Psychiatry

PCP submission

This is a 47 year old man who was working as conductor at a railroad when the COVID crisis hit and was laid off in March 2020. At the moment he became depressed and suffered with extreme anxiety, not knowing how he would manage his finances without a job.
He was without a job for several months when the manager of the railroad called him back, but said there were no guarantees that business would remain open for long. Therefore the patient decided to seek another job with the railroad at a nearby city. However, the very first day on the job, he suffered a panic attack and what he himself described as a “psychotic event”: he felt he saw a dark figure coming in his room and tried to attack him. But another part of himself defended him.
After the above event, the patient resigned from the railroad and took a job as a bus driver in the city where I have my practice. The first day on this new job, he suffered another panic attack, which is when he called me. During my interview, he mentioned many things, but the most salient are as follows:
– History of one episode of major depression and extreme anxiety a few days before his wedding in 2008. He was treated back then with Zoloft and was well controlled for 5 years, until in 2013 he decided to stop the medication. He has since struggled with sadness, negative thoughts, and anxiety. He said he managed his symptoms with art therapy, exercise and meditation. But losing the job railroad toppled over all of the balance he once felt.
– Suicidal thoughts. He says he’s thought of going back to the railroad and jumping in front of the train. He does not have weapons in his house.
– Marital issues. His wife has decided to leave the home to live with her parents because she cannot find work in this town and their marriage is severely affected by the patient’s emotional instability.
– Intrusive homosexual fantasies. He claims these are new, are directed to a male friend he has who is openly gay. The patient is inundated with shame because he comes from a very religious family.
– Constant rumination and “angry voices” telling him that he’s a loser, that he’s gay. I have tried to clarify this issue about the “voices” on the three visits we’ve had. He has said that it is not that he literally hears voices, but that his internal dialogue is continuous leading to shame and remorse. I am not 100% sure that this patient doesn’t hear voices, and this is a big concern for me.
– Insomnia. He says he’s tried melatonin (5mg) and meditation, but it is very difficult to fall asleep and to stay asleep.
– Extensive family history of mental health issues with depression, anxiety, panic. NO schizophrenia.
I ran labs on this patient and he has low levels of vitamin D (21 ng/ml) and mildly high cholesterol (201 mg/dl) and LDL (146 mg/dl). Liver and renal function tests are normal. CBC is normal. TSH is normal.

I prescribed venlafaxine 75 mg and he says the panic attacks subsided and he has been able to drive the bus everyday for the past week on his full schedule (which may be as much as 12 hours continuously or may be split 4 hours of driving in the morning, then another 4 hours at night). He still feels very anxious, still cannot sleep, still has intrusive thoughts and the rumination is so bad that he is sometimes distracted by the “voices” while he is driving to work. I asked him if he suffers from road rage or if he’s had any accidents. He says categorically “NO”. But he does admit that one day at the job he took some curves with haste, “which can be scary for the passengers’ ‘.

1. Is venlafaxine the best treatment for this patient? I am thinking of increasing the dose to 150 mg. However, I’m concerned about the side effects, since he is a public bus driver. Or would you recommend another medication or adding a second medication?
2. How can I decide if it is safe to allow this patient to work in public transportation (either driving the bus or the train – which by the way, he insists he wants to go back to the railroad)? Do I bear any responsibility in this matter?
3. How can I tell if the “voices” are auditory hallucinations versus what he’s calling an internal dialogue with himself?

It is very difficult to get a psychiatric consultation in the town where I practice. So I thank you in anticipation for your support in managing this case.

