Psychotherapy history

Sees a therapist every one to two weeks

Parents have tried many positive reinforcement strategies with little effect

Patient evaluation on initial visit

The patient presents with mild anxious symptoms, but reports his generalized worrying about multiple topics has greatly diminished, as has his walking in circles, since starting the SSRI

The greater clinical problem is inattention, hyperactivity, and impulsivity, which have only minimally responded to an SSRI, low-dose stimulant, and behavioral modification attempts

May now be underweight and short in stature

Current psychiatric medications

Fluoxetine (Prozac) 10 mg/d (SSRI)

Lisdexamfetamine (Vyvanse) 20 mg/d (stimulant)

Question

Is it possible that the SSRI is causing his weight loss instead of the more commonly accused and more often guilty stimulant?

Yes, in depression and anxiety studies, the SSRIs have been associated with appetite suppression and weight-loss adverse effects. Anorexia is noted in 7% of adults treated acutely with fluoxetine and 4% with sertraline

No, the SSRIs cause weight gain and appetite increase more often than weight-loss adverse effects

No, the stimulants are well known for their approved use, and off-label use as appetite suppressants in obese patients

No, the stimulants are well known for anorexia and weight-loss adverse effects while treating ADHD

Attending physician’s mental notes: initial evaluation

The patient’s anxiety appears to predominantly contain multifocal worries consistent with GAD, but his repetitive walking behaviors seem to be more in line with OCD

His repetitive movements and arm flapping could be related to mild ASD (formerly Asperger’s disorder in DSM-IVTR), but he has no other ASP symptoms

Regardless, his worries and repetitive behaviors seem controlled; but if history is accurate, his nearly curative SSRI is causing excessive weight loss and enuresis when used at higher therapeutic doses

Does meet ADHD, combined-type diagnostic criteria, and these symptoms are the most problematic for now

Case is complicated by current side effects and previous stimulant trials have been ineffective due to intolerability

Question

Which of the following would be your next step?

Remove the SSRI as his weight loss is problematic

Remove the stimulant as it is the most likely weight-loss agent

Switch to another SSRI in hopes of better tolerability

Switch to another stimulant in hopes of better tolerability

Switch to a novel antidepressant class to continue anxiolysis

Switch to a nonstimulant ADHD-approved medication

Further maximize his current medication regimen

Attending physician’s mental notes: initial evaluation (continued)

Anxiety is so well controlled that removing the SSRI could make things worse

ADHD is poorly controlled so the stimulant should be raised

It is clear that his parents are concerned immensely about his weight and height but it is unclear if the patient is truly at risk or falling off his growth curve, as the pediatrician is non-committal about this finding currently

Case outcome: initial visit

Parents are fully informed and educated about the risks and benefits of both his current medications

After coming for consultation, they are ambivalent about any changes due to the fact:

• – That they have had negative effects from previous stimulants and increasing this one worries them

  • They refuse an increase in his dose, and state they will consider this and call back

• – That they have had good effects from the SSRI, and despite current side effects, would not want his anxiety to return

  • As the patient has been in remission from his anxiety symptoms now for several months, they do reluctantly agree to lower his fluoxetine (Prozac) down to 5 mg/d to lower his side-effect burden and hopefully continue its effectiveness