What medication could you add to a dose-optimized SSRI to help with anxiety?

Your patient is a 44 yo man with a mild radiculopathy from an old basketball injury and severe generalized anxiety disorder. He previously responded to trials of sertraline 100mg daily and venlafaxine XR 150mg daily, but both caused significant sexual side effects.  He stopped each of the medications after a year when he was feeling …

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Is this physician experiencing burnout or something else?

A 35-year-old intensivist feels powerless and guilt-ridden. At times, her senses are heightened, and at other times, she feels numb. Sometimes when she is speaking with patients’ family members, she feels like she is no longer present in her body.  She currently has a patient who is dying of liver failure, and despite multiple phone …

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Coke and Subs: Is Suboxone maintenance for opioid use disorder contraindicated in someone with cocaine on urine screen?

Joe is a 42M who comes to see you to establish care after moving for work. He has a history of HTN, chronic pain from hand injuries at work, and opioid use disorder (OUD) maintained on buprenorphine-naloxone (SuboxoneⓇ, often referred to as “subs”) 16mg-4mg twice a day without any un-prescribed opioid use. He is a …

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Does this patient’s history of binging and purging make it unsafe to start bupropion?

Your patient is a 25 yo woman in a current major depressive episode. She was treated with escitalopram first, and then switched to sertraline. Each medication helped her depression and caused anorgasmia, which caused her to stop them.  She is moderately depressed, and wants to know if there is anything that she can take for depression that …

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How long should a patient with recurrent major depressive disorder continue their antidepressant?

Your patient is a 40 year old woman with a history of recurrent major depressive disorder. When she presented initially, she was feeling low, with decreased motivation, poor concentration, low energy, trouble sleeping, and thoughts of death. She had no plans to hurt herself. You referred her to therapy and started escitalopram, titrated to 10mg daily. At …

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Which SSRI should I choose?

What follows is a brief summary of the clinically important differences between the SSRIs, followed by 5 patient cases that ask, “Which SSRI?”   The five SSRIs most commonly used in the US for depression and anxiety are fluoxetine, paroxetine, sertraline, citalopram, and escitalopram.  The sixth SSRI, fluvoxamine, is mainly used to treat OCD.   All …

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What change could reduce anxiety in a patient with partial benefit from an SNRI?

A 62 yo woman has a history of chronic pain from osteoarthritis, severe sciatica, recurrent major depression, generalized anxiety, and insomnia. She takes chronic low-dose opioids for pain and an SNRI (duloxetine, titrated to 60mg BID) for pain, depression, and anxiety, with moderate improvement in pain and depression and mild improvement in anxiety.   She currently …

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What medication is FDA approved to help people drink less?

A 55-year old woman with a history of atrial fibrillation, cirrhosis from Hepatitis C, and at-risk alcohol use presents to the clinic for follow up. She takes her metoprolol and apixaban regularly. She has noticed occasional fatigue and nausea in the morning. You ask her about alcohol use. She says that with recent work stress …

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What caused low energy in a patient whose other depressive symptoms were improving with escitalopram?

One year after the death of her spouse, a 75 yo woman with hypertension on hydrochlorothiazide presents in a first major depressive episode with prominent neurovegetative symptoms (difficulty sleeping, low appetite with a 10lb weight loss, low energy, mild psychomotor retardation).  You start her on escitalopram 2.5mg for 1 week, then increase to 5mg, and …

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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.