What do you think of this case?

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pdoc241

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Forgive me, first time posting, new psych grad, long time lurker.

I have been tasked to evaluate a 32 female with GAD. She is a high functioning individual and was diagnosed with GAD several years back by her old psychiatrist (I agree with the Dx). She is very intolerant to SSRIs despite being successfully treated in the past which actually put her into remission for several years until she discontinued use per a joint decision between her and her old psychiatrist. Looking at records it looks like it took several months to get this patient just to the beginning therapeutic dosage of zoloft and she stabilized on 100 mg. I tried to get her back on it, told her to cut the 25 mg tabs in quarters, taking 1 quarter per day. She took it for about 1 week with increased symptoms even after the first dose and then when we went to a half pill she called me a few days in and we had to abandon ship. What she describes actually sounds like akathesia, "inner restlessness, feel it in my legs, makes me feel suicidal the feeling is so horrible" she says. Now I have no idea how she initially got on zoloft a few years ago, she states she was such a mess she isn't sure either. She is on clonazapam 0.5 mg TID as well. Anyone ever experience a patient with SSRI induced akathesia? What would your next move be? Oh I should add I tried propranolol on her too before we started as she told me the symptoms I figured it couldn't hurt - and it didn't but it also didn't help at all. My guess she will be intolerant to all 5HT drugs. Obviously do not want to just up her benzo dose. I hear things about lyrica for GAD but never used really in residency. Maybe a slower taper when shes ready to go again? I mean we went up from 6.25 to 12.5 after 1 week which is still faster than she went last time. Maybe more time for the drug to stay at steady state in her system before upping the dose would help. Any thoughts or experiences greatly appreciated!
 
SSRIs definitely have been described to cause EPS (particularly akathisia). The substantia nigra has inhibitory input from serotonin.

Why not CBT or buspirone? Klonopin might not be so evil in this case either. I do like Lyrica also, but hard for a lot of people to get covered for this indication and covered at all without failing gabapentin, which also might be worth trying, but I'm not a huge fan anecdotally.
 
thoffen said:
SSRIs definitely have been described to cause EPS (particularly akathisia). The substantia nigra has inhibitory input from serotonin.

Why not CBT or buspirone? Klonopin might not be so evil in this case either. I do like Lyrica also, but hard for a lot of people to get covered for this indication and covered at all without failing gabapentin, which also might be worth trying, but I'm not a huge fan anecdotally.
Click to expand...

Yeah I haven't had much luck with buspar anecdotally but I am going to get her plugged in with a therapist for some CBT. When you say Klonopin might not be so evil are you suggesting using it as a primary long term anxiolytic. In residency I had attendings on both ends of the sword with this. Some said that they get people up to 2-3 mg per day and that maintains them (never loses anxiolytic effect and they dont have to escalate doses). Others states short term only. Haven't figured out my practice style yet and the evidence is mixed I think it will be very variable depending on the patient.
 
You can definitely have akathisia on sertraline, but usually not until you hit 150mg or higher. What are the odds she has it at 12.5mg? Pretty low in my opinion. Any concern for somatic symptom disorder or illness anxiety disorder or histrionic personality disorder?

I agree with the above poster: augment with therapy. No side effects there!
 
pdoc241 said:
Yeah I haven't had much luck with buspar anecdotally but I am going to get her plugged in with a therapist for some CBT. When you say Klonopin might not be so evil are you suggesting using it as a primary long term anxiolytic. In residency I had attendings on both ends of the sword with this. Some said that they get people up to 2-3 mg per day and that maintains them (never loses anxiolytic effect and they dont have to escalate doses). Others states short term only. Haven't figured out my practice style yet and the evidence is mixed I think it will be very variable depending on the patient.
Click to expand...

