Visual Hallucinations

This was a non-formulary consult that we received, and I took a shot at figuring out how to manage the pt's current medical situation. This is NOT the actual note I wrote - I changed a lot of things, so it cannot be connected back to anyone. The basic ideas are still the same though, as a learning tool :). This is what I personally would recommend for this pt, but there's no one correct answer.

Non-formulary Consult – Aripiprazole

Subjective:

39 y/o pt with PMH significant for MDD, PTSD, MST, hyperlipidemia, knee pain, osteoporosis, prehypertension. As a child, pt was abused. He has been on many deployments. After his last return, severe depression and heavy alcohol use. Positive for suicidal ideations and attempts. Has visual hallucinations.

Medication History:

*ASA 81 qday

*fish oil 1000mg omega-3 qday
*Quetiapine up to 25mg/day x2 months
*Bupropion up to 150mg BID x1 year
*Olanzapine up to 20mg/day x7 months
*Prazosin up to 6mg/day x many years – did not complain of OH
*Mirtazapine up to 45mg  x2 months
*Aripiprazole 5mg qam – better mood but same visual disturbances

*Has also had adequate trials of venlafaxine, sertraline and fluoxetine

Current Psych Medications:
*Mirtazapine 60mg qhs
*Trazodone
*Prazosin

*Aripiprazole

Objective:

11/22/2011:
Lipids: TC, LDL, HDL: wnl, TG 287

9/30/11:
UDS-negative
Lipids: TC, LDL, HDL: wnl, TG 272

A1C, BP, BMI all wnl.
Assessment/Plan

1. MDD

                a. Depression has improved with dose increase of mirtazapine to 60mg qhs and addition of aripiprazole. Unable to evaluate if improvement was d/t increase in mirtazapine or addition of aripiprazole, but likely d/t increase of mirtazapine, because pt claims that depression sx have improved.

                b. Recommendation: Continue mirtazapine 60mg. Consider changing time of dose to qam, d/t increase in norepinephrine at this dose. Dosing at night could interfere with sleep.

2. PTSD

                a. Prazosin has improved his nightmares associated with PTSD. Still has ~1 nightmare/week. Currently on dose of 5mg qhs with no sx of OH.

b. Recommendation: Consider increasing dose and evaluate for further efficacy (max dose studied in VA population 16mg/day).

3. “Psychosis”

                a. Aripiprazole was started for mood, augmentation for depression, and minimize visual disturbances. Even after this medication was started, pt was still having visual disturbances.   

                b. Recommendation: D/C aripiprazole. Evaluate how pt does on monotherapy of mirtazapine 60mg.

                c. If trial of monotherapy does not work, then pt does meet criteria to begin atypical antipsychotic for PTSD. Consider using quetiapine, risperidone or olanzapine prior to aripiprazole d/t cost savings.

4. Serotonin Syndrome

a. Pt is on mirtazapine, trazodone, and sumatriptan - can lead to serotonin syndrome. Consider this if pt comes to clinic with sx of aggression.

b. Recommendation: evaluate how often pt is using sumatriptan.