A 54-year-old woman comes to the office due to irritability, insomnia, headache, and fatigue. The patient's medical conditions include hypothyroidism, treated with a stable dose of levothyroxine, and major depressive disorder. She had been doing well on paroxetine for 2 years but decided to stop the medication 3 days ago due to concerns about sexual side effects and weight gain. Since then, the patient has been very worried as she already feels "terribly anxious and depressed." She describes frequent tearfulness, feeling panicky, and body aches and pains.
Temperature is 37 C (98.6 F), blood pressure is 130/80 mm Hg, and pulse is 88/min. Physical examination is normal. Mental status examination shows an anxious, irritable mood with a full range of affect. The patient has no suicidal ideation.
Which of the following is the most appropriate next step in management of this patient?

Question

A 54-year-old woman comes to the office due to irritability, insomnia, headache, and fatigue.  The patient's medical conditions include hypothyroidism, treated with a stable dose of levothyroxine, and major depressive disorder.  She had been doing well on paroxetine for 2 years but decided to stop the medication 3 days ago due to concerns about sexual side effects and weight gain.  Since then, the patient has been very worried as she already feels "terribly anxious and depressed."  She describes frequent tearfulness, feeling panicky, and body aches and pains.
Temperature is 37 C (98.6 F), blood pressure is 130/80 mm Hg, and pulse is 88/min.  Physical examination is normal.  Mental status examination shows an anxious, irritable mood with a full range of affect.  The patient has no suicidal ideation.
Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Abrupt discontinuation of selective serotonin reuptake inhibitors (SSRIs) can precipitate an antidepressant discontinuation syndrome that consists of both physical and psychological symptoms, typically beginning within a few days from drug discontinuation and lasting several weeks. Patients may experience acute onset of depression, irritability, anxiety, fatigue, dizziness, gastrointestinal distress, and flu-like symptoms. Other physical symptoms include tremor, paresthesias, and "electric shock" sensations. The syndrome occurs more frequently following abrupt discontinuation of shorter half-life antidepressants (eg, paroxetine, venlafaxine) and less commonly with longer half-life drugs (eg, fluoxetine). Most patients experience only mild and transient discontinuation symptoms, but some cases can be severe. The best next step is to restart the patient's paroxetine to treat her withdrawal, followed by a slow taper over 2-4 weeks. The physician should reassure the patient that her mood symptoms are unlikely to represent a depressive recurrence and that her physical symptoms are not medically dangerous. An alternate strategy to restarting and tapering the same antidepressant is substitution of fluoxetine, which is more easily tapered due to its long half-life. (Choice A) Lorazepam would not target the underlying cause of the patient's condition, which is withdrawal from a serotonergic antidepressant. (Choice B) This patient's hypothyroidism has been controlled on stable doses of medication and is an unlikely cause of her acute symptoms. (Choice D) Bupropion is a norepinephrine and dopamine reuptake inhibitor often prescribed for depression due to its favorable side effect profile (no weight gain or sexual side effects). Bupropion would be a reasonable choice for this patient if she decided to resume treatment with an antidepressant, but it would not treat her acute withdrawal from a serotonergic drug. (Choice E) Venlafaxine is a serotonin-norepinephrine reuptake inhibitor that is associated with sexual side effects, making it a poor choice for this patient. It also commonly causes discontinuation symptoms with abrupt cessation. Educational objective: Abrupt discontinuation of short half-life antidepressants such as paroxetine or venlafaxine can result in an antidepressant discontinuation syndrome. Treatment consists of restarting the medication and gradually tapering or substituting an equivalent dose of long-acting fluoxetine. __________ References: Withdrawal symptoms after selective serotonin reuptake inhibitor discontinuation: a systematic review. (http://www.ncbi.nlm.nih.gov/pubmed/25721705) A review of the management of antidepressant discontinuation symptoms. (http://www.ncbi.nlm.nih.gov/pubmed/26834969) Selective serotonin reuptake inhibitor antidepressant treatment discontinuation syndrome: a review of the clinical evidence and the possible mechanisms involved. (http://www.ncbi.nlm.nih.gov/pubmed/23596418)

A 54-Year-Old Woman Comes to the Office Due to Irritability