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How do you counsel patients about taking medications for depression during pregnancy?

Sophia is a 33-year-old woman with a history of major depressive disorder (MDD). She is currently euthymic and taking sertraline 100mg daily. She has had 3 lifetime severe major depressive episodes and has taken sertraline on and off for the past 13 years. She has never participated in psychotherapy. During your most recent visit, she tells …

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How do you talk with patients about suicidal thoughts and behaviors?

David is a 60 yo man with chronic pain on opioids, PTSD, alcohol use disorder, and major depression, who was introduced in our last PsychSnap. He calls his primary care clinic every few weeks saying that he is going to kill himself if his pain isn’t better controlled. He now presents to a routine follow-up …

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Can suicide risk assessments prevent your patients from dying by suicide?

David is a 60 yo man with a history of chronic low back from severe disc disease on long-term opioids, PTSD, alcohol use disorder, and major depression. After his husband died 30 years ago, he tried to kill himself twice by hanging and was psychiatrically hospitalized for severe depression after each attempt. Since that time, he …

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What treatments help patients stop using methamphetamine?

Carter is a 41 year old man who comes to see you for a routine follow-up visit. He previously used cocaine on nights out with friends. Today, Carter tells you that he stopped using cocaine entirely because he found something better: crystal (methamphetamine). For the last year, he has used a little bit of crystal …

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How do you navigate chronic delusions to provide effective medical care?

Ms. Wren, an 80-year-old woman with heart failure and diabetes, was recently hospitalized for a heart failure exacerbation. She has been on your panel for a year, but you have not met her. The inpatient notes describe her as having chronic fixed paranoid delusions of a man who follows her and occasionally threatens to kill …

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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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