What is the best course of treatment for a patient experiencing increased anxiety, possibly exacerbated by inconsistent use of olanzapine (Zyprexa) and bupropion (Wellbutrin), and who has a history of suicidal ideation, tachycardia, and substance use, including marijuana and vaping?

From the Guidelines

The patient's current treatment plan should be adjusted to prioritize her safety and address her increased anxiety, despite her resistance to the proposed changes, by discontinuing Wellbutrin and starting buspirone for anxiety management, as supported by the most recent evidence from 1.

Current Situation

The patient presents with inconsistent use of anxiety medication, reporting occasional anxiety attacks, with the most recent one occurring about two weeks ago. During this episode, she doubled her doses of Xyprexa and Wellbutrin. She is currently experiencing increased anxiety but insists this began before increasing her medication doses.

Proposed Treatment Plan

The patient is resistant to the proposed treatment plan of transitioning to escitalopram, discontinuing Wellbutrin, and tapering off Xyprexa, instead requesting an increased Wellbutrin dose despite education that this could be exacerbating her anxiety.

• Discontinue Wellbutrin to avoid potential exacerbation of anxiety, as suggested by the patient's history and the potential risks associated with increasing doses of this medication, as noted in 1.
• Start buspirone for anxiety management, given its efficacy in treating anxiety disorders with a favorable side effect profile compared to other anxiolytics, as supported by general clinical practice guidelines.
• Schedule follow-up care with psychiatric services to closely monitor the patient's mental health status and adjust the treatment plan as necessary, considering the importance of collaborative care in managing patients at risk for suicide, as emphasized in 1 and 1.

Additional Considerations

• The patient reports past suicidal thoughts without active plans and uses marijuana and vapes, which may be contributing to her mental health symptoms. Education on the potential risks of these substances and their impact on mental health should be provided, as part of a comprehensive approach to her care.
• She also reports tachycardia for the past couple years but declined an offered EKG. The importance of monitoring her cardiac health, especially given her symptoms and medication regimen, should be emphasized, and alternative approaches to assessing her cardiac risk should be considered.
• The patient requested an Ozempic refill, which was deferred to the next visit to avoid potential medication interactions. This decision prioritizes her safety and allows for a more controlled introduction of new medications, minimizing risks of adverse interactions, as is prudent in managing patients with complex medication regimens, as suggested by 1.

From the FDA Drug Label

The following symptoms, anxiety, agitation, panic attacks, insomnia, irritability, hostility, aggressiveness, impulsivity, akathisia (psychomotor restlessness), hypomania, and mania, have been reported in adult and pediatric patients being treated with antidepressants for major depressive disorder as well as for other indications, both psychiatric and nonpsychiatric Although a causal link between the emergence of such symptoms and either the worsening of depression and/or the emergence of suicidal impulses has not been established, there is concern that such symptoms may represent precursors to emerging suicidality Consideration should be given to changing the therapeutic regimen, including possibly discontinuing the medication, in patients whose depression is persistently worse, or who are experiencing emergent suicidality or symptoms that might be precursors to worsening depression or suicidality, especially if these symptoms are severe, abrupt in onset, or were not part of the patient’s presenting symptoms

The patient's increased anxiety may be related to the bupropion medication. The drug label warns of potential neuropsychiatric adverse events, including anxiety, agitation, and panic attacks. Given the patient's history of suicidal thoughts and current symptoms, it is prudent to discontinue the bupropion as planned and monitor the patient's condition closely. The decision to start buspirone and stop wellbutrin may help alleviate the patient's anxiety symptoms. However, it is essential to continue monitoring the patient's mental health and adjust the treatment plan as needed. Key considerations include:

• Close monitoring of the patient's mental health
• Discontinuation of bupropion due to potential neuropsychiatric adverse events
• Alternative treatments, such as buspirone, to manage anxiety symptoms
• Regular follow-up appointments to assess the patient's condition and adjust the treatment plan as needed 2

From the Research

History of Present Illness

• The patient reports inconsistent use of her anxiety medication over the last year, with occasional anxiety attacks, the most recent being two weeks ago.
• At the time of the anxiety attack, the patient decided to double her dosing of Xyprexa and Wellbutrin, which she claims led to an increase in anxiety.
• The patient is adamant that the increased anxiety occurred prior to increasing the dose of Wellbutrin.
• Education was provided about Xyprexa and tachycardia, and an EKG was offered, but the patient refused.
• The patient was advised to try her medication consistently at the prescribed dose and return for follow-up in one week, but she expressed uncertainty about the effectiveness of this plan.
• The patient stated, "I just want something to help with anxiety."

Medication Adherence

• Medication adherence is crucial for effective treatment, as noted in the study 3, which highlights the importance of patients taking their medicines as prescribed to achieve the full benefit of treatment.
• The study 3 also mentions that non-adherence can be costly for the health service and may be intentional or non-intentional, with various factors affecting an individual's compliance with a medication regimen.

Anxiety and Suicidal Ideation

• The patient reported having thoughts of suicide in the past, but no active plan, and is a smoker of marijuana and vapes, which can exacerbate mental health issues.
• Education was provided on the potential impact of these substances on mental health, as noted in the study 4, which explores the relationship between anxiety and suicidal ideation.
• The study 4 found that anxiety severity correlated with suicidal ideation severity, irrespective of treatment.

Treatment Plan

• The initial plan was to transition the patient to escitalopram, stop Wellbutrin, and transition off Xyprexa, but the patient refused this plan.
• The patient requested an increased dose of Wellbutrin, despite education on the potential cause of increased anxiety, as noted in the study 5, which compares anxiety severity over time in patients prescribed SSRIs versus bupropion.
• The study 5 found that there were no significant interactions between group and time, suggesting that bupropion may not exacerbate anxiety in all patients.
• The patient was started on buspirone, and education was provided on the potential benefits and risks of this medication, as noted in the study 6, which reviews pharmacotherapy for anxiety disorders.
• The study 7 highlights the importance of optimal treatment of anxiety disorders, including both pharmacologic and behavioral interventions.

Tachycardia and Refill Requests

• The patient reported experiencing tachycardia over the last couple of years, which can be difficult to distinguish from anxiety.
• An EKG was offered, but the patient refused, opting to monitor the situation instead.
• The patient requested a refill on Ozempic, but education was provided on the potential impact of multiple medications on mental health, and it was decided to address this at the next office visit.