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Antidepressants/topiramate Lack of efficacy, oversedation and cognitive blunting: case report

A 13-year-old female to male transgender patient developed oversedation and cognitive blunting during treatment with topiramate for migraines. Additionally, the patient exhibited lack of efficacy during treatment with sertraline, aripiprazole and lurasidone for major depressive disorder [routes and duration of treatment to reactions onsets not stated]. The patient, who had a psychiatric history of major depression disorder, anxiety and trauma, was admitted to an inpatient child and adolescent psychiatry unit for recent and recurrent suicide attempts and self-harming behaviour. There had been extensive conflict between father and the patient. The father was not supportive of patient’s transgender identity, which had been the source of patient’s stress. Before the current referral for admission, the patient had been treated at an inpatient residential facility for 9 months. The patient had received lurasidone treatment, but could not tolerate it because of unspecified adverse effects. The patient’s history was notable for impulsivity, poorly regulated irritability and unstable self-esteem, which had been pervasive and continuous throughout patient’s early childhood. The patient was referred for the current admission for an overdose of 27 pills of lisinopril. On admission, the patient was severely depressed and exhibited poor concentration, anhedonia, low energy, suicidal plan and intent and reduced sleep quality. The past diagnoses included major depressive disorder, posttraumatic stress disorder, generalised anxiety disorder and obsessive compulsive disorder with onset of most symptoms at 10 years of age. The history also included migraines and asthma. Feature of borderline personality disorder (BPD) were also present. The patient was allergic to peanuts, dust, nuts and penicillin. The patients initial medications included sertraline up to 150 mg/day, and then in combination with aripiprazole 2 mg/day. The patient also tried hydroxyzine and quetiapine for poor sleep and anxiety. On admission, the patient was receiving lurasidone 80mg PM and escitalopram; along with topiramate 100mg two times a day for migraines and beclometasone for asthma. The patient’s depression was found to be resistant to treatments with lurasidone, sertraline and aripiprazole. Owing to patient’s remarkable depression, dose of escitalopram was increased for the first 5 days of hospitalisation. Despite, the patient showed very minor amelioration of the symptoms and developed possible side effects of topiramate as oversedation and cognitive blunting. The patients topiramate dose was tapered to 50mg two times a day, resulting in resolution of the side effects (over-sedation and cognitive blunting). Throughout hospital stay, the patient continued to show remarkable self-harming behaviours. The patient attempted suicide two times by asphyxiation and was found cutting thighs with plastic cutlery. Given the high level of suicidality, offlabel treatment