SSRI associated urinary retention.

[doctorpilgrim]

What antidepressant would be beneficial in males with moderate severity depression if multiple trials of SSRI are associated with urinary retention. Especially if only mild BPH treated with flomax.

As an example unable to tolerate fluoxetine,mirtazapine citalopram,buspirone due to severe urinary retention.
Venlafaxine urinary retention and incontinence.
Bupropion severe constipation and dry mouth.
Lithium urinary infection and bladder pain.
CBT tried 6 months.
Light therapy non compliance.

Bethanechol could be possibility, have used with TCA, but in case of ssri the urinary retention would be central.

I would appreciate feedback on clinical experience with ssri associated urinary retention.

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[whopper]

I had a patient with POTS syndrome, something I never even heard of until I met that guy and urinary retention.

Both disorders checkmated the patient. No med he could could tolerate or none worked effectively for his extreme and severe OCD, PTSD, and panic disorder. It was to the degree where he couldn't leave his house due to his anxiety except to his doctor's visits.

Anything anticholinergic caused urinary retention. I speculated he had some type of lowered actylcholine level in his bladder based on this.
Anything affecting the norepi receptors caused his BP to skyrocket to dangerous levels.
The only few meds he could tolerate didn't do anything or barely took the edge off.

I tried bethanechol-no benefit. I called up his urologist who thankfully worked with me on this case to a large degree and many outpatient docs I've met try to not talk to anyone on the phone. The urologist told me that acetylcholine agonists don't really do much to help and they're put in textbooks but they're really just relics. I'm not a urologist and maybe he was wrong but that's what he told me.

The only thing he told me he thought would work, and this was after several lesser invasive attempts were tried, was to place a urinary pacemaker device on his bladder that was going to be surgically connected to his spine but that this thing had about 60% of working and a relatively large risk of causing permanent back pain. The patient opted out.

This was the only patient I've ever had where I prescribed Marinol cause nothing was working and some of the meds tried even put him in the ER. E.g. I tried venlafaxine and he went into HTN crisis.

Marinol got rid of his PTSD nightmares, reduced some of his anxiety but everything else were still just as bad.

I was going to have the guy undergo ECT (yes I know ECT for OCD and anxiety disorders? but there were few other choices). I also was considering cingulotomy or deep brain stimulation. For better or worse I moved so another doctor had to take the patient.

 

[doctorpilgrim]

Thanks.
Does a male who develops ssri associated urinary retention, there are several proposed central mechanisms, have any options. There seem to be no pure DAT or DRI to target dopamine. Especially if norepinephrine worsens urinary retention. I have seen quite a few patients, one the urologist sent home on catheter for 3 to 4 weeks to start bladder retraining, where ssri may be implicated.

 

[nitemagi]

Is it an anxious depression? Way off label I might think about something like prazosin and explore if it gives some relief.

I'd also think about alternative therapeutic approaches other than meds/CBT. Especially since now you're getting into areas that don't clearly have an evidence base, so relying on things that's "evidence based only" isn't working. So I'd explore things like hypnosis, somatic therapies (Gestalt, for example), and maybe TcDCS/TMS.

Also consider doing genetic testing - if a very poor 2D6 metabolizer, for example. It's a very uncommon side effect to SSRIs, so I'd explore is there any secondary issues going on that might be impeding improvement.

 

[whopper]

In the specific case I had (not the case that started the thread) we did do genetic testing.
And unfortunately all the meds it said could work for the guy either worsened his POTS or caused urinary retention. I became convinced based on the genetic testing that some of the meds it proposed could work, fixing the POTS was out of the question, that's when I told him maybe if the urologist fixed the retention we could get him finally on something to get his life back in his hands.

But that led to a dead-end as well. This one one of the few patients I was convinced might end up committing suicide cause nothing was working; though that would've been several months down the road.

 

[heyjack70]

If all else fails he may need to get on an SSRI and do self cats.

 

[splik]

I'd also think about alternative therapeutic approaches other than meds/CBT. Especially since now you're getting into areas that don't clearly have an evidence base, so relying on things that's "evidence based only" isn't working. So I'd explore things like hypnosis, somatic therapies (Gestalt, for example), and maybe TcDCS/TMS.

There was an interesting paper in lancet psychiatry recently talking about "what to do when psychotherapy fails". With drugs with move onto different drugs. With therapy, we often abandon in, when actually there are many different approaches to therapy even within the same therapeutic orientation and the failure of one approach doesn't mean that "psychotherapy doesn't work", in the same way that one failed antidepressant trial doesn't mean that "meds don't work". Even within CBT there are different approaches like ACT, FAP, MBCT

 

[doctorpilgrim]

It is anxious depression in this case.
In case mentioned by whopper, I am curious to deciding between benzodiazepines and marinol.
In many cases patients also give up on medications and therapy too. It is hard to engage a patient when there are multiple failures with treatment.
Pramipexole is an idea, though it does have low 5 HT and alpha activity.