Specialist response

Hi. Thank you for sharing your consult. This is a challenging situation. You have done a great job assessing his symptoms and history. He’s fortunate to have you as a PCP. You might use a PHQ-9 to assess depression symptoms and GAD-7 to assess anxiety symptoms. Does he use alcohol, smoke marijuana, and/or use illicit drugs? If so, how much and how often? For what reason(s)? Using substances might exacerbate his symptoms. Does this person have a trauma history? You might provide him the PTSD Checklist 5 to complete: https://www.ptsd.va.gov/professional/assessment/documents/PCL5_Standard_form.PDF This assesses somatic dissociation: https://emdrtherapyvolusia.com/wp-content/uploads/2016/12/SDQ-20.pdf The below website is a great resource about trauma and dissociation. The dissociative experiences scale II explores various dissociative phenomena. http://traumadissociation.com/des This is another great resource: https://www.isst-d.org/ The “voices” vs inner dialogue might reflect dissociative symptoms. It’s possible that he developed a Major Depressive Episode with psychotic features after he was laid off. He might have OCD that has become more salient. This can help you to assess. https://iocdf.org/wp-content/uploads/2016/04/04-Y-BOCS-w-Checklist.pdf You might find this algorithm helpful: https://psychopharm.mobi/algo_live/ 1. Venlafaxine is a good option. At 75-150mg daily it has SSRI properties. At 225mg daily it also has Norepinephrine Reuptake Inhibition properties. Higher doses for 2-3 months are required for maximal effect for anxiety. He should start the higher dose on a day that he doesn’t work. But the main concern is elevated BP in the long term. 2. Great question. You should speak with your Medical Director and Risk Management team. 3. You can assess for dissociation and OCD per above. Typically voices associated with psychosis sound like they are outside the head, vary in volume, say short phrases, and can’t be controlled. You might add a low dose antipsychotic to see if his voices/mood improve. Risperidone 1mg qhs is an option. You can increase 1mg/qhs/week until 4mg qhs. Long term there is an increased risk of weight gain, HTN, hypercholesterolemia, and DM. You’ll need to monitor BMI monthly for 3 months then quarterly. You’ll need to monitor BP, FBG, fasting lipids at baseline and then at 3 months and then annually. You should obtain a baseline EKG and monitor EKG at 3 months then annually. Antipsychotics can prolong QTc. Additional side effects to monitor are sedation, tremor, muscle stiffness, akathisia, dizziness, insomnia, agitation, nausea, and vomiting. Tardive Dyskinesia is a potential long term complication. Here is an article about TD assessment and management : https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3709416/pdf/tre-03-161-4138-1.pdf In addition to medication history and clinical symptoms, you might use the Abnormal Involuntary Movement Scale to assess and monitor Tardive Dyskinesia (TD) symptoms: http://www.cqaimh.org/pdf/tool_aims.pdf Here is an article about the AIMS clinical utility: https://www.psychiatrist.com/JCP/article/Pages/2018/v79n03/17cs11959.aspx The main medication for treatment of TD is INGREZZA, which contains valbenazine. It’s FDA approved for TD. The initial dose for INGREZZA is 40 mg once daily. After one week, increase the dose to the recommended dose of 80 mg once daily. Continuation of 40 mg once daily may be considered for some patients. Somnolence and QTc prolongation are the main side effects to monitor for. For ways to decrease long term suicide risk, it’s important to increase protective factors and to decrease modifiable risk factors. Here is an article that describes these in more detail: https://www.sprc.org/sites/default/files/migrate/library/RiskProtectiveFactorsPrimer.pdf Decreasing abuse of alcohol or drugs is beneficial because their abuse is a risk factor for suicide. You can use a PHQ-9 to assess and monitor depressive symptoms. Treating depressive and anxiety symptoms will decrease his long term suicide risk. Access to mental health treatment will decrease his long term suicide risk. You might ask him to complete a suicide safety plan and keep a copy for your medical record: https://suicidepreventionlifeline.org/wp-content/uploads/2016/08/Brown_StanleySafetyPlanTemplate.pdf At each visit you should inquire about depressive symptoms, including specifically asking if he has current or recent thoughts about suicide, and alcohol use. These are important aspects of primary care suicide prevention per this article: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3146379/ The Columbia-Suicide Severity Rating Scale is a commonly used evidence-based scale for suicide assessment: https://suicidepreventionlifeline.org/wp-content/uploads/2016/09/Suicide-Risk-Assessment-C-SSRS-Lifeline-Version-2014.pdf https://cssrs.columbia.edu/ You might recommend therapy. Bright Heart Health and FasPsych offer telepsychiatry and teletherapy services. Please feel free to contact me with additional questions!

PCP follow up

First, allow me to say that I deem your answer to this consult as THE BEST response that I have EVER received from ANY specialist. And I’ve been in practice for 30 year. The links and resources you provided are invaluable and I shared them with my colleagues here in my office. It’s almost impossible to get an appointment with a psychiatrist in this city, so your response was very welcomed. THANKS SO VERY MUCH! About the patient, I increased the dose of venlafaxine to 150 mg every morning and the anxiety has almost disappeared, the patient says he no longer has suicidal ideas, he feels brighter, his mindset is constructive and he says he’s no longer having the internal debate (voices) nor the intrusive thoughts. The only problem he’s still suffering is insomnia. He’s tried melatonin and Benadryl and he still tosses and turns at night. Of course, because he is a city bus driver with varied work schedule, I am very concerned about how to manage his medications. Any suggestions? Oh, by the way, this patient does not drink alcohol, nor does he use any drugs. In fact, he was studying to become a pastor and he left the seminar to get married. And after 20 years of marriage, his wife is planning on leaving him, which, in addition to losing his job as a train conductor, is causing most of the anxiety. I would appreciate suggestions on managing insomnia in this patient. Again, thank you very much for all the support.

Specialist follow up

Hi. Thank you for your incredibly kind words. I’m glad that you found my response helpful. How great that he feels better! I bet he’s very relieved. You might ask him to monitor his sleep with this diary: http://yoursleep.aasmnet.org/pdf/sleepdiary.pdf This sleep education might be helpful: http://sleepeducation.org/treatment-therapy/cognitive-behavioral-therapy Reviewing sleep hygiene is essential: https://www.sleepfoundation.org/articles/sleep-hygiene “ Strong sleep hygiene means having both a bedroom environment and daily routines that promote consistent, uninterrupted sleep. Keeping a stable sleep schedule, making your bedroom comfortable and free of disruptions, following a relaxing pre-bed routine, and building healthy habits during the day can all contribute to ideal sleep hygiene.” This is the Practice Guideline for Insomnia by the American Academy of Sleep Medicine: https://jcsm.aasm.org/doi/10.5664/jcsm.6470#d3e976 The guideline states that the same recommendations are applied to the elderly except with dose reductions, except for Belsomra. You might trial Belsomra 5mg qhs x 1 week and then increase to 10mg qhs, if indicated. There aren’t any particular side effects to monitor. If unavailable or doesn’t find beneficial, Trazodone 50mg qhs insomnia and can increase to 100mg qhs insomnia, if indicated. Monitoring dry mouth, nausea, and headache will be important. I hope this helps!