Case outcome: multiple interim follow-ups through 16 months

The patient is converted to a different stimulant, mixed amphetamine salts-XR (Adderall-XR) and titrated gradually to 60 mg/d for effect

With each increase, the patient reports less depression and at the higher dose, she records her lowest depression rating scale score, which is near remission

Motivation is improved and fatigue lessened. She is well focused at work. The patient reports she is very happy with the complex, yet effective medication regimen of SNRI, atypical antipsychotic, stimulant, and trazodone

As the patient had a dramatic response to the stimulant medication, it was decided to discontinue some of her medications, which were deemed to be minimally effective. The aripiprazole (Abilify), given its longer-term metabolic and extrapyramidal risks, is gradually tapered without any return in her suicidal ideation

Several weeks later, the patient developed bilateral recurrent masseter muscle spasms that were not alleviated by anticholinergic therapy, and therefore, judged not to be dystonia or EPS

The patient states that she is quite anxious at work now due to new job descriptions and that she felt these were “nervous tics.” However, she fails to respond to the non-addictive anxiolytic hydroxyzine (Vistaril), and the BZ are avoided due to her previous alcohol misuse history

TD/withdrawal dyskinesia is now the working diagnosis, which seems to be triggered by the withdrawal of aripiprazole (Abilify)

• – Previous AIMS scores were all negative

The aripiprazole (Abilify) is restarted at a low dose to stop the withdrawal dyskinesia and the abnormal movements dissipate. Next, she is more gradually and slowly tapered off this atypical antipsychotic in hopes of avoiding withdrawal dyskinesia albeit at some increased risk for TD permanence

Simultaneously, her mixed amphetamine salts-XR (Adderall-XR) is also gradually lowered as it was felt her dyskinesia could be from D2 receptor toxicity due to stimulant use (i.e., motor tics)

At this point, removing her therapeutically effective stimulant may risk depressive relapse, which is problematic, but this risk is weighed against worsening her possible TD

Attending physician’s mental notes: 16-month follow-ups

This patient was in near remission and now she has a possible, irreversible movement disorder, although many patients improve over time from their withdrawal dyskinesias

Removal of all potentially offending agents is needed to lower the risk of TD permanence

Best case scenario is that this dyskinesia is stimulant-induced motor tics, which should reverse

Patient will likely relapse into depression

Case debrief

The patient has a lengthy history of chronic depression, substance misuse, and mild personality disorder traits. Her MDD appears unipolar in nature, and had been partially responsive at best to antidepressant treatments in the past but she has never fully remitted

This case was complicated in that she did achieve near remission for the first time in many years with the addition of an atypical antipsychotic and a stimulant to her SNRI

Unfortunately, both classes of agents are clinically utilized in the treatment of depression but carry the risk for movement disorder development, which ultimately occurred

Over the next few months, the patient had her trazodone discontinued due to ineffectiveness in treating insomnia and was placed on doxepin (Sinequan) and titrated to 200 mg/d to help the insomnia but also to act as a fully dosed TCA as well. The SNRI, duloxetine (Cymbalta), was discontinued

She became slightly more depressed, but did not fully relapse to her admission baseline of full MDD symptoms

The patient’s stimulant was also discontinued while she was titrated onto the doxepin, and one week after the final 10 mg/d of mixed amphetamine salts (Adderall-XR) was discontinued, all of her abnormal jaw movements ceased