Case outcome: first interim follow-up visits one to two weeks later

All medications except for the SSRI escitalopram (Lexapro) are discontinued

The SSRI is increased to 20 mg/d because

• – The 10 mg/d dose was not effective

• – The intrusive images are felt to be obsessional, and often high-dose SSRIs are needed to alleviate OCD symptoms

A SARI, trazodone (Desyrel) 50–100 mg at bedtime, is given to treat insomnia

• – Insomnia is an acute risk factor for suicide

• – Aggressive treatment here may lower risk of suicide and avoid an inpatient stay

• – He immediately sleeps better and his suicidal ideation is reduced

• – This off-label use of an SARI may also provide MDD augmentation treatment

Question

If his images are from OCD, how long should a clinician wait for an SSRI to become effective?

A few weeks at the minimum therapeutic dose, just like treating other anxiety disorders

Several weeks at the minimum dose as OCD responds more slowly than other anxiety disorders

Several weeks at a high dose are often required to adequately treat OCD

A dozen weeks at a high dose is often required to adequately treat OCD

Attending physician’s mental notes: second interim follow-up visit at three to four weeks

Several more weeks may be needed for the SSRI to take effect

What if these symptoms are psychotic?

• – SSRI sometimes treat depressive psychosis, but an antipsychotic may be warranted

Atypical antipsychotics are often used in OCD patients who fail to respond to adequate dose and duration of SSRI treatment

• – This patient has not had an adequate dose and duration of his high-dose SSRI yet, but waiting several weeks may be too risky

• – Using an atypical antipsychotic now could speed his response to his SSRI

• – It may also decrease his agitation acutely

Case outcome: second interim follow-up visit at three to four weeks

The patient is no better

• – Depressed and suicidal still

• – His intrusive images continue

• – He is “fed up waiting to get better” and is not sure “how much more he can take”

• – He and his parents ask if there is anything more to do outside waiting for his SSRI to become effective

Inpatient admission is considered

Outpatient collaboration of providers and number of visits is increased instead

Question

What would you do?

Admit to an inpatient setting and modify treatments there

Await for 20 mg/d escitalopram (Lexapro) to become effective while increasing psychosocial supports and safety planning

Increase escitalopram (Lexapro) to 30 mg/d, which is super-dosed and off-label, but may be warranted and helpful in treatment-resistant OCD

Add an atypical antipsychotic

Add a BZ

Case outcome: interim follow-up visits through four to six weeks later

An atypical antipsychotic is added to his escitalopram (Lexapro) 20 mg/d and the trazodone (Desyrel) 50–100 mg at bedtime

• – Ziprasidone (Geodon) 20 mg twice a day is started

  • The first few days is taken without food, to lower its bioavailabilty by half and to hopefully avoid akathisia similar to what occurred with the prior aripiprazole (Abilify) trial

  • This is changed to with food to obtain full bioavailability and allow further dose titration after a few days

  • This atypical antipsychotic is chosen, as similar to aripiprazole, ziprasidone tends to minimize weight gain and metabolic disorder side effects relative to other atypical antipsychotics

    • This teenager is sensitive to his weight and does not want to gain weight

There is too much sedation

• – Asks for a medication change

• – This increases his despondency, as he knows titration will take longer and that he feels more worthless as he sleeps more and is even less productive and worthwhile

The atypical antipsychotic ziprasidone is tapered off and the atypical antipsychotic lurasidone (Latuda) is started instead

• – A similar strategy due to absorption and bioavailability is employed, where he takes it without food for a few days

  • This keeps the initial dose and EPS risk lower

• – Next, it is taken with food; however, unlike ziprasidone, lurasidone is therapeutic in treating his psychosis at 40 mg/d

• – Similar to ziprasidone, this newer atypical antipsychotic also carries a lower risk of weight gain and metabolic disorder compared to other agents in the class

However, family calls to report that he is worse in between sessions

There is more agitation, sleep is worse, and he gets shivers and sweats with some palpitations and headaches now

• – This is not like the activating and akathisia side effects where he was restless on aripiprazole (Abilify) and fluoxetine (Prozac)

• – This is felt to be mild serotonin syndrome from the current SSRI, escitalopram, SARI, trazodone, and his recently added atypical antipsychotic, lurasidone (Latuda)

  • The latter interacts at 5-HT2A, 5-HT1A, and 5-HT7 receptors

• – Lurasidone (Latuda) is lowered to 40 mg/d without food (likely 20 mg equivalent bioavailability) and the side effects resolve

• – Several days later in an attempt to obtain better efficacy with the atypical antipsychotic, he is rechallenged with 40 mg/d with food and the same side effects return