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CPAN Case of the Month – February 2023

Patient: 16-year-old being treated for Major Depressive Disorder and Generalized Anxiety Disorder with Panic Attacks.

Each month, PCPs call CPAN with a wide variety of mental health questions. Find out how CPAN helped a pediatrician with their 6-year-old patient with ADHD.

Patient: 16-year-old being treated for Major Depressive Disorder and Generalized Anxiety Disorder with Panic Attacks.

Reason for CPAN consultation: PCP needed assistance switching medications.

The adolescent was an established patient with the PCP whose anxiety and depressive symptoms had significantly worsened following parental death and change in household dynamics. The PCP prescribed Escitalopram 10mg PO Daily and Psychotherapy. Subsequently, the dose increased to 20mg PO Daily.

At this dose, the patient reported only some improvement in depressive symptoms but worsening anxiety. The PCP then consulted with the CPAN psychiatrist regarding switching medications.

Through consultation, the CPAN psychiatrist discussed the limitation of Escitalopram dosage, given the risk of cardiovascular and orthostatic adverse effects, along with relative potency compared with other antidepressant medications in its class. However, given each antidepressant medication has unique characteristics, switching between them can be a complicated process.

In this case, a cross taper plan was recommended with Sertraline, which is a more potent antidepressant medication with a larger therapeutic window. Risks associated with cross taper, particularly Serotonin Syndrome, were discussed in detail as were the appropriate steps regarding avoiding and management.

Take home point:

Sometimes patients have an inadequate response to a psychotropic medication and may have to switch to a different one. Switching between medications can be a very sensitive decision given each medication’s unique characteristics. Feel free to call CPAN to discuss the safest and most applicable ways to do so. Our team is always available to help you take care of patients and their families.