Case outcome: interim follow-ups through six months

Because of her resistant depression, SSRI and SNRI failure, she was placed on off-label ziprasidone (Geodon) 20 mg twice a day with food (required for adequate absorption and bioavailablity) while continuing her SNRI duloxetine (Cymbalta). She wanted to avoid weight gain, and at the time, no atypical antipsychotic was FDA approved for depression augmentation. Ziprasidone is fairly benign for metabolically induced weight gain (antipsychotic-associated weight gain [AAWG]). It also has theoretical antidepressant potential as it antagonizes 5-HT2A receptors, partially agonizes 5-HT1A receptors, and acts as a weak SNRI pharmacodynamically

Unfortunately, she experienced akathisia and it was discontinued

Next, as she was educated about the rationale of the atypical antipsychotic family of medications, she agreed to start aripiprazole (Abilify) as it has similar serotonergic properties. As it also causes akathisia, it was started at 2.5 mg/d and gradually increased over several weeks for effect up to 15 mg/d

Six months later she was “80%–90% better” and doing well clinically on the SNRI plus atypical antipsychotic combination. She had 10 lbs of AAWG as her only side effect. Blood pressure and metabolic parameters were normal

As she was doing well, she was advised to continue her medication regimen as it is

Question

Considering her current regimen and its risk/benefit profile, what would you do next?

Keep the regimen as it is

Lower the aripiprazole (Abilify) gradually, as she is in remission for a few months and the risk for movement disorders is higher in affective disorder patients, and continue her duloxetine (Cymbalta) alone

Keep regimen as it is, but add a weight-losing medication such as orlistat (Xenical), topiramate–phentermine combination (Q-Symia), naltrexone–bupropion combination (Contrave), lorcaserin (Belviq), or off-label metformin (Glucophage) to mitigate the AAWG and avoid future metabolic disorder

Attending physician’s mental notes: nine months

The patient, after two decades, is in remission. This SNRI plus atypical antipsychotic combination appears to have treated her recurrent MDD and affective lability

She still experiences some PMEs but these are less severe and better tolerated than baseline, and she is less labile with regard to social stressors

The atypical antipsychotics do carry TD and metabolic risks with long-term use

• – MDD guidelines would suggest that as she has had three or more MDEs, effective medicines should be continued to prevent future recurrence. She is less than one year in remission

• – There is risk for TD and metabolic syndrome and these should be monitored routinely, and informed consent should be given throughout ongoing treatment

• – For example, annual AIMS (Abnormal Involuntary Movement Scale) and blood work to detect elevated lipids and blood sugars should be considered

She experiences rare to absent illusions/hallucinations

Case outcome: interim follow-ups through nine months

The chief complaint is now PMS that has been mitigated partially so far

After discussion of these options, the patient wishes to continue her current regimen

A few months later, her primary care physician (PCP) calls and states the patient has lateral jaw movements and feels she should be seen for this

Patient arrives and has involuntary, intermittent lateral jaw movements. AIMS examination is positive for new-onset TD