Pharmacologic Augmentation for Anxiety and PTSD in a Patient with Suicidal Ideation and Mood Lability on Risperidone
Add an SSRI, specifically sertraline starting at 25-50 mg daily and titrating to 150-200 mg daily over 4-6 weeks, as this is the first-line evidence-based treatment for both anxiety and PTSD with proven efficacy in reducing core PTSD symptoms and anxiety. 1, 2
Primary Recommendation: SSRI Monotherapy Addition
- Sertraline is the preferred SSRI based on the strongest placebo-controlled evidence in PTSD, demonstrating a 60% responder rate versus 38% for placebo, with significant improvements in Clinician-Administered PTSD Scale scores 2
- Start sertraline at 25 mg daily as a test dose given the patient's history of mood lability, then increase to 50 mg after 3-7 days if tolerated 1
- Titrate by 25-50 mg increments every 1-2 weeks to a target dose of 150-200 mg daily, monitoring closely for behavioral activation, especially in the first month 1
- Critical safety consideration: Monitor intensively for suicidal ideation in the first 24-48 hours after each dose change, given her recent suicidal ideation history 1
Why Not Increase Risperidone Alone
- While risperidone at 0.5-2 mg daily shows moderate efficacy for PTSD-related nightmares and sleep disturbances, it has failed to demonstrate efficacy for core PTSD symptoms in the largest controlled trial (n=247 veterans) 1, 3
- The major VA cooperative study found risperidone augmentation produced no significant reduction in CAPS scores compared to placebo (mean difference 3.74,95% CI -0.86 to 8.35, p=0.11) 3
- Risperidone is best reserved as augmentation for treatment-resistant cases or specific target symptoms (nightmares, psychotic features), not as primary anxiety/PTSD treatment 1
Alternative SSRI Options if Sertraline Fails
- Fluoxetine 10-20 mg daily, titrating to 40-60 mg over 3-4 weeks (longer half-life allows slower titration intervals) 1
- Citalopram/escitalopram may have fewer drug-drug interactions, but avoid citalopram doses >40 mg daily due to QT prolongation risk 1
- Avoid paroxetine given its association with increased suicidal thinking compared to other SSRIs and severe discontinuation syndrome 1
Monitoring and Titration Strategy
- Assess response using standardized scales (CAPS for PTSD, HAM-A for anxiety) at baseline, 2 weeks, 6 weeks, and 12 weeks 2
- Expect initial anxiety/agitation as a potential early adverse effect; this typically resolves within 1-2 weeks but may require dose reduction 1
- Full therapeutic response may not occur until 12 weeks, so maintain adequate trials before declaring treatment failure 1, 4
- Common tolerable side effects include insomnia (35%), diarrhea (28%), nausea (23%), and fatigue (13%) 2
When to Consider Risperidone Augmentation
Only consider increasing risperidone to 1 mg or higher if:
- The patient fails adequate SSRI trial (12 weeks at therapeutic dose) 4, 5
- Prominent psychotic symptoms, severe agitation, or treatment-resistant nightmares persist 1
- Target dose for augmentation is 0.5-2 mg daily (mean effective dose 1-2.3 mg) 1, 5
Critical Safety Warnings
- Boxed warning for suicidality: All SSRIs carry increased risk of suicidal thinking/behavior in patients under age 24, with pooled absolute risk of 1% versus 0.2% for placebo (NNH=143) 1
- Schedule weekly visits for the first month, then biweekly through week 12 given her recent suicidal ideation 1
- Educate patient and family about behavioral activation symptoms (restlessness, insomnia, impulsiveness, aggression) that may emerge early in treatment 1
- Ensure parental/family oversight of medication adherence and monitoring for adverse effects 1
What NOT to Do
- Do not use topiramate as first-line treatment despite some efficacy data, as one case series reported emergent suicidal ideation as an adverse effect 1
- Avoid benzodiazepines for chronic anxiety/PTSD management due to dependence risk and lack of efficacy for core PTSD symptoms 1
- Do not combine multiple serotonergic agents initially without careful monitoring for serotonin syndrome 1