Basic Patient Information: Female, Age 34, with significant childhood traumas. Condition: Severe depression and PTSD.
1999: Patient presented with depression and was treated with 50 mg of Zoloft. Within a short time, patient began having paradoxical reaction, and stopped taking the medication.
2006: Patient began taking antidepressants again.
2007: Patient began seeing a psychiatrist to try to find the right combination of antidepressants for her treatment.
- October 11, 2007: Patient was on 112.5 mg of Effexor XR. Doctor wanted to rule out possible bi-polar diagnosis and prescribed lowest dosage of Lithium.
- November 1, 2007: Patient became significantly depressed (also in correspondence with ovulation). No mood improvement.
- November 8, 2007: Patient expressed suicidal ideation, but no plan.
- November 13, 2007: Patient was going to attempt suicide, but stopped the intended actions and contacted a counselor as well as the prescribing doctor for help and treatment.
2008: Patient remains on Effexor XR, no Lithium, and no additional suicidality noted or reported.
QUESTIONS: Is it possible that the patient was experiencing another paradoxical reaction, similar to the 1999 occurrence, with the new combination of the Lithium and Effexor XR? What additional medical documentation is available as proof to validate this concern, for keeping in the patient's medical record?