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  #1  
Old 06-27-2012
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Drug Depression Management; Sertraline did not work!

A 70-year-old woman is evaluated because of depressed mood, anhedonia, decreased appetite, impaired sleep, and decreased energy. Although the patient feels somewhat hopeless about the future, she adamantly states that she would never take her own life. Her judgment appears intact. Medical history is unremarkable, and she has not had previous episodes of depression. She is taking no medications. Findings on physical examination and laboratory evaluation, including thyroid function testing and vitamin B12 measurement, are unremarkable.
Sertraline, 50 mg/d, is begun. The patient returns for a followup visit 5 weeks later and reports that she is tolerating the
medication well but has no significant change in symptoms, which is validated with a standardized symptom assessment
tool. The sertraline is therefore increased to 100 mg/d. Six weeks later, she again reports no side effects and no
improvement.
Which of the following is most appropriate at this time?
(A) Add methylphenidate
(B) Discontinue sertraline and begin citalopram
(C) Reassess in 4 weeks
(D) Refer for electroconvulsive therapy
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  #2  
Old 06-27-2012
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I tried order of elimination and came up to D.

ECT for unresponsive cases & for pts who cant tolerate regular drug tx
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Old 06-27-2012
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may be D........?????
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Old 06-29-2012
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(A) Add methylphenidate
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Old 06-29-2012
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..........B?
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Old 06-29-2012
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Quote:
Originally Posted by neoeinstein View Post
..........B?
Switching to same class of AD does not work.

Addition of Methylphenidate is controversial.

Reassessing in 4 weeks is not going to help.

So, the answer is (D) Refer for electroconvulsive therapy

Quote:
ECT should be considered for patients with severe major depressive disorder that is not responsive to psychotherapeutic and/or pharmacological interventions, particularly those with significant functional impairment who have not responded to numerous medication trials

Last edited by Novobiocin; 06-29-2012 at 06:46 PM.
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Old 06-29-2012
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Quote:
Originally Posted by Novobiocin View Post
Switching to same class of AD does not work.

-UTD 19.3

and MTB3 2nd Ed too p.473


Maybe if the pt has suicidal tendencies or psychotic features, I will choose ECT

Last edited by neoeinstein; 06-29-2012 at 07:08 PM.
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Old 06-30-2012
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Quote:
Originally Posted by neoeinstein View Post

-UTD 19.3

and MTB3 2nd Ed too p.473


Maybe if the pt has suicidal tendencies or psychotic features, I will choose ECT
Ans is b. Nice expln.

There is another question in which patient was not showing response to ssri and and was to add Li/thyroxine. Can't remember it clearly
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Old 06-30-2012
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Successful treatment of depression often requires more than one medication.

Quote:
The Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial treated more than 4000 depressed patients at multiple sites. Initial treatment with the SSRI citalopram alone achieved a 30% remission rate. Random assignment of treatments to nonresponders at multiple steps eventually resulted in remission in approximately two thirds of patients. There was no difference whether inadequate responders were randomized to receive a different SSRI, a non-SSRI antidepressant, a combination of two antidepressants, augmentation with lithium or thyroxine, or cognitive therapy. These results suggest that depression is similar to chronic medical disorders in which multiple treatments may be equally effective, and monitoring outcomes and adjusting therapy are
essential to optimizing outcomes.
http://psychiatryonline.org/data/Boo...ssion3rdEd.pdf

Quote:
A number of strategies are available when a change in the treatment plan seems necessary. For patients treated with an antidepressant, optimizing the medication dose is a reasonable first step if the side effect burden is tolerable and the upper limit of a medication dose has not been reached [II]. Particularly for those who have shown minimal improvement or experienced significant medication side effects, other options include augmenting the antidepressant with a depression-focused psychotherapy [I] or with other agents [II] or changing to another non-MAOI antidepressant [I]. Patients may be changed to an antidepressant from the same pharmacological class (e.g., from one SSRI to another SSRI) or to one from a different class (e.g., from an SSRI to a tricyclic antidepressant [TCA]) [II]. For patients who have not responded to trials of SSRIs, a trial of an SNRI may be helpful [II]. Augmentation of antidepressant medications can utilize another non-MAOI antidepressant [II], generally from a different pharmacological class, or a non-antidepressant medication such as lithium [II], thyroid hormone [II], or a second-generation antipsychotic [II]. Additional strategies with less evidence for efficacy include augmentation using an anticonvulsant [III], omega-3 fatty acids [III], folate [III], or a psychostimulant medication [III], including modafinil [III]. If anxiety or insomnia are prominent features, consideration can be given to anxiolytic and sedative-hypnotic medications [III], including buspirone, benzodiazepines, and selective γ-aminobutyric acid (GABA) agonist hypnotics (e.g., zolpidem, eszopiclone). For patients whose symptoms have not responded adequately to medication, ECT remains the most effective form of therapy and should be considered [I]. In patients capable of adhering to dietary and medication restrictions, an additional option is changing to a nonselective MAOI [II] after allowing sufficient time between medications to avoid deleterious interactions [I]. Transdermal selegiline, a relatively selective MAO B inhibitor with fewer dietary and medication restrictions, or transcranial magnetic stimulation could also be considered [II]. Vagus nerve stimulation (VNS) may be an additional option for individuals who have not responded to at least four adequate trials of antidepressant treatment, including ECT [III]

Last edited by Novobiocin; 06-30-2012 at 08:20 AM.
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Old 06-30-2012
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