideline on management of chronic insomnia disorder in adults recommends cognitive behavioral therapy for insomnia (CBT-I) as the initial treatment for chronic insomnia disorder, which can be performed in primary care 1. Therefore, adding a structured sleep hygiene program, including consistent sleep/wake times, evening blue light reduction, and CBT-I, could help improve sleep quality. Additionally, considering the addition of lamotrigine (starting at 25mg daily and slowly titrating to 100-200mg daily over 4-6 weeks) could help stabilize mood without sedation, addressing both depressive symptoms and preventing mood cycling, while also potentially helping with anxiety and sleep disturbance.
Key considerations for treatment include:
- Mood stabilization to prevent mood cycling and improve depressive symptoms
- Sleep management to address chronic insomnia
- Anxiety management to reduce symptoms of GAD
- Close monitoring for potential side effects of medications, particularly quetiapine and lamotrigine
- Regular follow-up with a psychiatric provider to adjust treatment as needed.
From the Research
Treatment Options for MDD, GAD, ARFID
- The patient's symptoms, including decreased need for sleep, increased sociability and talkativeness, and moderate depression, suggest a complex clinical presentation 2, 3.
- The patient's minimal response to several months on lexapro 10mg qd indicates a need for alternative or adjunctive treatment strategies 4, 5.
- Quetiapine 50 mg has enabled the patient to get a few hours of broken sleep, suggesting its potential utility in addressing sleep disturbances 3.
Atypical Antipsychotics as Augmentation Therapy
- Atypical antipsychotics, such as quetiapine, have been shown to be effective in augmenting mood stabilizer therapy in bipolar disorder 2, 3.
- Quetiapine has been found to be effective in treating manic and mixed episodes, as well as bipolar depression, with significant efficacy and high remission rates 3.
- The use of atypical antipsychotics, including quetiapine, as augmentation therapy may be considered for patients with MDD who have not responded to initial treatment with antidepressants 4.
Nonpharmacologic and Pharmacologic Treatments for MDD
- The American College of Physicians recommends monotherapy with either cognitive behavioral therapy or a second-generation antidepressant as initial treatment for patients with moderate to severe MDD 4.
- Combination therapy with cognitive behavioral therapy and a second-generation antidepressant may be considered as initial treatment for patients with moderate to severe MDD 4.
- For patients who do not respond to initial treatment with an adequate dose of a second-generation antidepressant, switching to or augmenting with cognitive behavioral therapy or a different second-generation antidepressant may be considered 4.
Considerations for Treatment
- The patient's history of chronic insomnia, non-responsive to gabapentin, trazodone, hydroxyzine, melatonin, or magnesium, suggests a need for alternative strategies to address sleep disturbances 4.
- The patient's response to quetiapine 50 mg, enabling a few hours of broken sleep, suggests its potential utility in addressing sleep disturbances, but may require careful consideration of potential side effects and interactions 3, 4.