Case Report Reveals SSRIs Work Alongside MG Therapy in Adolescent Patient

A new case report suggests that selective serotonin reuptake inhibitors (SSRIs) may still be a viable solution for patients with myasthenia gravis (MG) who also suffer from depression.

Previous research has raised concerns that SSRIs could worsen MG symptoms, but the case report, based on the experiences of a 13-year-old patient, calls those concerns into question. The report was published in the journal Cureus.¹

The authors noted that psychological comorbidities are common among adults with MG. About a third of adults with MG also suffer from depression, the authors add, and these patients tend to have a higher risk of suicide attempts.²

“This is partly attributed to the social and physiological challenges experienced by this patient population, namely fatigue symptoms associated with MG,” they explained.¹

MG is less common in children than in adults, with an incidence rate of only 1 to 5 cases per million person-years.³ The investigators said there is “little” literature on the psychiatric implications of MG in pediatric patients.¹ They hoped to improve understanding of the psychiatric effects of MG by publishing their case report.

The case involved a 13-year-old female patient with MG who was taken to the emergency department for suicidal ideation and apparent self-intoxication with a diphenhydramine medication.

“The day after the incident, her father took her to the hospital, initially mistaking her sedation and lack of movement for an MG attack,” they wrote.

The patient was then transferred to a children's hospital, where she was stabilized and underwent a number of assessments, including the Children's Depression Inventory, which showed a “very high” T score of 75. The patient also had indicated that she had a history of self-harm and had a long history of suicidal thoughts, although she had never considered attempting suicide before.

“Prior to this hospital presentation, she was receiving outpatient therapy and was prescribed an SSRI,” the authors noted. “However, the father later found the full bottle of SSRI since she had not taken it.”

The patient was prescribed fluoxetine (Prozac) and was admitted to the hospital's behavioral health unit. Soon his mood changed. Whereas she was previously indifferent to the staff and barely participated in activities, she is now more motivated and actively participates in her care and therapy sessions. She said her suicidal thoughts also stopped, investigators reported.

The patient's MG also remained well controlled and she was eventually discharged with a prescription for 10 mg of fluoxetine and 180 mg of pyridostigmine (Mestinon).

The authors noted that they made their prescribing decision cautiously, given the potential for negative interactions between the two drugs. Fluoxetine, they noted, can block acetylcholine receptors at the neuromuscular junction.

“Pyridostigmine is also known to act at this site by inhibiting the enzyme acetylcholinerase, thereby increasing the amount of acetylcholine available for electrical signaling between nerves and muscles, leading to improvement in the symptoms of muscle fatigue associated with MG” , said the authors. “These results suggest the possibility of using pyridostigmine and fluoxetine [having] opposing actions at the neuromuscular junction.

The fact that both therapies appear to perform the desired functions in this patient suggests that the interactions between the two therapies may be more complicated than previously thought. The authors said more research is therefore needed to better understand how both can be used with patients. They also said that other treatment modalities, such as individual, group and family therapy sessions, also appeared to help the patient, highlighting the potential of multimodal approaches.

“This case highlights the need for comprehensive assessment and management of mental health symptoms in pediatric patients with MG,” they wrote.

The references:

1. Arce MI, Breetz KA, Martin CA. Treatment of depression in adolescents with myasthenia gravis. Curéus. 2024;16(4):e58408. Published April 16, 2024. doi:10.7759/cureus.58408.
2. Nadali J, Ghavampour N, Beiranvand F et al. Prevalence of depression and anxiety in patients with myasthenia gravis (MG): a systematic review and meta-analysis. Brain behavior. 2023;13(1):e2840. doi:10.1002/brb3.2840
3. Peragallo JH. Pediatric myasthenia gravis. Semin Pediatrician Neurol. 2017;24(2):116-121. doi:10.1016/j.spen.2017.04.003