SSRI's/SNRI's and bruxism

[delicatefade]

Interesting case I saw in the family med clinic this week.

39y/o female with TMJ disorder, hx of MDD, hx of generalized anxiety. Has been in therapy in the past for psych disorders. Has been on and off antidepressants because of concern that they worsen her nighttime bruxism/teeth clenching.

I did a quick lit search and it does seem that certain drugs have been reported to be associated with nighttime bruxism, particularly the SSRI's and venlafaxine. She has been on Paxil and Wellbutrin in the past. She felt that Paxil worsened her bruxism. Wellbutrin did not worsen the bruxism but also didn't help much with the anxiety component of her psych disorders.

We're trying to figure out what we can give to help her but will probably turf her to psychiatry at this point. My thoughts were either Effexor or Lexapro but Effexor comes up associated with bruxism a couple times. Wellbutrin would seem like a great choice if she had only depression and no anxiety. We also kicked around the idea of a tricyclic.

Just wondering what the folks in this forum thought.

---

Members don't see this ad.

 

[masterofmonkeys]

FYI effexor IS venlafaxine.

You might see if a shorter half-life SSRI might decrease side effects, as I've been told they often do.

Zoloft is one of the shorter half lives IIRC.

 

[delicatefade]

I knew that (thanks though)...I just switched from generic to brand name in mid thought....I guess the reason I was stuck on effexor is that I've read it's great for combined depression/anxiety but she's pretty worried about things that may trigger and/or worsen her bruxism.

 

[masterofmonkeys]

I know you said she'd been in therapy in the past. What kinds of therapy?

Sounds like wellbutrin worked for the depression side of things?

Exercise, Mindfulness-based interventions (Mindfulness-based Stress Reduction and/or Mindfulness-based Cognitive Therapy), biofeedback/relaxation, and other time-limited therapies have a pretty decent track record with anxiety.

Depending on what kind of psychotherapy she'd received in the past, she may want to try something more symptom-focused like the above.

 

[Doc Samson]

Interesting case I saw in the family med clinic this week.

39y/o female with TMJ disorder, hx of MDD, hx of generalized anxiety. Has been in therapy in the past for psych disorders. Has been on and off antidepressants because of concern that they worsen her nighttime bruxism/teeth clenching.

I did a quick lit search and it does seem that certain drugs have been reported to be associated with nighttime bruxism, particularly the SSRI's and venlafaxine. She has been on Paxil and Wellbutrin in the past. She felt that Paxil worsened her bruxism. Wellbutrin did not worsen the bruxism but also didn't help much with the anxiety component of her psych disorders.

We're trying to figure out what we can give to help her but will probably turf her to psychiatry at this point. My thoughts were either Effexor or Lexapro but Effexor comes up associated with bruxism a couple times. Wellbutrin would seem like a great choice if she had only depression and no anxiety. We also kicked around the idea of a tricyclic.

Just wondering what the folks in this forum thought.

I wouldn't see this as a turf, sounds like a very appropriate referral. If Wellbutrin was helpful for her depression and did not exacerbate her anxiety, then I might go back to that and add Klonopin BID. I'd also echo MoM's call for CBT - I might, in fact, make the Klonopin dependent on it (no pun intended).

 

[Anasazi23]

If the antidepressants are effective, and she needs them, get a night guard for her to wear. I've had patients that have had to resort to these.

Otherwise, try lowering the dose. It could be theorized that it's the dopaminergic effects some ADs impart. Cogentin would be an option in that case.

 

[billypilgrim37]

Speech ordered THIS for a patient today.

 

[whopper]

You might see if a shorter half-life SSRI might decrease side effects, as I've been told they often do.

Shorter t1/2 SSRIs & SSRIs increase the chances & intensity of discontinuation syndrome so you also got to watch that.

The Paxil & Effexor have very short t1/2s. Pristiq if I remember correctly has only 12 hrs of a half life.

Some patients can sometimes reach a magic dosage where they don't experience side effects but do experience the benefits they want with an antidepressant. Dosage trials can help but they will be slow because antidepressants can take weeks to take effect.

 

[masterofmonkeys]

oh I should mention that if she has physical symptoms associated with the anxiety,MBCT and/or biofeedback is definitely indicated.

Disclaimer: Currently working on a meta-analyses of mindfulness-based therapies. And I'm buddhist/hindu so I'm kinda biased.

 

[delicatefade]

Not sure what kind of therapy she had done in the past, and she does already wear a nightguard. From what I could gather, she was interested in medication but wanted something that would treat both depression and anxiety without exacerbating her bruxism. Paxil worsened her bruxism, and Wellbutrin wasn't really "calming" enough although it did not make her bruxism worse. She's not interested in benzos so we didn't have to go through that battle.

Any thoughts on using an SSRI or SNRI anyway and adding something like the following to try to alleviate the bruxism:
-buspirone
-clonidine
-propranolol
-gabapentin
-tiagabine

It looks like the above have all been mentioned at least in case reports.

I know we're probably getting out of the realm of FP here but I find these kinds of cases interesting. I'm going into PM&R so I'm often going to face physical problems with psychologic overlay and be forced to try to treat both simultaneously.

 

[Faebinder]

Try Cymbalta.. it's an SNRI and indicated for anxiety.

Also you could attempt Pristiq which is a metabolite of Effexor and see if it still has the same problems as Effexor.

 

[whopper]

Pretty much every non SSRI/SNRI approach should be tried. As mentioned above, buspirone in some cases reduced bruxism and has been known to augment the effect of an antidepressant.

So if you do find an SSRI or SNRI that helps this patient & they are experiencing bruxism, buspirone should be considered.

 

[TheWowEffect]

Any evidence of REM behavior disorder? Any sleep medicine follow up? These are important things to consider. Klonopin will help immensly if there is REM behavior disorder.

 

[delicatefade]

Not sure about REM or sleep disorder although getting a sleep study had been discussed between my attending and I. We ended up putting her back on Wellbutrin with some Buspar on top to help with the anxiety component and *maybe* with the bruxism.

 

[originial dream]

oh I should mention that if she has physical symptoms associated with the anxiety,MBCT and/or biofeedback is definitely indicated.

Disclaimer: Currently working on a meta-analyses of mindfulness-based therapies. And I'm buddhist/hindu so I'm kinda biased.

I am also reading about mindfulness based stress reduction therapies. I would love to see your meta-analyses when your done.