Cases That Test Your Skills

Depression, medication, and ‘bad blood’

Current Psychiatry. 2007 May;6(5):97-100
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References

We also place Mr. G in a day treatment program for mentally ill chemical abusers. A psychiatrist sees him every 2 weeks, and staff supervise him daily.

The authors’ observations

Mr. G’s extended hospital stay allowed us to closely observe him and offered ready access to laboratory facilities while we cross-tapered medications. In outpatient treatment, however, a serious and life-threatening medication-induced complication could easily be missed.

Clinical Point

Duloxetine, escitalopram, and paroxetine have not been reported to cause neutropenia

If economically feasible, take CBCs for all patients before prescribing any medication that could cause neutropenia, such as an antidepressant or mood stabilizer. Make sure geriatric or medically ill patients have had a CBC ≤3 months before presentation and are seeing a primary care physician as needed. Order follow-up CBC for these patients 1 month after presentation, then every 6 months if CBC is normal.

For medically healthy outpatients, be sure CBC has been checked ≤6 months before presentation. Monitor CBC and urge the patient to see a primary care doctor if infection symptoms emerge. Watch for gingivitis, tooth abscess, and other oral cavity infections—which often are overlooked—and sore throat or fever.

Also check electrolytes and screen for SSRI-induced hyponatremia at baseline for all at-risk patients.

Stop the offending drug when WBC reaches 9/L or with absolute neutrophil count (ANC) 9/L, then take a peripheral smear to confirm neutropenia. If the patient is asymptomatic, check ANC 2 to 3 times weekly, particularly if he or she recently had an infection or started a medication that can cause neutropenia. Neutropenia should resolve within 6 to 8 weeks of stopping the offending drug.

If neutropenia persists, order bone marrow biopsy in collaboration with an internist or hematologist to test for cancer. If the biopsy is negative, test for:

  • HIV infection
  • antinuclear antibodies to check for collagen vascular disease
  • antineutrophil antibody to rule out immune neutropenia
  • serum folate and B12 deficiency secondary to low WBC.
Also perform an immunoglobulins/immune evaluation to check for defects in cellular or humoral immunity, and bone marrow culture to test for infection.8

FOLLOW-UP: Stressor and relapse

Seven months later, Mr. G is readmitted for depression. Three months earlier, he had stopped all medications and resumed drinking after a family member died. WBC at admission is 3.70×109/L

Clinical Point

Make sure older or medically ill patients have had a CBC≤3 months before starting medication that can decrease WBC counts

We restart sertraline, 150 mg/d. WBC falls to 2.83×109/L 12 days later, so we add lithium, 300 mg/d. Two days later, WBC returns to normal and he is discharged. His depression has been stable throughout this second admission, and he is euthymic at discharge.

We refer Mr. G to an outpatient psychiatrist, who sees him monthly. Several months later, the psychiatrist reports a WBC of 4.58×109/L.

Nearly 1 year later, Mr. G still lives at the assisted-living facility. He has not been rehospitalized for depression, is functioning well, and has a girlfriend.

The authors’ observations

Mr. G’s abnormal blood counts after sertraline rechallenge confirms that the SSRI probably was causing leukopenia. If we had restarted bupropion and neutropenia recurred during that regimen, we could have more certainly established a bupropion-leukopenia connection.

Related resources

Drug brand names
  • Bupropion • Wellbutrin
  • Carbamazepine • Tegretol, others
  • Citalopram • Celexa
  • Clozapine • Clozaril
  • Duloxetine • Cymbalta
  • Escitalopram • Lexapro
  • Fluoxetine • Prozac
  • Lamotrigine • Lamictal
  • Lithium • various
  • Mirtazapine • Remeron
  • Oxcarbazepine • Trileptal
  • Paroxetine • Paxil
  • Phenobarbital • various
  • Phenytoin • Dilantin
  • Propylthiouracil • various
  • Sertraline • Zoloft
  • Trazodone • Desyrel
  • Valproic acid • Depakene
  • Venlafaxine • Effexor
Disclosure

The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

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