Each time prazosin was increased by 2 mg daily to target a specific daytime or nighttime symptom. In this patient, daytime symptoms were more distressing than nightmares and hence this patient required 25 mg prazosin during the daytime and 20 mg at bedtime. On

prasozin 45 mg, the patient reported almost complete remission (90% improvement according to the patient clinically), including daytime symptoms such as hyperarousal, flashbacks and Inhibitors,research,lifescience,medical daytime re-experiencing of the trauma and nightmares. For insomnia, daytime doses of prazosin were switched to 13 mg in the morning, 8 mg at noon and 24 mg at bedtime. Not only did this fail to improve insomnia but the patient also started to re-experience daytime PTSD symptoms. The baseline blood pressure (BP) and heart rate (HR) were 120/56 (sitting), 105/70 (standing), 73 (sitting), 71 (standing). The patient’s BP and HR on prazosin were 102/72 (sitting), 100/70 (standing), 80 (sitting) and 88 (standing). Inhibitors,research,lifescience,medical In addition, the patient was also on lisinopril 10 mg daily and hydrochlorothiazide 50 mg daily, both taken orally. Orthostasis is defined as a decrease in systolic BP by more than 20 mmHg or a decrease in diastolic BP by more

than 10 mmHg or a pulse increase of more than 10 beats/min. This patient, despite being on a high dose of prazosin and two other antihypertensives, did not have orthostasis or Inhibitors,research,lifescience,medical any other symptoms associated with it. Comorbid bipolar depression was managed with a rational combination therapy: lamotrigine 200 mg at

bedtime, melatonin 6 mg Inhibitors,research,lifescience,medical at bedtime, mirtazapine 45 mg at bedtime, pramipexole 4 mg at bedtime [Aiken, 2007], methylphenidate [Candy et al. 2008] 20 mg in the morning and 20 mg at noon (use of methylphenidate for short-term treatment of bipolar depression should be considered aggressive) and zolpidem 15 mg at bedtime. Lamotrigine Inhibitors,research,lifescience,medical was chosen [Yatham et al. 2009; Koola et al. 2011] over lithium for bipolar depression and because she had psoriasis and diabetes mellitus. In addition, she CYTH4 was on angiotensin-converting enzyme inhibitor (for hypertension) and likely to take nonsteroidal anti-inflammatory drugs for arthritis. Quetiapine was not considered because of the risk of metabolic syndrome including obesity. For behavioral activation, the patient was asked to paint things she enjoyed in the past when she was not depressed. After three and a half months, the patient’s PHQ-9 decreased from 23 (initial presentation) to 8. With the above-mentioned treatments, the patient’s functioning improved in the following areas: able to focus better, doing a variety of things instead of just hibernating, improved memory, clear thinking, enjoying time with her granddaughter, working more in the flower garden and she could selleck chemicals travel alone. The patient was followed for 1 year by the treatment team.