Psychopharmacologic Management of Anxiety in an Adolescent with Congenital Long QT Syndrome

[Author Affiliation]Tricia B. Minton. 1 University of Cincinnati College of Medicine, Cincinnati, Ohio.Joanna Rosing. 2 Department of Anesthesiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.David S. Spar. 3 Division of Pediatric Cardiology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.Jeffrey R. Strawn. 4 Department of Psychiatry, University of Cincinnati College of Medicine, Cincinnati, Ohio.Blanca Garcia-Delgar. 5 Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York.Barbara J. Coffey. 5 Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York.Address correspondence to: Barbara J. Coffey, MD, MS, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1230, New York, NY 10029, E-mail: barbara.coffey@mssm.eduChief Complaint and Presenting ProblemA. was a 16-year-old adolescent girl with a history of congenital long QT syndrome and generalized anxiety and panic disorder with agoraphobia that had resulted in school avoidance. She was referred for anxiety symptoms that were difficult to control in the context of her cardiac condition.History of Present IllnessMother reported that A. had a history of separation anxiety as a young child, and a brief period of depressive symptoms when she was ∼14 years old, but these resolved spontaneously and did not require psychiatric treatment. A. was referred at age 16 for generalized anxiety symptoms, full-symptom panic attacks, and secondary depressive symptoms. Specifically, she endorsed irritability, restlessness, dreadful anticipation, and uncontrollable worries regarding school, her family, her brother, the future, and her friends, which occurred for several hours each day. In addition, she experienced initial insomnia, often lying in bed at night worrying about the next day, the events of the previous day, and her future. Her panic attacks occurred several times each week and included a myriad of somatic and cognitive symptoms, such as dyspnea, palpitations, nausea, tremulousness, sweating, and a sense that she might die.A.'s symptoms had been occurring for nearly a year, but had intensified recently, prompting her and her family to seek treatment from her primary care physician. She was initially treated with sertraline 25 mg and titrated to 100 mg daily, and lorazepam 1 mg daily on an as needed basis. She was also referred to a psychotherapist. Pharmacotherapy and psychotherapy were started in parallel, given the severity of the symptoms. Despite these efforts, A.'s anxiety and panic symptoms increased, and she became unable to attend school. At that time, the only precipitant was significant distress surrounding her brother's diagnosis of bipolar disorder, although it was noted that, contemporaneously, her family attempted to accommodate her anxiety to minimize associated familial conflict. A. denied obsessive-compulsive symptoms, symptoms of mania (other than irritability), and psychotic symptoms. A. was subsequently referred to the emergency department, and treatment in a partial hospitalization program was recommended.During the course of A.'s partial hospitalization, sertraline was titrated to 200 mg daily and lorazepam 1 mg was continued pro re nata for panic attacks. In addition, hydroxyzine 50 mg twice daily and melatonin 6 mg were added to target anxiety and dyssomnia, respectively. Continuing to struggle with severe anxiety, feeling overwhelmed with regard to falling further behind at school, and having "failed," A. developed suicidal ideation (Columbia Suicide Severity Rating Scale [CSSRS] Intensity scores of 1-2) (Posner et al. 2011). Based on concerns that she had developed increasing depressed mood, social withdrawal, some anhedonia, and increased guilt--consistent with a diagnosis of major depressive disorder--extended release of bupropion was initiated at 150 mg qAM. …