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Original Question
Subjective: CC (chief complaint): “My anxiety and depression are very bad” HPI: M.P. is a 35-year-old Caucasian male who has been in the care of another provider and is here at the clinic to “get a second opinion because my meds are not working,” citing persistent depression, anxiety, superstitions, and fleeting homicidal thoughts. Endorses homicidal thoughts since 2008, states he believes they began as a result of seeing a disturbing movie, and “the images stuck in my head for a long time, and they were so disturbing, and the anxiety kept throwing them at me on a constant basis.” Describes having depression and anxiety since 2009 with intermittent periods of exacerbation. Reports having superstitions about turning dials, specifically avoiding the number 6, “I avoid anything with a 6 in it,” and dark floor tiles, “I will step all around them but not on them”. The patient describes the depression and anxiety as particularly “bad” during this visit, indicating periods of significant distress. His symptoms are negatively impacting his work and relationships, causing persistent sadness, loss of interest in activities, lack of concentration, and restlessness. Denies suicidal thoughts, plans or intent. Endorses current homicidal thoughts but no plan or intent. Reports insomnia, sleeps for 5 hours at night. No recent changes in appetite or weight and denies experiencing racing thoughts or psychotic symptoms. Trauma History: Sexual abuse at 4 y/o by an uncle, but does not remember anything about the event of abuse, nor does he actually remember telling his mother about the event. Past Psychiatric History: Patient has been previously seen by a psychiatrist since 2009 and was diagnosed with OCD. Was admitted as an inpatient for seroquel overdose in 2009, discharged after 1 week. Denies any previous suicidal ideation or self-harming behavior. Previous medication use: gabapentin stopped due to increased HR, stopped taking buspirone and Lexapro as it was not effective, and Seroquel overdosed- non-intentional. He previously saw a therapist but stopped because he was unable to connect with her. Substance Abuse History: Tobacco: ex-smoker, ETOH- Denies; stopped drinking 4 years ago; Cannabis: history 4 years ago, no current use; Illicit drugs: Denies Family Psychiatric/Substance Abuse History: Mother-Depression and anxiety, suicidal attempt with recurrent hospitalizations, Sister-Depression, anxiety. Denies any Substance abuse problem. Medical History: Echo and EKG- Normal, Started on Metoprolol for increased HR by Cardiologist Current Medications: Venlafaxine 150 mg twice daily – 12-year history of use Mirtazapine 30 mg at bedtime – 2-month history of use Metoprolol 50 mg daily at lunch – 1.5-month history of use KlonoPIN 1mg as needed – one and off since 2009 Allergies: NKDA Is this right medication management for this client Pharmacologically, adjusting the current regimen includes gradually tapering venlafaxine while considering alternative SSRIs like Sertraline starting at 25 to 50mg and gradually increasing given its efficacy in OCD. Since Mirtazapine is not helping the patient to sleep, Trazodone is often used off-label for insomnia due to its sedative effects at lower doses. A typical starting dose is 25-50 mg at bedtime Augment with Atypical Antipsychotics like aripiprazole typical doses range from 2-15 mg daily to target intrusive thoughts and manage other symptoms, Lamotrigine: Starting dose is typically 25 mg daily, titrated up slowly to minimize the risk of rash, with a target dose ranging from 100-200 mg daily for mood stabilization.
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