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Psychiatry Education Forum Academy Forums Clinical Case Discussions Difficult Case with Anxiety, Depression & Antidepressant Withdrawal.

  • Difficult Case with Anxiety, Depression & Antidepressant Withdrawal.

  • Dr. Harvinder Singh

    May 13, 2021 at 11:41 am

    Posting this here after patient’s permission.

    Patient in mid 40s initially presented (1 yr ago) with symptoms consistent with venlafaxine withdrawal after her primary care physician stopped venlafaxine (as this medication stopped working after positive response in past).

    Her symptoms are consistent with MDD, GAD and panic attacks. No current or past history of mania, hypomania, psychosis or trauma. Extensive neurology evaluation done with no neurological findings seen and they cleared her from neurological standpoint.

    Current symptoms: worsening depression (but no known stressors), anxiety (after waking up) with panic attacks (requiring visit to ER 1-2/week recently): dominance of anxiety recently.

    Medication Trials for last 1 year:

    · Fluoxetine 20 mg: initial trial to help with antidepressant trial but not helpful.

    · Paroxetine 20 mg: mild help but dose not increased due to sedation (switched to CR)

    · Paroxetine CR 25 mg: trial not helpful for anxiety

    · Sertraline: reports made mood changes worse (trial in past before she came to me)

    · Venlafaxine 150 mg: longest but stopped working after some time

    · Desvenlafaxine: at 25 mg dose (50 mg is activating anxiety)

    · Duloxetine 30 mg: not able to tolerate

    · Mirtazapine 15 mg: (not helpful for sleep)

    · Trazodone 25 mg: can cause excessive grogginess in morning

    · Ativan 0.5- 1 mg: helpful as PRN for panic attacks

    · Valium 5 mg: not able to tolerate

    · Clonazepam: helpful initially but stopped giving relief after 2 months & not able to tolerate taper.

    · Hydroxyzine 25-50 mg twice to three times daily: not helpful for anxiety

    · Gabapentin 100 mg twice daily to 300 mg three times daily: sedation and not helpful for anxiety

    · Imipramine 10 mg twice daily: added for panic attacks but not able to tolerate due to sedation.

    · Quetiapine: excessive sedation at 12.5 mg dose

    · Haldol + vistaril injection in ER: helpful for panic attacks.

    She is currently on:

    • Escitalopram 10 mg daily (initiated 3 weeks ago) +
    • Clonazepam 1 mg twice daily +
    • Trazodone 25 mg as needed for sleep (using rarely).
    • She is interested in stopping Clonazepam (with slow taper using compounding pharmacy once stable) due to sedation. Clonazepam was added as standing dose 4 weeks ago as she visited ER 1-2 times/week for panic attacks (which was consistent with cross tapering of antidepressants).

    What are your thoughts regarding next step options if Escitalopram trial is not helpful. I am working on giving full 4-6 weeks of trial on each medication with goal of pushing the dose slowly based on her toleration and response.

  • Elizabeth Richardson

    May 13, 2021 at 12:32 pm

    For anxiety and augmentation to AD, have you considered adding busprione with the intention to get to therapeutic dosing of 60mg/day. In addition, have you considered adding supplementation of ashwagandha for anxiety and EPA 1500mg/day as an accelerant.

    • Dr. Harvinder Singh

      May 13, 2021 at 12:47 pm

      Hi Elizabeth. Buspirone is my next option depending on how she responds to the recent addition of escitalopram.

      Ashwgandha is not tired yet but she tried l-theanine 200 mg with no benefits. What is your preferred dose for Ashwgandha?

      I like the EPA augmentation option. Thanks.

  • Katherine

    May 13, 2021 at 7:05 pm

    Hi, What are your thoughts on augmenting an SSRI with lithium as an adjunct for her MDD?

    • Dr. Harvinder Singh

      May 13, 2021 at 7:15 pm

      Most of her medication trials are limited due to the sedation side effects and stops them immediately despite multiple encouragement and education. I will keep lithium as an option if Lexapro followed by Buspirone augmentation is not helpful.

      Her anxiety is more severe with panic attacks at this time compared to depression.

  • Gary Graham

    June 6, 2021 at 5:39 am

    I am just wondering would a beta-blocker or alpha 2 agonists have a place in this client’s treatment?

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