I'd get her off the klonopin little by little if you can. once she's on a decent does for a good amount of time, she'll probably never come off of it, and the congitive effects can be a big deal down the line
 
I've had similar patients in the past. I tend to avoid benzos as they really aren't helpful in this particular case. I've used low dosage Gabapentin a couple of times a day and that higher dosages have diminishing returns. Can use Hydroxyzine in a pinch for those that don't get sleepy with it. Lots of education in that you can't medicate anxiety out of a person completely. It's impossible. And you can back this up by talking about the side effects from past medications used.

Your biggest ally? Weekly psychotherapy.
 
PistolPete said:
You can definitely have akathisia on sertraline, but usually not until you hit 150mg or higher. What are the odds she has it at 12.5mg? Pretty low in my opinion. Any concern for somatic symptom disorder or illness anxiety disorder or histrionic personality disorder?

I agree with the above poster: augment with therapy. No side effects there!
Click to expand...

But then what am I doing pharmacologically for her? I really don't think she has a PD from chatting with her and neither did the previous doc. Again I'm hearing this from the previous doc but he stated she would call stating she had this terrible nervous energy in her legs and she was pacing around. And yes at 12.5 mg. This stopped after about 1 week of discontinuation of the SSRI. For what it's worth I should also add she was genetically tested and it advised caution on all SSRIs for her due to side effects or lack of clinical response. I'm not really sure how to interpret it although it was testing for the SERT gene I believe. I am thinking about maybe seeing if she would want to give the SSRI another go, this time go very slow like maybe a quarter pill a month and maybe increase the benzo in the interim until I can get her on a therapeutic dose then gradually taper the benzo off.
 
I've definitely had patients that have reported akathisia-like symptoms with SSRIs - typically I ascribe this to paradoxical worsening in anxiety associated with initiation of the SSRI, but sometimes it doesn't resolve. I'd try and use something more sedating if you can (paroxetine, escitalopram) as that may help with some of this. I've never used pregabalin for GAD but there's evidence to support its use at 300+ mg total daily dose with a TID dosing regimen.

It sounds like even though the sertraline has been previously helpful the titration is going to be a pain, so why not try a different agent to see if the titration might be a bit easier?
 
Education and agreeing with her that medications are not perfect. They are imperfect, we cannot tell how medications will work as we have limited understanding on neurobiology and neurochemistry. The imperfection comes in the form of side effects.

Psychoeducation on sustained BZD treatment is important as she's working in therapy. There is no quick fix. There cannot be. The brain is rigid, it must work in a rigid function. Also education that desperation is not her ally. Once she understands this, the treatment process is much less chaotic.
 
Thanks for all the tips guys. i don't think she is using benzos as a crutch as she's voiced to me several times her desire to get off the benzos since they don't do anything for her and not uptitrate when suggested if we were to trial another SSRI. I think psychotherapy will be key for her. I am leaning towards Lyrica maybe. But yeah she states and maybe it's toward the obsessive side that the Zoloft put her into remission and that she had no anxiety on it once she was able to get on it and her symptoms all came back once she was taken off the med. It's just odd you would think if a patient had such dramatic resolution of symptoms on a drug you would really want to get the patient back on the drug that worked. Looking at the notes it was a bounce back and forth due to these anxiety/akathesia symptoms for 3 months and she finally was on 25 mg. From there they seem to have titrate her up much more quickly (although extremely slow by comparison to most patients).
 
Try another SSRI first? Sertraline can have a lot of side effects at least in my experience, and she sounds like a patient whose anxiety takes form of somatic monitoring, so she reacts dramatically side effects. Citalopram or escitalopram with the same slow titration schedule might work better.
I rarely see much benefit in buspirone in someone who's spent a lot of time on benzodiazepines.
 
Nefazadone is probably the least anxiogenic SSRI for most people.
 
Well it is blocking reuptake of 5HT, but you are right it does more. BMS did a lot of work using Serzone on anxiety disorders. I think it worked, but the patent ran out and there was an exaggerated safety scare that ended the effort.
 
As far as SSRI and akathesia I remember recently reading about a big malpractice case involving Paxil causing akathesia leading to a suicide in a hospital or jail.
 
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