I am treating a woman aged 50 years for major depression, alcoholism and general anxiety disorder. Her previous provider had her venlafaxine (Effexor) 300 mg for quite some time. I added L-methylfolate (Deplin) to the venlafaxine because her depression was not improving. I also started her on buspirone (Buspar) 7.5 mgs b.i.d. for anxiety. The patient’s alcoholism prevents her from taking benzodiazepines.

After landing in the emergency department with symptom-related anxiety, she was started on gabapentin (Neurontin) and titrated to 800 mg/day. Early on in the treatment, I tried the mood stabilizer aripiprazole (Abilify), with no success. The patient remains significantly anxious and has been encouraged to take up yoga class or tai chi to control her breathing and palpitations. What else do you suggest? — Debra Woodard, CRNP, Sykesville, Md.

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The patient and treatments described sound quite complicated. The maximum recommended daily dose of venlafaxine is 225 mg/day. While physicians and psychiatrists may prescribe in excess of that dose, nurse practitioners should avoid off-label prescribing. If the woman’s depression was not controlled on venlafaxine, consider a selective serotonin reuptake inhibitor (SSRI), such as sertraline (Zoloft) or citalopram (Celexa) and titrate the dose as needed.

If her depression was not controlled on a maximum dose of an SSRI, adding the dopamine-norepinephrine reuptake inhibitor buproprion (Wellbutrin) works well. Limited studies show that the antiseizure medication gabapentin may be beneficial in patients with bipolar and ADHD disorders, alcohol withdrawal, restless leg syndrome, migraine and other pain disorders. Gabapentin does not have an indication for the treatment of anxiety or major depression. Such atypical antipsychotics as aripiprazole are quite expensive and would not be a first-line choice. There are reports of using L-methylfolate, a medicinal food, for treatment-resistant depression.

Cognitive behavior therapy can be quite helpful in patients with anxiety disorders. At this point, I would refer this patient to psychiatry to confirm the diagnosis, and work with her on an effective treatment plan that likely will involve multiple medications. Exercise, including yoga and tai chi, can be part of the treatment plan for patients who are depressed and anxious. — Eileen F. Campbell, MSN, CRNP (162-2)