Case Study: Managing Breakthrough Anxiety and Anger in a Patient on Combination Antidepressant Therapy

Case at a Glance

A 39-year-old male with a history of depression and anxiety, treated with escitalopram and bupropion, presents with persistent anger issues and breakthrough anxiety. He is questioning the efficacy of his current medication regimen and exploring alternative therapies, including cannabis products, while expressing significant dissatisfaction with his current psychotherapy.

Patient's Story

The patient is a 39-year-old male with a history of depression and anxiety, and he suspects other undiagnosed mental health conditions may be present. Despite being on a stable medication regimen, he reports experiencing significant 'anger issues' and 'sudden peaks in anxiety.' These unresolved symptoms have prompted him to consider asking his physician for a medication re-evaluation, questioning whether a dosage adjustment or a change in medication would be more effective. He also inquired about the potential benefits and risks of using CBD gummies and THC products as a means of 'calming down,' expressing concern about possible interactions with his prescribed medications.

Initial Assessment

The patient presented with chief complaints of emotional dysregulation, specifically anger and acute anxiety, despite ongoing pharmacotherapy for depression and anxiety. His weight is stable at approximately 155 lbs, with no other stated physical health issues. His inquiry into non-prescribed substances like THC and CBD suggests a search for alternative coping mechanisms due to inadequate symptom control with his current treatment plan.

The Diagnostic Journey

Upon further questioning, the patient clarified his medication regimen as Escitalopram 20mg daily and Bupropion 150mg daily. He reported that a previous physician had instructed him to take the medication at night. When a current doctor suggested switching to a morning dose, the patient attempted the change but experienced a 'really bad anger reaction.' Consequently, he reverted to taking his medication at night. The patient is also engaged in counseling with a social worker but finds the sessions to be unhelpful. He described the therapist as supportive but providing little concrete guidance or effective therapeutic intervention. He further noted significant communication barriers, making it difficult to understand the therapist's intended meaning. This lack of a productive therapeutic alliance appears to be a major obstacle in his treatment.

Final Diagnosis

Major Depressive Disorder and Generalized Anxiety Disorder, with partially controlled symptoms. The patient's primary presenting issues are emotional dysregulation (anger) and breakthrough anxiety, which are manifestations of his underlying conditions. A significant contributing factor to his lack of progress is a suboptimal therapeutic relationship and potentially sub-therapeutic psychotherapeutic intervention.

Treatment Plan

The recommended treatment plan involved a multi-faceted approach. First, a comprehensive medication review was initiated to discuss the patient's adverse reaction to morning dosing and to evaluate the current dosages. Options to be considered include adjusting the bupropion dose or exploring alternative agents. Second, the patient was strongly advised against the use of THC products for managing psychiatric symptoms, citing risks of exacerbating anxiety and unpredictable drug interactions. The importance of evidence-based treatment was emphasized. Finally, and most critically, the patient was encouraged to seek a referral for a new psychotherapist. The goal is to establish a strong therapeutic alliance with a provider skilled in modalities such as Cognitive Behavioral Therapy (CBT) or Dialectical Behavior Therapy (DBT), which are proven to be effective for managing emotional dysregulation.

Outcome and Follow-up

The patient was receptive to reviewing his medication and seeking a new therapist. He was provided with resources to find a new provider specializing in CBT. A follow-up appointment was scheduled for four weeks to monitor for any medication adjustments and to discuss his progress in establishing more effective psychotherapeutic support. The long-term goal is to achieve better symptom control through an optimized combination of pharmacotherapy and robust, evidence-based psychotherapy.