depression

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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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 choose an antidepressant?

You see a 24 yo woman in a severe major depressive episode and offer her sertraline and a referral to therapy. After the visit, the medical student rotating with you asks why you chose sertraline for this patient. He follows with, “I guess I’m asking…how do you choose an antidepressant?” You answer his question in three …

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How can we help depressed but not (majorly) depressed patients?

Eric is a 60 year old man presenting with a depressed mood, low energy, and low appetite for the past 2 months. He notes increasing conflict with his partner, but no anhedonia, insomnia, difficulty concentrating, or thoughts of worthlessness or suicide. A year ago, he experienced a depressed mood and low energy for 2 months that …

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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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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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