Pistol Prozac Pete
A 42-year-old female sees you for follow-up 8 weeks after starting citalopram (Celexa), 20 mg daily, for major depression. Laboratory findings 8 weeks ago were normal and she has no other medical problems. Her baseline PHQ-9 score was 18. She reports that her sleep quality, concentration at work, and appetite have all improved. She says she feels “somewhat better.” A repeat PHQ-9 score is 10.
A PHQ score of what would indicate remission of her depression symptoms?
≤4 indicates remission
After serving a jail sentence for his second DUI, a 34-year-old male consults you at the urging of his partner for help with alcohol abstinence. He has already enrolled in Alcoholics Anonymous but is also interested in medication to help him maintain abstinence.
Name 3 medications FDA approved for the treatment of alcohol use disorder.
Disulfiram, Acamprosate, and Naltrexone
A 14-year-old male is brought to your office by his parents, who are concerned about his behavior. Recently he was caught shoplifting video games. He started smoking cigarettes at age 10, and he has a history of truancy from school for the past 2 years. His parents report that they have caught him starting fires outside of their home, and he often teases the family dog, whom he has injured on several occasions. What is the most likely dx?
Conduct disorder
A 24-year-old female with polycystic ovary syndrome (PCOS) presents with a 4-month history of sadness, anxiety, anhedonia, exhaustion despite sleeping 9 hours daily, and increased appetite. She is not currently sexually active and is not planning to become pregnant in the near future. Her vital signs are normal other than a BMI of 32 kg/m2. She has facial comedonal acne with a few papules, and mild hirsutism. Her medications include metformin (Glucophage) for PCOS and topical tretinoin (Retin-A) for acne. She scores 16 on the PHQ-9 and is not suicidal.
What is the best first choice of medication for this patient and why?
Bupropion (Wellbutrin); favorable weight loss effects in high BMI patients.
During a visit to establish care, a 60-year-old female requests a refill of temazepam (Restoril), which she has used for the past several months because of difficulty staying asleep. Her sleep problem started when her husband was being treated for cancer. Other than well controlled hypertension and occasional symptoms from osteoarthritis in her knees, she has no significant medical problems. She is not obese, does not smoke, usually limits her alcohol consumption to two glasses of wine on weekends, and has negative screening questionnaires for depression and anxiety. Her husband has not mentioned that she has been snoring.
What is the next best step in management?
Doxepin (Silenor) would be preferred to temazepam and can be used for those with difficulty staying asleep. Doxepin and controlled-release melatonin are recommended as first-line agents in older adults.
A 68-year-old female is seen emergently for an episode of loss of consciousness preceded by dizziness. She says that she takes medication for depression but she doesn’t remember its name. An EKG shows a prolonged QT interval.
Which SSRI/SNRI has been found to be associated with a dose-dependent QT interval prolongation?
Citalopram, especially in doses >40 mg
A 36-year-old male sees you for follow-up of his first episode of major depressive disorder. His baseline PHQ-9 3 weeks ago was 15. He smokes a pack of cigarettes per day and expressed an interest in stopping smoking at his initial visit, so you prescribed bupropion (Wellbutrin SR), 150 mg every 12 hours. His PHQ-9 score at this visit is 12. He says that the bupropion is giving him headaches and making him jittery, and asks to be switched to a different antidepressant.
Name 1 other antidepressant (ie not Chantix) shown to be an effective smoking cessation aid.
Nortriptyline
A mother brings her 5-year-old son to the Swift River office for evaluation of attention-deficit/hyperactivity disorder (ADHD). His third-grade teacher reports that he has trouble sitting still and paying attention in class.
What is the next best step in treatment?
Parent training behavioral management programs should be used before medication in children under age 6.
A 30-year-old unmarried male reports nervousness all the time, irritability at home, trouble concentrating, tense muscles in his neck and shoulders, and headaches. He says, “I cannot shut my mind off” at night. He also reports intermittent upper abdominal pain that he has tried to treat with over-the-counter famotidine (Pepcid). He drinks 2–3 beers a week and does not use recreational drugs. He works as an Assistant (to the) Regional Manager and says he has been worried about his job over the last year (there's been a recent bear outbreak in his town). His concerns started gradually after a different supervisor named Jimothy was assigned to his department. Despite having received a good annual performance evaluation 6 months ago and an amazing beet farm, he says he now worries constantly that he is not doing a good job.
