We rule out anxiety disorder secondary to a general medical condition (OSA) and diagnose Mr. J with anxiety disorder not otherwise specified.
The authors’ observations
We continue paroxetine at 20 mg/d because it was working fairly well with minimal side effects. The sleep medicine specialist maintained modafinil, 200 mg/d. Laboratory studies—including a comprehensive metabolic panel, complete blood count with differential, and thyroid stimulating hormone—were within normal limits except a fasting blood glucose of 123 mg/dL, for which we referred Mr. J to his primary care physician.
OUTCOME: Discontinue paroxetine?
One month later, Mr. J denies panic attacks, other anxiety symptoms, or other psychiatric symptoms and is sleeping well. However, he reports that his mildly decreased concentration persists and he wants to stop paroxetine.
After discussing the risks and benefits, Mr. J and the treatment team decide to continue paroxetine at 20 mg/d. We cite peer-reviewed literature that recommends continuing antidepressants for at least 1 year and possibly indefinitely after symptom resolution to control panic disorder symptoms.9 In addition, we discuss the lack of studies comparing different lengths of treatment with SSRIs for apparent OSA-induced panic attacks that respond to SSRI/CPAP therapy. Because Mr. J was doing well and experiencing minimal side effects, he feels he would be better served with a longer period of psychopharmacologic treatment.
Six months later, Mr. J says his anxiety symptoms are well controlled and generally unchanged except for an occasional “little flutter” of anxiety every 3 or 4 days that lasts several seconds. For 1 year, he reports no recurrence of panic attacks, compliance with CPAP, and stable OSA.
Related resource
- Saunamäki T, Jehkonen M. Depression and anxiety in obstructive sleep apnea syndrome: a review. Acta Neurol Scand. 2007;116(5):277-288.
Drug brand names
- Alprazolam • Xanax
- Amphetamine/dextroamphetamine • Adderall
- Atomoxetine • Strattera
- Clonazepam • Klonopin
- Ergocalciferol • Calciferol
- Modafinil • Provigil
- Methylphenidate extended release • Concerta
- Paroxetine • Paxil
- Pramipexole • Mirapex
- Propranolol • Inderal
- Sertraline • Zoloft
Disclosure
The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.