Symptoms reemergence

Dosage adjustment or augmentation if symptoms reemerge after sustained euthymia [avoid prescription switch to a different agent)... 

After 6 to 9 months, the antidepressant can usually be tapered over a period of several weeks to avoid withdrawal symptoms, which may increase or even mimic relapse. If symptoms reemerge, medication should be reinstated and maintained for an additional 3 to 6 months before an attempt is made to taper them again. In patients with recurrent unipolar depressions, indefinite prophylactic treatment may be required. 

Dose and coworkers (257) compared verapamil with placebo in eight patients using an ABA design. Seven showed some degree of response, five with symptoms reemerging to a minor extent with placebo, and two showing no relapse on placebo. A concomitant antipsychotic was used in two and lithium in one. 

It symptoms reemerge, consider treatment with an SSRI or SNRI, or consider restarting the benzodiazepine sometimes benzodiazepines have to be used in combination with SSRIs or SNRIs for best results... 

If symptoms reemerge, consider treatment with an SSRI or SNRI, or consider restarting hydroxyzine... 

Due to individual physiologic differences, there can be wide variations in effective dosages of the same medication from patient to patient. Also, when a medication is stopped (by either therapeutic plan or noncompliance), complete elimination of the drug does not occur immediately, or even within known half-life parameters. This partially explains why recurrence of psychosis may not immediately appear in the noncompliant schizophrenic and why depressive symptoms reemerge weeks (or days) after an antidepressant is discontinued. (The therapist can help educate the patient as to the potential consequences of medication discontinuation.)... 

This study also found that new schizophrenic symptoms often emerged during the 6 weeks of placebo treatment, whereas worsening of symptoms was prevented by antipsychotics. Heinz Lehmann (33) coined the term psychostatic to describe the ability of phenothiazine antipsychotics to prevent the reemergence of symptoms. 

An important issue in maintenance treatment is the rate of relapse upon discontinuation of therapy. This differs markedly from study to study, perhaps due to their varying durations. In addition, the definition of relapse varied, so that the rate was higher when defined as a modest reemergence of psychotic symptoms rather than an exacerbation sufficient to cause rehospitalization. Using the former criteria, the relapse rate may be as high as 5% to 20% per month, whereas the more conservative criteria might yield a 1% to 10% rate. 

As noted earlier, evidence indicates that atypical antipsychotics may also produce NMS ( 488). Several patients have developed NMS after treatment with clozapine, risperidone, or olanzapine. A few of these cases are classic NMS, with symptoms such as markedly elevated temperature and CPK levels. For each drug, approximately a dozen reported cases fulfill a reasonably stringent criteria for NMS, whereas the rest can be considered borderline. The number of NMS cases, however, appears low relative to use. In addition, some of the patients on clozapine who developed NMS were also receiving neuroleptics. There are cases of patients who had NMS on clozapine alone, however, and when rechallenged with clozapine experienced another NMS episode. Similarly, rechallenge with olanzapine- or risperidone-induced NMS has resulted in either questionable or definite reemergence of NMS. 

Many of these patients derive benefit from short-term BZD therapy only. In one study, 50% of those treated with diazepam (15 to 40 mg/day) for 6 weeks maintained their improvement during subsequent placebo therapy for an additional 18 weeks ( 23). In another study, 70% treated for 4 weeks with either lorazepam or clorazepate maintained improvement during 2 weeks on placebo (24). Even the chronically anxious may benefit from brief (4 to 6 weeks) treatment ( 25). In many cases, although discontinuation of medication may eventually lead to a reemergence of anxiety, symptoms may not always be continuous, be functionally significant, or cause patients to seek further treatment (26). 

Benzodiazepine-dependenf anxiefy pafienfs and insulin-dependenf diabetics are nof addicfed fo fheir medications. When benzodiazepine-dependenf pafienfs stop fheir medication, disease symptoms can reemerge, disease symptoms can worsen (rebound), and/or withdrawal symptoms can emerge... 

Be sure to differentiate reemergence of symptoms requiring reinstitution of treatment from withdrawai symptoms... 

Patients who have been on the medications for some time need to be advised against abrupt discontinuation, which can lead to a severe withdrawal syndrome and possible convulsions. A reduction in dose is likely to lead to a reemergence of the anxiety symptoms for which the person is being treated, such as panic attacks. If this is due only to drug withdrawal, the symptoms usually subside within two weeks. For this reason, as stated above, it is best to taper off benzodiazepine dosage very slowly after prolonged use. 

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