What is the best course of action for a 51-year-old female patient experiencing anxiety, frustration, and depression, currently taking Propranolol (propranolol) for anxiety, Hydroxyzine (hydroxyzine) for sleep, and Venlafaxine XR (venlafaxine) 225mg daily, which may be causing intermittent mouth spasms?

From the Guidelines

The patient's treatment plan should prioritize addressing her depressive symptoms, as they are currently the primary concern, and consider a unified protocol that combines cognitive behavioral therapy (CBT) for both depression and anxiety, as recommended by the 2023 ASCO guideline update 1. The patient is experiencing mouth spasms likely related to her increased Effexor (venlafaxine) dosage of 225mg daily. The recommended plan is to gradually decrease the venlafaxine XR from 225mg to 150mg daily to help relieve these mouth spasms, which are a potential side effect of this medication at higher doses. The patient reports that propranolol is effectively managing her anxiety symptoms by reducing physical manifestations like shakiness, and Hydroxyzine (Vistaril) is helping with sleep despite occasional nighttime awakenings. However, she continues to struggle with cognitive symptoms including poor concentration, overthinking, feeling overwhelmed, lack of motivation, and procrastination, which contribute to her feelings of depression and frustration. Some key points to consider in her treatment include:

• The dose reduction of venlafaxine is appropriate as it targets the specific side effect (mouth spasms) while maintaining therapeutic benefit.
• Venlafaxine works by increasing serotonin and norepinephrine levels in the brain, and dose-dependent side effects like muscle spasms can occur, particularly at higher doses.
• The patient denies suicidal/homicidal ideation, auditory/visual hallucinations, or side effects from propranolol or Vistaril, indicating these medications are generally well-tolerated.
• According to the American College of Physicians, selecting between either cognitive behavioral therapy or second-generation antidepressants to treat patients with major depressive disorder is recommended after discussing treatment effects, adverse effect profiles, cost, accessibility, and preferences with the patient 2. Considering the patient's symptoms and the current treatment plan, it is essential to monitor her response to the dose reduction of venlafaxine and adjust her treatment plan as needed to prioritize her depressive symptoms and overall well-being.

From the FDA Drug Label

Stopping venlafaxine HCl too quickly or changing from another antidepressant too quickly may cause serious symptoms including: • anxiety, irritability • feeling tired, restless or problems sleeping • headache, sweating, dizziness • electric shock-like sensations, shaking, confusion, nightmares • vomiting, nausea, diarrhea

The plan to gradually titrate Venlafaxine XR 225mg daily down to 150mg daily may help minimize the risk of these symptoms. Gradual tapering is recommended when reducing the dose of venlafaxine to avoid serious symptoms.

• The patient should be closely monitored for any changes in mood, behavior, or physical symptoms during the tapering process.
• It is essential to follow the healthcare provider's instructions and not to stop or change the dose of venlafaxine without consulting them first 3.

From the Research

Patient's Current Condition

• The patient is a 51-year-old female who has been taking propranolol for anxiety, which has helped with her symptoms of "shakiness" 4.
• She reports difficulty in managing her thoughts, including overthinking, poor focus, and feeling overwhelmed and stuck.
• The patient also experiences procrastination and a lack of motivation, which contributes to her feelings of depression and frustration.
• Hydroxyzine has been helpful for her sleep, although she still wakes up occasionally at night.

Medication and Side Effects

• The patient is currently taking Venlafaxine XR 225mg daily, which may be contributing to her intermittent mouth spasms 5.
• A plan to gradually titrate her Venlafaxine XR dosage down to 150mg daily has been discussed as a potential solution to alleviate the mouth spasms.
• The patient denies any side effects from propranolol or Vistaril.
• Studies have shown that selective serotonin reuptake inhibitors (SSRIs) and serotonin and norepinephrine reuptake inhibitors (SNRIs) can be effective in treating anxiety and depressive disorders, but may have varying side effect profiles 6, 5, 7.

Treatment Options

• Beta-blockers, such as propranolol, have been shown to be effective in treating anxiety symptoms, particularly somatic symptoms like "shakiness" 4, 8.
• However, the evidence for the effectiveness of beta-blockers in treating anxiety disorders is limited, and more research is needed to fully understand their benefits and risks 8.
• SSRIs and SNRIs, such as Venlafaxine, may be effective in treating anxiety and depressive disorders, but may have side effects like mouth spasms, and require careful dosage management 6, 5, 7.