Has a patient with post-traumatic stress disorder (PTSD), moderate anxiety, and depression, taking sertraline (sertraline), experienced tactile hallucinations, such as formication, while on this medication?

From the Guidelines

The patient should consider switching to bupropion (Wellbutrin) due to its weight-neutral profile and minimal sexual side effects, which can help alleviate the concerning side effects experienced with sertraline, as suggested by the most recent guideline evidence 1. When managing a patient with a history of moderate anxiety, depression, and PTSD, it is crucial to prioritize medications that minimize adverse effects on weight and sexual function.

• Bupropion is a suitable alternative, as it has been shown to be effective in treating depression and anxiety components of PTSD, with a more favorable side effect profile compared to sertraline 1.
• The patient should start with a low dose of bupropion (150 mg daily) for one week, then increase to 300 mg daily if tolerated, under close medical supervision.
• Alternatively, mirtazapine at a higher dose (30-45 mg) could be considered, as it has less weight gain potential at higher doses despite being sedating at lower doses.
• For the tactile hallucinations, it is essential to rule out other causes like substance withdrawal, medical conditions, or formication, and to taper off sertraline gradually while transitioning to the new medication.
• Continuing prazosin for nightmares and maintaining therapy for PTSD is recommended, as emphasized in the 2023 U.S. Department of Veterans Affairs and U.S. Department of Defense clinical practice guideline 1.
• Non-pharmacological approaches like CBT, mindfulness practices, and regular exercise can complement medication management and help with both PTSD symptoms and weight management.

From the FDA Drug Label

Psychiatric Disorders-Frequent: yawning, other male sexual dysfunction, other female sexual dysfunction; Infrequent: depression, amnesia, paroniria, teeth-grinding, emotional lability, apathy, abnormal dreams, euphoria, paranoid reaction, hallucination, aggressive reaction, aggravated depression, delusions; Rare: withdrawal syndrome, suicide ideation, libido increased, somnambulism, illusion

The patient in question denies tactile hallucinations, but the drug label does mention hallucinations as a possible side effect of sertraline, although it is listed as infrequent.

• Hallucinations are a potential side effect of sertraline.
• The patient's symptoms, such as emotional blunting and worsening insomnia, are also mentioned in the drug label as possible side effects of sertraline.
• To address the patient's weight gain, the healthcare provider may consider alternative treatments or lifestyle modifications, as the drug label notes that weight increase is a frequent side effect of sertraline 2.
• Given the patient's history of PTSD and anxiety, the healthcare provider may also consider alternative treatments that do not worsen weight gain, such as therapy or other medications 2.
• It is essential to monitor the patient's symptoms and adjust the treatment plan as needed to minimize the risk of adverse effects 2.

From the Research

Patient's Symptoms and Medication

• The patient is a male in his late 40's with a history of moderate anxiety and depression, PTSD, and has been taking sertraline since January.
• He reports significant side effects, including weight gain, sexual dysfunction, emotional blunting, involuntary movements, and worsening insomnia with sleep disturbances.
• The patient denies sleepwalking episodes and tactile hallucinations, and has quit THC and rarely drinks alcohol.

Tactile Hallucinations and Sertraline

• There is no direct evidence in the provided studies that links sertraline to tactile hallucinations.
• However, study 3 mentions that sertraline can cause adverse events, but does not specify tactile hallucinations as one of them.

Alternative Treatments and Weight Gain

• Study 4 suggests that mirtazapine may be an alternative treatment option, as it has a unique mechanism of action and may cause less sexual dysfunction than SSRIs.
• However, mirtazapine is more likely to cause weight gain or increased appetite than SSRIs, which may be a concern for this patient.
• Study 5 and 6 suggest that combining bupropion with sertraline may be an effective treatment option, as it can boost antidepressant response and reduce SSRI-associated sexual side effects.
• Bupropion may also be a good alternative to consider, as it is less likely to cause weight gain than other antidepressants.

Monitoring and Management of Side Effects

• Study 7 highlights the importance of systematically monitoring patients for adverse drug reactions, and suggests that nurse-administered checklists can be an effective tool in doing so.
• Regular monitoring and management of side effects can help to minimize their impact and improve treatment outcomes.