A 29-year-old woman presents with a diagnosis of panic disorder and generalized anxiety disorder (GAD), for which she is treated with paroxetine for 6 months. She seeks consultation because she reports “not feeling myself” in recent months. She saw her primary care doctor a year ago for panic attacks, which occurred about once monthly. The primary care doctor was reluctant to give her benzodiazepines, and prescribed paroxetine 20 mg/d. This dose produced tremor, which improved at 15 mg/d. Her panic symptoms completely resolved for 6 months, and her function at work improved. However, about 3 months ago, she began to feel less interested in social activities and less interested in her work. She denied low energy or other depressive symptoms. She had one depressive episode 4 years ago, after a break-up, which improved a year later without medication treatment. She has no other mood episodes in the past, and denies any manic or hypomanic episodes. Manic symptom denial was confirmed in a phone call by the consultant to the patient’s mother. She denies any other past psychiatric symptoms, has no medical illnesses, no drug allergies, and no past trauma. She is single and in a long-standing relationship, and has been productive and functioning well at her work in a publishing company for 5 years. She has no current or past history of alcohol or drug abuse of any kind.
The PL impression was that she was experiencing the side effect of apathy syndrome from serotonin reuptake inhibitors. The use of benzodiazepines, like lorazepam, initially on an as needed basis, and if needed on a regular basis, was recommended. Specifically, it was recommended that paroxetine be stopped and replaced with a benzodiazepine. Since she has no substance abuse history, her risk of benzodiazepine abuse or addiction is very low, probably less than 5% based on some data. She has a troublesome SRI side effect, and long-term SRI treatment itself will be associated with tolerance and major withdrawal symptoms. Her panic symptoms are not very frequent, only once monthly, and she has no need for SRI treatment for any other recurrent mood condition. Thus, the PL consultant was impressed by the limited nature of her panic symptoms, and the troublesome nature of her SRI side effects, along with absence of a need for constant, long-term treatment of any medication. This clinical picture, along with absence of substance abuse, would support the prescription of benzodiazepines instead of SRI agents.