From the Guidelines
For a 19-year-old female with MDD, GAD, ARFID, and symptoms suggesting possible bipolar spectrum disorder, I strongly recommend a medication change to a mood stabilizer, such as lamotrigine, starting at 25mg daily and gradually titrating up to 100-200mg daily over 4-6 weeks, as the minimal response to Lexapro and presence of possible mixed features suggests that an antidepressant alone may be insufficient or potentially destabilizing 1. The patient's decreased need for sleep, increased sociability, and talkativeness while still depressed, indicate a possible bipolar spectrum disorder, which requires a different treatment approach than unipolar depression. The use of second-generation antidepressants, as recommended by the American College of Physicians, may not be sufficient in this case, given the patient's minimal response to Lexapro 1. For sleep, continuing quetiapine 50-100mg at bedtime is reasonable since it has shown some benefit, and adding a structured sleep hygiene program, including consistent sleep-wake times, avoiding screens before bed, and creating a calm bedtime routine, is essential 1. Cognitive Behavioral Therapy for Insomnia (CBT-I) should be pursued alongside medication management, as it is a recommended treatment for chronic insomnia disorder, and can be effective in improving sleep quality 1. For ARFID, referral to a specialized eating disorder program with nutritional counseling is important, and regular monitoring for mood shifts is crucial, as the presentation suggests possible bipolar spectrum disorder rather than unipolar depression. Key considerations in the treatment plan include:
- Monitoring for potential side effects of lamotrigine, such as rash or increased risk of seizures
- Regular follow-up appointments to assess the patient's response to treatment and adjust the medication regimen as needed
- Collaboration with a therapist or counselor to provide CBT-I and address any underlying psychological issues contributing to the patient's symptoms
- Education on sleep hygiene practices and stress management techniques to promote overall well-being.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Treatment Options for MDD, GAD, ARFID
The patient in question is a 19-year-old female with Major Depressive Disorder (MDD), Generalized Anxiety Disorder (GAD), Avoidant/Restrictive Food Intake Disorder (ARFID), exhibiting decreased need for sleep, increased sociability and talkativeness, while still being moderately depressed. She has shown minimal response to several months on Lexapro 10mg qd and has a long-standing history of chronic insomnia non-responsive to various treatments. Considering her complex condition, the following treatment options can be explored:
- Cognitive Behavioral Therapy (CBT): As suggested by 2, CBT can be considered as an initial treatment for patients with MDD, including those with mild, moderate, or severe symptoms. It can be used as monotherapy or in combination with second-generation antidepressants.
- Switching or Augmenting Antidepressants: Given the patient's minimal response to Lexapro, switching to a different second-generation antidepressant or augmenting with a second pharmacologic treatment may be considered, as recommended by 2.
- Quetiapine: The patient has shown some response to Quetiapine 50mg, which enabled her to get a few hours of broken sleep. As noted in 3, Quetiapine can be effective for acute bipolar depression, but its use in MDD and insomnia should be carefully considered, weighing the potential benefits against the risks of side effects such as extrapyramidal symptoms, sedation, and weight gain.
- Escitalopram: Although the patient is already on Lexapro (escitalopram), the studies 4 and 5 suggest that escitalopram can be an effective treatment for MDD, with a favorable tolerability profile. However, the patient's minimal response to Lexapro 10mg qd may indicate the need for a different approach.
Considerations for Treatment
When selecting a treatment option, it is essential to consider the patient's specific symptoms, comorbidities, and preferences, as emphasized by 2. The treatment plan should be personalized, taking into account the potential benefits, harms, and adverse effect profiles of each option. Additionally, the patient's history of chronic insomnia and non-response to various treatments should be carefully considered when selecting a treatment approach.
Residual Symptom Structure
The study 6 highlights the importance of addressing residual depressive symptoms, which can be a strong predictor of depression relapse. The patient's residual symptoms, such as decreased need for sleep and increased sociability, should be carefully monitored and addressed in the treatment plan.