 

[whopper]

I am curious to deciding between benzodiazepines and marinol

Benzos were tried.

They worked.

But the same thing happened each time.
1-It works but his anxiety and other anxiety-like traits such as obsessions and compulsions were never fully treated 2-the benzo had to be raised again and again because he developed a tolerance and dependence to them, and then 3-> he was on high dosages of a few benzos and he was then just as bad as he was before even with the benzos. (1 to 3 took about 6 months).

He had been through several doctors that just did #1 to 3 several times. A reason why he stuck with me was because I was the first psychiatrist (per him) that told him that the benzos really should be temporary only. To my disbelief he actually read the Ashton Manual before I ever met him. Most psychiatrists I've met haven't even heard of it.

His medication regimen by the time I left him was the following (to the best of my memory). I also forgot to mention guy only slept 1-2 hours a night without meds and a sleep study ruled out sleep apnea but it too did not put us in a direction on what to do about his sleep.

A beta blocker for his POTS-it did nothing for his anxiety. Forgot the dosage.
Gabapentin 1200 mg TID (reduced his anxiety somewhat and helped him sleep)
Mirtazapine 15 mg at bedtime (above this dosage he hallucinated, only helped him sleep. No other benefit).
Tramadol, forgot the exact dosage but it was extremely high. This actually did reduce his anxiety and OCD somewhat. There is data showing it reduces OCD.
Marinol-forgot the exact dosage but it was high-reduced nightmares and anxiety but OCD and depression remained significant.

Every SSRI, SNRI were tried. Several TCAs were tried. Wellbutrin, Buspirone, Seroquel (he got TD even with Seroquel at a low dosage), Depakote, Tegretol, Lamictal, N-Acetylcysteine, SAM-E, St. John's Wort, fish oil, vitamin D3, EMDR, CBT, etc, In short everything except for MAO-Is were tried and he either couldn't tolerate it or he was on it at the maximum dosage for 1.5 months with no benefit whatsoever or minimal benefit.

I was going to try Ketamine but had no way to deliver it to him except for as an inpatient and the pharmacy told me they weren't happy with the idea of giving it to him. I actually asked one of the top researchers in the field to figure out a way for him to get it as an outpatient but we couldn't figure out a way. (Actually from what I understand it may be possible to do this outpatient now-but this was about a year ago).

Why didn't we try an MAO-I? Without Mirtazapine or Tramadol he didn't sleep AT ALL. He would've needed a washout period for those meds and we tried but he couldn't tolerate not sleeping for a few days straight. After we discussed he'd have to off of them for weeks we gave up on that idea.

Some ideas other and including what I mentioned above ECT (despite that it doesn't help OCD/anxiety much), deep brain stimulation, and cingulotomy were my next considerations. I was also considering placing him on buprenorphine because there is data showing that opioids could treat OCD but it's not recommended because SSRIs are effective (in most) and non-addictive.

Some other disheartening things about his case were that another doctor that I highly respect reviewed his case, one of the top people in the field in OCD reviewed it and he was also seen several times at a major private facility run by top doctors in the country and we were all stuck.
The only reason why I didn't hate myself over not getting him better was because some top doctors in the field told me I did some good work, not in results, but in the methodology and not giving up on the guy. He gone through several psychiatrists that after having to put some real effort in the case just terminated him and told him to go somewhere else.

During our interviews he told me things to the effect that he had been through pretty much everything except for psychosurgery and he was willing to give that a try but if it didn't work he didn't see a point in going on.

Again, for better or worse I moved. It was actually kind of a relief to not have to work on that case anymore, but also a disappointment cause I had the guy for such a long time and we knocked off everything off the list minus an MAO-I and psychosurgery and I wanted to get him better before I signed off on it.

I called the next doctor who had him who told me that he was too scared to allow the guy to do psychosurgery so he told the guy he was going to try everything all over again that he already tried-and failed on. The patient gave up on that doctor and I don't know what happened to him after that.

 

[doctorpilgrim]

I have to say Good job, whopper.

I am leaning on low dose trial of Mirtazapine on pharmacological basis seems to be a good fit here, atleast superficial logic

Reversal of SSRI-Associated Urinary Retention With Mirtazapine Augmentation
Lenze, Eric J. MD

Based on Irritable bowel syndrome, I am considering Interstitial cystitis and also referring him for urodynamic studies to a urologist. Also getting a d3 level. He will never agree to ect, dont have any experience with TMS. My thoughts are that being anxious depression with anhedonia but not melancholic features he may not respond to ect.
MAOI especially EMSAM is also an option, but then again dose titration, with mirtazapine I am thinking 3.75mg.

I wish we had experienced therapists like nitemagi and other posters in our area, makes me want to go back to residency to learn more therapy like hypnosis, biofeedback etc. Although our program director was huge on therapy and we had half day weekly psychotherapy clinic for four years. That was obviously not enough.