Pt is a 36-year-old female with a history of depression and anxiety who was managed by her primary care provider with an initial medication regimen of Sertraline 50mg daily and Buspirone 5mg daily. She was admitted to psychiatric inpatient care from 03/10/2021 to 03/15/2021 due to worsening depression and suicidal ideation in the context of psychosocial stressors. The patient had endorsed the feeling of intermittent hopelessness along with some erratic sleep and appetite patterns. There was no reported history of hypomanic or manic symptoms, nor has there been a reported history of psychosis. The patient also engaged in alcohol use, reporting consumption of 4-8 drinks daily in the weeks prior to admission. No other substance use was reported.  

During the hospitalization, her Sertraline was increased to 100mg daily dose, Buspirone was discontinued, and Aripiprazole was added at 5mg dose for augmentation. The patient had reported some initial sedation as side effects from the Aripiprazole which subsided after switching the medication to nighttime administration.  

The patient showed improvements in mood and affect, participated in groups and socialized with peers.  The patient felt well throughout 2021, remained abstinent from alcohol use, and continued on the same medication regimen. She became pregnant in September of 2021 and followed her Obstetrician-Gynecologist's recommendation to hold the Aripiprazole. However, she consecutively developed worsening depressive symptoms, including feeling of hopelessness, had reduced appetite, and reduced oral intake. She switched psychiatrists and was restarted on Abilify 5mg at 10 weeks pregnant and Sertraline was increased to 150mg daily dose with positive therapeutic benefit.  She started to eat more regularly and was more positive, and her depressive thoughts resolved.

Throughout the follow up visits in 2022-2024, she remained stable on this medication regimen consistent of Abilify 5mg and Sertraline 150mg daily dose.  In the beginning of 2024, she again switched providers and endorsed mood instability and a new medication Vilazodone 40mg daily was added to the regimen and Sertraline was gradually tapered off. Bupropion was started as a new antidepressant in August 2024 in combination with Aripiprazole 5mg and Vilazodone 40mg daily. However, the patient did not improve and started to express that she would like to taper off her medications. In August 2024, Vilazodone was decreased to 10mg daily dose and stopped in October 2024. Pt then was maintained on Aripiprazole 5mg and Bupropion 150mg daily and Zoloft was restarted at 12.5mg. In December 2024, the patient started to taper off her medications, taking Zoloft 12.5mg and Abilify 2mg every other day. She stopped taking any psychiatric medication on 01/11/2025.  

On 01/16/2025, the patient was seen by me as new provider endorsing involuntary movements in her jaw, tongue, and facial muscles which was new to her as she never had experienced any extra-pyramidal symptoms. She reported pain in her teeth at night and recurrent headaches. She was seen by her dentist and neurologist who did not find any organic abnormalities.  

I offered to order Benztropine 02/10/25 which she declined to take after reviewing the side effects. She took a supplement consistent of ginkgo, vitamin E and zinc and started to wear a mouth guard. She reported on 02/27/2025 that her symptoms were about 90% better. On 03/27/2025 she reported that her symptoms had worsened greatly with the onset of her menses. A trial of Benztropine 0.5mg BID did not provide improvement and the patient’s symptoms continued to bother and significantly interfere with her life during her 3 month follow up.  At this point, I ordered Ingrezza 40mg daily which was not approved by her insurance. The patient continued to report ongoing withdrawal- dyskinesia symptoms up to her 8 months follow-up visit after discontinuation of the atypical antipsychotic.  In the following months, her involuntary movements improved significantly.