What is the diagnosis and how long must symptoms be present to make said diagnosis?
GAD; 6 months
A 72-year-old male sees you for a routine follow-up visit. His medical history includes Parkinson’s disease, hypertension, and hypercholesterolemia. His current medications are carbidopa/levodopa (Sinemet), 25/250 mg 3 times daily; lisinopril/hydrochlorothiazide (Zestoretic), 10/12.5 mg daily; and lovastatin, 40 mg daily.
The patient’s wife is with him and reports that he has seemed more depressed over the past month, with decreased appetite and a loss of interest in some of his hobbies, including reading. His vital signs are normal. A physical examination is notable for a pill-rolling tremor at rest, mask-like facies, bradykinesia, and mild cogwheel rigidity of the upper extremities. His Geriatric Depression Scale–15 score is 7.
What antidepressant would be preferred for this patient?
Venlafaxine (Effexor XR)
You are treating a 53-year-old female for her first episode of moderate major depression. Her initial PHQ-9 score was 16. After 6 weeks of antidepressant treatment at a therapeutic dosage all depressive symptoms have resolved. She is not experiencing any medication-related side effects.
Evidence suggests that after achieving symptom remission this patient should continue antidepressants for at least an additional...
4-9 Months (though most recommend at least 6 months)
A 63-year-old male presents for advice on smoking cessation. He was recently hospitalized with acute coronary syndrome and is highly motivated to quit smoking. He says that he has quit several times in the past but never for an extended period of time. He currently smokes 20 (1 pack) cigarettes per day. He would prefer to utilize nicotine replacement patches exclusively to quit smoking.
What is the preferred treatment schedule for the patient's preferred method of smoking cessation?
21 mg for weeks 1-6
14 mg for weeks 7-8
7 mg for weeks 9-10
A 24-year-old female presents with intermittent dizziness, muscle cramps, occasional abdominal cramps, and irregular menses for the last year. She tells you that she started exercising daily 6 months ago to lose weight and improve her appearance. She is currently attending law school and does not smoke, drink alcohol, or use drugs, and does not take oral contraceptives because she is not sexually active. She says that she has not been skipping meals in order to lose weight, and that she sometimes eats more than she should. On examination her BMI is 23 kg/m2, her blood pressure is 90/60 mm Hg, and her pulse rate is 84 beats/min. You note calluses on the dorsal aspect of her right hand, but no other skin lesions. Laboratory findings include a hematocrit of 42% (N 37–47), a serum sodium level of 134 mEq/L (N 136–145), a potassium level of 2.9 mEq/L (N 3.4–4.4), and a normal TSH level. Screening with the PHQ-4 is negative.
What is first line treatment?
Cognitive-behavioral therapy
You are evaluating a 13-year-old female with a 3-month history of headaches, abdominal discomfort, difficulty sleeping, and increasing nervousness. She has always been a good student but her symptoms have resulted in increased absence from school. A physical examination and laboratory findings are normal. There is no history of bullying, abuse, or alcohol or drug use.
What is the first line Tx AND what percentage of children experience this Dx?
CBT; Anywhere from 5-32% based on the population studied
A 56-year-old female is diagnosed with major depression. Her past medical history is notable for well controlled type 2 diabetes and a history of breast cancer 6 months ago that was treated with segmental mastectomy followed by breast irradiation. Her current medications are metformin (Glucophage), 500 mg twice daily, and tamoxifen (Soltamox), 20 mg daily.
What antidepressant(s) should be AVOIDED in this patient?
Paroxetine and fluoxetine are strong inhibitors of CYP2D6 and have been shown to decrease tamoxifen’s conversion to endoxifen.
