What alternative or adjunct therapy is suitable for a 73-year-old female patient experiencing anxiety, currently taking 200mg of Zoloft (sertraline), bowel movement (BM) medication, and atorvastatin, who reports feeling 'on edge'?

From the Guidelines

For a 73-year-old female experiencing edge feelings on 200mg Zoloft (sertraline) who also takes bowel movement medication and atorvastatin, I recommend adding buspirone (BuSpar) 5mg twice daily as an adjunct therapy, as this approach is supported by the most recent and highest quality study 1. The feeling of being "on edge" suggests possible serotonin overstimulation at the current high dose. Buspirone works well with SSRIs without increasing serotonin syndrome risk and can specifically target anxiety symptoms. Some key points to consider when making this decision include:

• The patient's age and medication sensitivity, which increases with age, making it essential to use the lowest effective dose 1.
• The importance of monitoring for adherence, side effects, and adverse events when introducing new medications or adjusting existing ones 1.
• The consideration of patient values and preferences in treatment decisions, including the potential risks and burdens of combination therapy 1.
• The availability of alternative treatment options, such as cognitive-behavioral therapy (CBT), behavioral activation (BA), structured physical activity, and exercise, which may be beneficial for patients with moderate symptoms of anxiety 1. Any medication change should be gradual, particularly when reducing Zoloft, which should be tapered by 25-50mg every 1-2 weeks to avoid discontinuation symptoms. Regular follow-up within 2-4 weeks of any medication change is essential to monitor effectiveness and side effects.

From the FDA Drug Label

The administration of buspirone hydrochloride tablets to a patient taking a monoamine oxidase inhibitor (MAOI) may pose a hazard. The concomitant use of buspirone with MAOIs intended to treat depression is contraindicated.

The patient is taking Zoloft (an SSRI), and considering an alternative or adjunct therapy.

• Buspirone may be a potential alternative, but it is essential to consider the risk of serotonin syndrome when combining buspirone with SSRIs.
• Given the patient's current medication regimen, including Zoloft, BM med, and atorvastatin, it is crucial to exercise caution when introducing buspirone.
• The FDA drug label does not provide direct guidance on the specific combination of Zoloft and buspirone, but it does highlight the potential risks associated with concomitant use of serotonergic agents 2.
• A conservative approach would be to monitor the patient closely for signs of serotonin syndrome if buspirone is added to their regimen.

From the Research

Alternative or Adjunct Therapy Options

The patient is currently taking 200mg of Zoloft and experiencing feelings of being "on edge", while also taking BM medication and atorvastatin. Considering alternative or adjunct therapy options, the following points are relevant:

• Mindfulness-based stress reduction (MBSR) has been shown to be noninferior to escitalopram, a commonly used first-line psychopharmacological treatment for anxiety disorders 3.
• MBSR has been found to improve mental health and reduce symptoms of anxiety and depression in various studies 4, 5.
• Cognitive therapy, MBSR, and behavior therapy have been compared in a randomized controlled trial for the treatment of chronic pain, with results suggesting that all three treatments produce similar reductions in pain and improvements in physical function, mood, and sleep disturbance 6.
• Predictors and moderators of treatment response have been identified, including low levels of cognitive/behavioral function at pre-treatment, favorable expectations of benefit from treatment, and sound working alliances 7.

Potential Benefits and Considerations

Potential benefits of alternative or adjunct therapy options include:

• Reduced symptoms of anxiety and depression
• Improved mental health and well-being
• Enhanced cognitive and behavioral function
• Better management of chronic pain Considerations for the patient's specific situation include:
• The patient's current medication regimen and potential interactions with alternative or adjunct therapies
• The patient's individual needs and preferences for therapy
• The availability and accessibility of alternative or adjunct therapy options

Next Steps

Based on the available evidence, the following next steps could be considered:

• Consultation with a healthcare professional to discuss alternative or adjunct therapy options
• Exploration of MBSR or other mindfulness-based interventions as a potential adjunct to the patient's current treatment plan
• Consideration of cognitive therapy or behavior therapy as alternative or adjunct options for managing chronic pain or anxiety symptoms.