A 25 year-old female seeks treatment for anxiety and depression. She experienced repeated childhood sexual abuse by her father at ages 8-10. In the last few years, she has had constant depression, with periods of worsening related to life stresses. She is also constantly anxious, with panic attacks at times, and flashbacks and nightmares that occur in waves (i.e., a week or two of multiple flashbacks/nightmares, followed by 2-3 weeks without them). She doesn't abuse substances, is a single mother with two children, and lives on disability. She reports anxiety and depression in family members but they mostly avoid psychiatrists, so most are not diagnosed.
Five years ago, she received fluoxetine, later sertraline and duloxetine, each with mild benefit. In the past year, she took venlafaxine, which helped her anxiety moderately at 150 mg/d, but then she began to worsen again in the past few months. Her psychiatrist tried to switch venlafaxine to citalopram, but she experienced marked serotonin withdrawal. Current medications are Effexor 75 mg/d, clonazepam 1 mg twice daily, and quetiapine 50 mg for sleep.