P2.C059: Calcium channel and beta blocker intoxication: A management challenge in an overmedicated psychiatric patient.

Introduction: This is a case of a 16-year-old female patient with a history of Major Depressive Disorder (MDD) and General Anxiety Disorder (GAD) admitted to a Pediatric Intensive Care Unit (PICU) due to a suicide attempt with hypertension control drugs.
MDD is a prevalent mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest in previously enjoyed activities.

Case Description: Treatment guidelines for depression and anxiety typically include pharmacotherapy, psychotherapy, and family interventions. Antidepressants like selective serotonin reuptake inhibitors (SSRIs) are commonly prescribed. However, these medications carry black box warnings for increased suicidal ideation, especially in adolescents. In this case study, the patient was managed by a psychiatrist through telemedicine and by a clinical psychologist. Pharmacotherapy medications included: escitalopram (SSRls), lamotrigine, buspirone, hydroxyzine, and trazodone. These medications possess varying mechanisms of action and adverse side effects. All of them, with the exception of escitalopram, were prescribed off label. Especially lamotrigine, which is not indicated for any of the patient's diagnosis.

Discussion: Upon hospital arrival, the patient experienced severe cardiovascular and respiratory distress, needing admission to the Pediatric Intensive Care Unit (PICU). It was informed by the family that the patient ingested an unknown quantity of nifedipine (calcium channel blocker) and metoprolol succinate (beta blocker). Given the level of hypoxemia, hypotension and respiratory failure; mechanical ventilation, vasopressor support and fluid resuscitation were employed to stabilize her condition. Treatment included: epinephrine drips, midazolam, fentanyl and cisatracurium continuous infusions. Patient was maintained with mechanical ventilation for almost two weeks and moved from PICU to a psychiatric ward 17 days later. She didn't receive any of the psychiatric prescription drugs during her PICU stay and was prescribed only buspirone upon transfer to the psychiatric ward.

Conclusion: Collaboration between critical care, psychiatry, and pediatric cardiology teams was vital in managing the patient's complex presentation. This case emphasizes the intricate interplay between pharmacotherapy for mental illness and acute medical complications in adolescents following suicide attempts. Mental health providers must inform parents/guardians about the risks and benefits of multiple pharmacotherapy approaches for common adolescent mental illnesses like MDD and GAD. Including the higher risk of suicide ideation/intent within pediatric patients. Also, optimal management strategies should be implemented to avoid overmedication and ensure treatment complementation with evidence-based psychotherapy.