When should you stop an SSRI trial for depression due to lack of efficacy?

30 yo woman with generalized anxiety disorder presents in her first major depressive episode. She is depressed, hopeless, sleeping poorly, exhausted, and losing weight (6 pounds in the last month). She has never taken psychiatric medications before. She would like to try a medication to treat both depression and anxiety (so bupropion is out).  You prescribe …

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How do you manage the side effects of SSRIs?

What do you do when a patient taking an SSRI presents with anorgasmia, bruxism, or hyponatremia? Firstly – believe your patient. Your 60 yo may experience an increase in suicidal thoughts even though the textbook says that she shouldn’t. In general, your options for managing side effects from medication are: The balance between the medication benefits …

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How do you evaluate for bipolar disorder in depressed patients? 

Olivia is a 19 yo woman who presents to primary care during her first major depressive episode. She feels depressed every day with a deep sense that she will always be a failure. She can’t concentrate well enough to read anymore, though she can follow short TV shows. She has low energy and wakes up every morning at …

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How do you get started with patients with chronic pain?

Dr. Link is a 35-year-old primary care physician, who recently joined an academic faculty practice in a new city. Today, she is seeing Martha, a 70-year-old woman, who has been cared for by this clinic for >10 years. She has chronic pain in her back from osteoarthritis, diabetes (A1c 7.5), obesity, depression, hypertension, and sleep …

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Getting into the holiday SBIRT: how do you help patients cut back on drinking?

You met Ivy two years ago. Your clinic had just implemented universal screening for unhealthy alcohol use as per the 2018 USPSTF recommendation using the National Institutes on Alcohol Abuse and Alcoholism (NIAAA) single item screening question “How many times in the past year have you had *** (4 for women, or 5 for men) or more …

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How do you taper long-term benzodiazepines?

We return to Mr. Davis, a 75-yo man who has taken temazepam 30mg at bedtime for 15 years for insomnia. He recently fell and fractured his wrist. You discussed the risks and benefits of continuing vs stopping temazepam and the rationale for tapering the medication as described in the prior PsychSnap. Mr. Davis decides to move forward …

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How do you counsel an older patient about the risks of benzodiazepines?  

Mr. Davis is a 75-year-old man with a history of hypertension, type 2 diabetes (A1c 6.8), and insomnia. He recently moved to be closer to his grandchildren and is establishing primary care with you. His medications are amlodipine 10 mg daily, metformin 500 mg twice daily, semaglutide 1 mg weekly, atorvastatin 40 mg daily, and …

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Beyond seasonal depression: how can bright light therapy be used in the management of mood disorders?

Michelle is a 45 yo woman with a history of recurrent major depression. She took several antidepressants in her 20s that were either intolerable (escitalopram) or ineffective (sertraline, venlafaxine). She has been taking fluoxetine 20mg for many years, which she says “puts a floor” on her depression. Higher doses of fluoxetine make her feel too activated. She …

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How do you talk with patients about their substance use?

You log in to Zoom for the morning clinic video visits and meet Zeke, a 28 yo man without much medical history, here to establish care with you. As he’s sharing his daily routine, Zeke says that after work–he’s a 4th grade teacher–he comes home so overwhelmed with what’s going on for his students that …

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The opinions expressed in PsychSnaps do not necessarily represent the views and opinions of the University of California, San Francisco. The opinions in PsychSnaps should not be used as a substitute for medical advice from a qualified, board-certified practicing clinician.