Case outcome: first interim follow-up visit four weeks later

Declines escalating the SSRI due to sexual side effects

Felt tiagabine (Gabitril) dosing is reasonable but mildly fatiguing

As hydroxyzine (Vistaril/Atarax) is the lowest therapeutically dosed of the three, he opts to increase this up to 100 mg/d at the risk of daytime sedation

• – Returns acknowledging the same symptoms as his first appointment

• – States that he is too tired on the increased hydroxyzine dose to continue it

Question

Do you find hydroxyzine a reasonable anxiolytic?

Yes, for short-term, adjustment-based anxiety symptoms

Yes, for longitudinal anxiety treatment

Yes, especially for use in patients who cannot risk taking a BZ anxiolytic, i.e., addictive patients

Yes, for treating GAD and agitation but not for PD or OCD

No

Attending physician’s mental notes: second interim follow-up visit at two months

This was easy in that escalating the SSRI seems to be helping gradually

He is now about 50% better with global improvement in his GAD symptoms and agrees to continue the SSRI and off-label SGRI

Will need to discuss with him long-term maintenance on the SSRI and also some pharmacologic antidotes if his sexual side effects become intolerable or threaten poor medication adherence in the future

Tiagabine (Gabitril) has a limited evidence base where switching from an SSRI to tiagabine monotherapy may maintain efficacy while alleviating SSRI sexual dysfunction

Case outcome: second interim follow-up visit at two months

The patient is tapered off hydroxyzine altogether and begrudgingly agreed to try a higher dose of paroxetine (Paxil-CR) at 37.5 mg /d while continuing the tiagabine (Gabitril) 12 mg/d

• – A moderate reduction in anxiety symptoms occurs

• – There were greater sexual side effects noted

• – Can see the benefit of the increased SSRI dosing

Felt to be 20%–30% better compared to the last appointment

Question

If he continues toward full symptom remission, but develops major sexual side effects, what would you do?

Just switch to tiagabine (Gabitril) monotherapy

Lower the SSRI and try a less sexual side effect-prone drug, such as bupropion-XL (Wellbutrin-XL), trazodone-ER (Oleptro), mirtazapine (Remeron), vilazodone (Viibryd)

Add bupropion-XL (Wellbutrin-XL) at doses of 300 mg/d or more to the SSRI/SGRI combination to alleviate his sexual dysfunction

Add buspirone (BuSpar) to alleviate his sexual dysfunction

Add sildenafil (Viagra) to alleviate his sexual dysfunction

Lower the SSRI and switch to a BZ as they have lower incidence of sexual side effects

Case outcome: interim follow-up visits through five years

The patient completes graduate school and finds a permanent job in his field of choice

Reports much new performance anxiety and hyperarousal around this

There is now stress in other areas of his life as well, but these create more dysphoria and despondency suggesting possible onset of depressive illness

Tolerates the same medication regimen with good effects until late in his fifth year of treatment when the adjustment issues and his GAD symptoms begin to escalate

Begins seeing his psychotherapist again, and is unwilling to increase his SSRI any further

Question

What would you do next?

Nothing, as the psychotherapy should address his adjustment disorder issues

Augment the current tiagabine plus paroxetine-CR combination with a third agent

Switch his currently failing combination to an SNRI