What additional medication can be considered for a patient with post-traumatic stress disorder (PTSD) and occasional psychotic symptoms, currently taking escitalopram (20 mg/day), clonazepam (2 mg/day), and lisdexamfetamine (Vyvanse, 50 mg/day), who continues to experience severe obsessive thoughts and anxiety?

From the Guidelines

For a patient with PTSD, psychotic symptoms, and persistent obsessive thoughts and anxiety despite current treatment with escitalopram, clonazepam, and Vyvanse, I recommend adding an atypical antipsychotic such as quetiapine (starting at 25-50 mg at bedtime, gradually increasing to 150-300 mg daily as tolerated) or aripiprazole (starting at 2-5 mg daily, increasing to 5-15 mg daily as needed) to address both the psychotic symptoms and obsessive thoughts. This recommendation is based on the most recent and highest quality study available, which suggests that atypical antipsychotics can be effective in reducing symptoms of psychosis and anxiety in patients with schizophrenia 1. Although the patient in question has PTSD and not schizophrenia, the principles of treatment for psychotic symptoms can be applied, and atypical antipsychotics have been shown to be effective in reducing symptoms of anxiety and depression as well.

Key Considerations

• The patient's current medication regimen includes escitalopram, clonazepam, and Vyvanse, which suggests that they are already being treated for symptoms of anxiety and depression.
• The addition of an atypical antipsychotic such as quetiapine or aripiprazole can help to address the patient's psychotic symptoms and obsessive thoughts.
• The patient should be monitored for metabolic side effects (weight gain, lipid and glucose abnormalities), extrapyramidal symptoms, and sedation when taking atypical antipsychotics.
• Alternative treatment options, such as augmenting with clomipramine, may be considered if the patient's obsessive thoughts are the predominant issue.

Treatment Options

• Quetiapine: starting at 25-50 mg at bedtime, gradually increasing to 150-300 mg daily as tolerated
• Aripiprazole: starting at 2-5 mg daily, increasing to 5-15 mg daily as needed
• Clomipramine: starting at 25 mg daily and gradually increasing, may be considered for patients with predominant obsessive thoughts

Monitoring and Follow-up

• Regular monitoring for metabolic side effects, extrapyramidal symptoms, and sedation is necessary when taking atypical antipsychotics.
• Follow-up appointments should be scheduled to assess the patient's response to treatment and adjust the medication regimen as needed.

From the FDA Drug Label

The efficacy of RISPERIDONE in the treatment of irritability associated with autistic disorder was established in two 8-week, placebo-controlled trials in children and adolescents (aged 5 to 16 years) who met the DSM-IV criteria for autistic disorder. Results of these trials are as follows: In one of the 8-week, placebo-controlled trials, children and adolescents with autistic disorder (n=101), aged 5 to 16 years, received twice daily doses of placebo or RISPERIDONE 0.5-3.5 mg/day on a weight-adjusted basis. RISPERIDONE, starting at 0.25 mg/day or 0. 5 mg/day depending on baseline weight (< 20 kg and ≥ 20 kg, respectively) and titrated to clinical response (mean modal dose of 1.9 mg/day, equivalent to 0.06 mg/kg/day), significantly improved scores on the ABC-I subscale and on the CGI-C scale compared with placebo.

Risperidone may be considered as an additional medication for a patient with post-traumatic stress disorder (PTSD) and occasional psychotic symptoms, currently taking escitalopram, clonazepam, and lisdexamfetamine, who continues to experience severe obsessive thoughts and anxiety, due to its efficacy in treating irritability associated with autistic disorder, which may be related to the patient's symptoms 2.

• The patient's symptoms of severe obsessive thoughts and anxiety may be related to their PTSD and psychotic symptoms.
• Risperidone has been shown to be effective in reducing symptoms of irritability, which may be beneficial for this patient.
• However, it is essential to note that the patient's specific condition and symptoms may not be directly addressed by the available data, and the use of risperidone should be carefully considered and monitored by a healthcare professional.

From the Research

Additional Medication Considerations

For a patient with post-traumatic stress disorder (PTSD) and occasional psychotic symptoms, currently taking escitalopram (20 mg/day), clonazepam (2 mg/day), and lisdexamfetamine (Vyvanse, 50 mg/day), who continues to experience severe obsessive thoughts and anxiety, the following additional medications can be considered:

• Risperidone, an atypical antipsychotic agent, which has been shown to be effective in treating obsessive-compulsive disorder (OCD) and may be useful in augmenting pharmacologic response in OCD 3
• Increasing the dose of escitalopram, as high-dose escitalopram (up to 40 mg/day) has been found to be effective in the treatment of patients with schizophrenia and comorbid OCD 4

Mechanism of Action

The mechanism of action of these medications involves:

• Risperidone's potent dopaminergic and serotonergic antagonist activity, which may help alleviate psychotic symptoms and obsessive thoughts 3
• Escitalopram's selective serotonin reuptake inhibition, which may help reduce symptoms of OCD and anxiety 5, 6

Potential Benefits and Risks

The potential benefits and risks of these medications include:

• Risperidone: beneficial effects on psychosis, agitation, and OCD symptoms, but may cause intolerable side effects in some patients 3
• High-dose escitalopram: significant improvement in OCD symptoms, but may require careful monitoring of side effects and tolerability 4