From the Guidelines
The patient should continue with Escitalopram 5 mg daily and closely monitor her symptoms, as this medication is likely to help manage both depression and anxiety symptoms, while discontinuing Wellbutrin and Zyprexa is appropriate given her current presentation. The decision to switch from Wellbutrin SR 150 mg daily and Zyprexa 5 mg daily to Escitalopram 5 mg daily for treatment of moderate, recurrent major depressive disorder appears to be in response to the patient's increased anxiety, which worsened when she inconsistently took her previous medications 1. The patient had been missing doses of her medications and then compensated by increasing both Zyprexa and Wellbutrin on her own, which she reports helped with her thoughts but increased her anxiety.
Key points to consider in this case include:
- The patient's inconsistent medication adherence and self-adjustment of doses, which can lead to unpredictable effects and increased risk of side effects.
- The potential for SSRIs like Escitalopram to manage both depression and anxiety symptoms, making it a suitable choice for this patient's current presentation.
- The decision to discontinue Wellbutrin, which can sometimes worsen anxiety, and Zyprexa, suggesting her thought disturbances may no longer require antipsychotic intervention.
- The importance of consistent medication adherence and regular follow-up to monitor response to the medication change and adjust dosing if needed, as SSRIs typically take 2-4 weeks to reach full effectiveness 1.
Given the evidence from the American College of Physicians and the Annals of Internal Medicine, it is crucial for the patient to understand the importance of adhering to the prescribed medication regimen and reporting any side effects or concerns to her healthcare provider 1. Close follow-up is recommended to monitor response to the medication change and adjust dosing if needed, ensuring the best possible outcome for the patient's morbidity, mortality, and quality of life.
From the FDA Drug Label
5. 2 Serotonin SyndromeThe development of a potentially life-threatening serotonin syndrome has been reported with SNRIs and SSRIs, including Escitalopram, alone but particularly with concomitant use of other serotonergic drugs (including triptans, tricyclic antidepressants, fentanyl, lithium, tramadol, tryptophan, buspirone, amphetamines, and St John’s Wort) and with drugs that impair metabolism of serotonin (in particular, MAOIs, both those intended to treat psychiatric disorders and also others, such as linezolid and intravenous methylene blue).
The patient is taking Escitalopram and Wellbutrin (which is a serotonergic drug) and Zyprexa. The patient reports increased anxiety and increased thoughts after missing a couple of doses and then increasing both Zyprexa and Wellbutrin. Key points:
- The combination of Escitalopram and Wellbutrin may increase the risk of serotonin syndrome.
- The patient's symptoms of increased anxiety and thoughts may be related to the increased doses of Zyprexa and Wellbutrin.
- It is recommended to monitor the patient closely for signs of serotonin syndrome, such as mental status changes, autonomic instability, and neuromuscular symptoms.
- The patient should be advised to contact their healthcare provider immediately if they experience any of these symptoms.
- The healthcare provider should consider adjusting the patient's medication regimen to minimize the risk of serotonin syndrome 2, 3.
From the Research
Patient's Condition
The patient is experiencing a recurrent episode of moderate major depressive disorder (MDD) and has been prescribed Escitalopram Oxalate Tablet, 5 MG, to be taken orally once a day for 30 days. The patient has also been taking Wellbutrin SR Tablet Extended Release 12 Hour, 150 MG, and ZyPREXA Tablet, 5 MG, but these medications have been stopped.
Increased Anxiety
The patient reports increased anxiety, which may be related to the stopped medications or the missed doses of Escitalopram Oxalate Tablet. According to 4, higher levels of anxiety can predict poorer outcomes for patients with MDD.
Treatment Options
The patient has increased the dosage of both ZyPREXA and Wellbutrin, which has helped with their thoughts but increased their anxiety. This suggests that the patient may benefit from alternative treatment options. According to 5, Mindfulness-Based Stress Reduction (MBSR) has been shown to be noninferior to escitalopram in reducing anxiety levels.
Therapeutic Interventions
Therapeutic interventions such as psychotherapy, pharmacotherapy, or a combination of both may be effective in treating adjustment disorder and anxiety, as suggested by 6 and 7. The choice of treatment should be based on the patient's specific needs and symptoms.
Assessment of Anxiety
The assessment of patient-reported symptoms of anxiety is crucial in identifying anxiety disorders and monitoring treatment, as stated in 8. A precise, reliable, and valid assessment of the patient's reported symptoms is necessary for evidence-based medicine.
Key Points
- The patient's increased anxiety may be related to the stopped medications or missed doses of Escitalopram Oxalate Tablet.
- Alternative treatment options such as MBSR may be beneficial in reducing anxiety levels.
- Therapeutic interventions such as psychotherapy, pharmacotherapy, or a combination of both may be effective in treating adjustment disorder and anxiety.
- A precise assessment of patient-reported symptoms of anxiety is necessary for evidence-based medicine.