You are treating a 32-year-old female named Jackie for her first episode of major depression after holding down an entire hospital team by herself. She has been adherent to her medication regimen and has been asymptomatic for 12 months. She would like to stop her antidepressant.
Which medication carries the lowest risk of serotonin withdrawal symptoms and which carries the highest?
Lowest: Fluoxetine (3 wk half life)
Highest: Paroxetine (~21 hrs half life)
A 23-year-old male with opioid use disorder requests buprenorphine therapy. He is still actively using immediate-release oxycodone (Roxicodone) and he took a dose 2 hours ago. When should this patient begin buprenorphine induction?
8-12 hours after last opioid use
In a patient comes to you concerned that he may have Bipolar disorder because his mother carries a diagnosis of Bipolar disorder. What is the percentage chance this patient may have inherited the disease?
4-15%
A 24-year-old male presents with insomnia and says he is “not able to shut his mind off at night.” He asks for a refill of alprazolam (Xanax) prescribed by another physician, whom he calls "McDreamy". He has had problems with anxiety since late childhood and has had several impairing depressive episodes that tend to be more severe during the winter months. He does not drink alcohol or use recreational drugs. His mother has had similar symptoms for 15 years.
What is the most appropriate next step?
Administer the Mood Disorder Questionnaire (MDQ)
A 71-year-old male is diagnosed with major depression. He also has severe degenerative arthritis of the back and knees, managed with chronic NSAID therapy.
What antidepressant class increases bleeding risk and should be AVOIDED in this patient?
Sertraline (Zoloft)
During a health maintenance visit, a 32-year-old female asks you about discontinuing her antidepressant. She has been taking fluoxetine (Prozac), 20 mg daily, for the last year and has been in remission for the last 8 months. This is her first episode of MDD. Her PHQ-9 score at this visit is 3.
What is the likelihood of recurrence?
> 50%
A 17-year-old male is brought to your clinic by his father due to declining school performance. A brief history leads you to screen the son for alcohol misuse.
What tool can be used to screen adolescents for BOTH alcohol and drug abuse?
The CRAFFT screen
A 32-year-old female informs you that she and her husband have decided to have a child. She was diagnosed with major depression 3 months ago but it has been well controlled with paroxetine (Paxil). She also had an episode of major depression 10 years ago that also responded to paroxetine. She would like to continue taking the paroxetine during her pregnancy.
What defects are linked to this antidepressant?
Studies have consistently linked paroxetine to an increased risk of ventricular and atrial septal defects. It is considered a pregnancy category D medication, so a treatment change would be indicated in this situation. A few studies suggest a slight association between citalopram use in pregnancy (pregnancy category C) and an increased risk of major congenital musculoskeletal malformations and craniosynostosis.
A 55-year-old female is diagnosed with mild depression. Her PHQ–9 score is 11. She states that she would rather not take prescription drugs and prefers an alternative treatment.
What nonpharmacologic therapy has the best evidence for treatment of depression?
Exercise
An 82-year-old female presents with a 3-month history of sadness, anorexia, a 6-lb weight loss, and insomnia. She has no history of cognitive impairment. Her medical history is notable for hypertension, hypothyroidism, and stent placement following an ST-elevation myocardial infarction 3 years ago. She had one episode of heart failure shortly after her myocardial infarction but none since. Her current medications include lisinopril (Prinivil, Zestril), 10 mg daily; spironolactone (Aldactone), 25 mg daily; metoprolol succinate (Toprol-XL), 25 mg daily; levothyroxine (Synthroid), 50 µg daily; and aspirin, 81 mg daily. Her TSH and electrolyte levels were normal 6 months ago. Her last mammogram and colonoscopy were at age 80 and she has declined further cancer screening.
A physical examination reveals an anxious, frail-appearing female, with a BMI of 19 kg/m2. Her blood pressure is 150/80 mm Hg. She is alert and oriented to person, place, and time. An EKG shows normal sinus rhythm, a PR interval of 0.24 sec, and incomplete right bundle branch block with a QTc of 0.43 seconds. Her PHQ-9 score is 15.
What is first-line treatment for this patient’s depressive symptoms?
CBT