A 22-year-old man comes to the office for follow-up regarding anxiety. The patient was referred for treatment by the student health service due to severe anxiety accompanied by sweaty palms and shaky voice, as well as blushing when meeting new people and giving oral presentations. He was diagnosed with social anxiety disorder and started on fluoxetine 2 weeks ago. Today, the patient reports that his anxiety in social situations has not improved and that he has started to feel uncharacteristically tense and jittery, "like I've had too much coffee." He says, "If anything, my anxiety is worse than before, and I feel anxious most of the time." The patient now has difficulty falling asleep. He has no significant medical history. The patient does not use illicit drugs. Vital signs are stable, and physical examination is unchanged from the initial presentation. Which of the following is the most appropriate next step in management of this patient?

Question

A 22-year-old man comes to the office for follow-up regarding anxiety.  The patient was referred for treatment by the student health service due to severe anxiety accompanied by sweaty palms and shaky voice, as well as blushing when meeting new people and giving oral presentations.  He was diagnosed with social anxiety disorder and started on fluoxetine 2 weeks ago.  Today, the patient reports that his anxiety in social situations has not improved and that he has started to feel uncharacteristically tense and jittery, "like I've had too much coffee."  He says, "If anything, my anxiety is worse than before, and I feel anxious most of the time."  The patient now has difficulty falling asleep.  He has no significant medical history.  The patient does not use illicit drugs.  Vital signs are stable, and physical examination is unchanged from the initial presentation.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Selective serotonin reuptake inhibitors (SSRIs) are often a first-line treatment for depressive and anxiety disorders given their efficacy, tolerability, and general safety in overdose. Common early adverse effects include nausea, diarrhea, headache, increased anxiety, and insomnia or somnolence. These effects usually occur in the first few weeks of treatment initiation or dose increase and diminish or resolve over time. This patient's worsening anxiety, with jitteriness, insomnia, and new-onset anxiety in nonsocial situations, most likely reflects the stimulating effects of fluoxetine. The mechanism may be due to SSRI-induced activation of presynaptic 5HT1A (leading to inhibition of serotonin release and a net decrease in serotonin levels) before the full effects of the medication (net increase in serotonin levels) are seen. The most appropriate next step is a temporary dose reduction with the goal of improving tolerability; dose increases may subsequently be reattempted. Patients with anxiety disorders are especially sensitive to the activating effects of antidepressants and should generally be started at lower doses than those typically used to treat depression (eg, half the normal starting dose), with a gradual increase to a therapeutic level over several weeks. (Choices A, B, and F) Compared to benzodiazepenes, buspirone (an anxiolytic that acts on the serotonergic system) is associated with a lower risk of dependence and fewer side effects but also has weaker anxiolytic effects; it is useful as augmentation therapy when anxiety is not well controlled with SSRIs. Because this patient's increased anxiety and insomnia are most likely from fluoxetine, adding buspirone or zolpidem (a hypnotic medication used in insomnia) is not indicated, and a higher fluoxetine dose would likely exacerbate his symptoms. (Choices D and E) Because it may take several weeks for the full effect of an SSRI to be seen, switching to another medication after 2 weeks would be premature without first attempting dose reduction. Bupropion is an activating antidepressant that could further increase anxiety and insomnia. Benzodiazepines (eg, clonazepam) are not preferred as long-term monotherapy due to risks of abuse and dependence. These drugs are sometimes prescribed adjunctively for extreme anxiety in the first weeks of treatment but should be tapered and discontinued once the antidepressant takes effect. Educational objective: Activating effects (eg, anxiety, insomnia) are possible early adverse effects of selective serotonin reuptake inhibitors but frequently improve with time. Patients with anxiety disorders are more sensitive to activating adverse effects and may benefit from a temporary dose reduction or initiation at a lower-than-normal dose. References: Side effects of antidepressants during long-term use in a naturalistic setting. (http://www.ncbi.nlm.nih.gov/pubmed/23726508) Antidepressant efficacy and side-effect burden: a quick guide for clinicians. (http://www.ncbi.nlm.nih.gov/pubmed/26576188)

A 22-Year-Old Man Comes to the Office for Follow-Up Regarding