A 42-year-old man is admitted to a psychiatric ward and gives a six-month history of severely depressed mood, loss of appetite and weight, insomnia, and auditory hallucinations commanding him to hang himself. While on the ward, he spends his time joking and socializing with other patients, smoking heavily, eating double portions, and sleeping soundly without hypnotic medication. Despite this, he continues to complain of hallucinations and a severely depressed mood, and states he will kill himself if discharged. It is noted that he is homeless, that the weather has been unseasonably cold recently, and that he admits he does not care to live in homeless shelters, citing how dangerous they can be.
What would be the most appropriate option for management of this patient?
Correct Answer B:
The Minnesota Multiphasic Personality Inventory assesses a wide range of personality variables, and also rates responses on a “lie scale”, an “infrequency scale”, and a “suppressor scale”, which can be useful in identifying malingering. It would not make a final determination of the patient’s degree of truthfulness, but would provide supporting evidence.
A. Patients taking MAOIs must be reliable in following certain dietary restrictions. Since there is some question as to this patient’s reliability, an MAOI would be inadvisable.
C, D & E. These would be risky and questionable ethically. Nicotine withdrawal particularly is extremely uncomfortable - even genuinely ill patients may leave the hospital if smoking is denied them.
Each of the following patients comes to your office asking if they can stop their medications.
Which patient would you feel most comfortable tapering off the medication mentioned?
This is a case where you should actively be working with the patient to eventually stop the antipsychotic. The psychotic symptoms should resolve once the condition is adequately treated with an antipsychotic. Usually the patient can be tapered off the haloperidol fairly quickly while continuing on the antidepressant. The risk of tardive dyskinesia is reduced by using the antipsychotic for as short a time period as possible, and using an atypical antipsychotic whenever possible.
A. Most bipolar patients will require indefinite treatment with a mood stabilizer to prevent future episodes. If this is not done, it is believed that a “kindling phenomenon” occurs. This refers to the observation that future episodes will occur with progressively less time between them, more severe symptoms, and less of a response to treatment.
C. This patient is at higher risk for a recurrence of symptoms since stabilization of mood is not sufficient to prevent psychosis.
D. His treatment may be more necessary if his stress level is about to increase.
A 49-year-old male presents with depressed mood that has been going on for 6 months now. He has lost interest in the things he used to enjoy, feels sleepy all the time and skips work frequently. He admits that this mood change impairs his ability to function daily. The patient is taking phenelzine (2 months) but does not see any improvement. You would like to switch it to paroxetine.
What is the safest way to do it?
Before changing the therapy from phenelzine to paroxetine, two weeks wash out time should be allowed in order to prevent the adverse effects of serotonin accumulation. If caution is not taken while changing the anti-depression therapy it may result in serotonin syndrome. Both phenelzine (MAOI) and paroxetine (SSRI) are serotonin increasing agents; it results in accumulation of the levels of serotonin, which on the other hand would increase risk of psychosis.
You are asked to see a 60 year old man with a history of recurrent depression who has failed to respond to several second-generation antidepressants. You are considering a trial of a tricyclic antidepressant.
What is the most relevant investigation to perform prior to initiating this treatment?
Correct Answer C:
When using a tricyclic antidepressant, it is important to consider that the central nervous system and heart are the two main systems that are affected in toxicity. Initial or mild symptoms include drowsiness, a dry mouth, nausea, and vomiting. More severe complications, include hypotension, cardiac rhythm disturbances, hallucinations, and seizures.
Electrocardiogram (ECG) abnormalities are frequent and a wide variety of cardiac dysrhythmias can occur, the most common being sinus tachycardia and intraventricular conduction delay (QRS prolongation). Seizures and cardiac dysrhythmias are the most important life threatening complications.
Activated charcoal is ineffective for the treatment of acute ingestions of which one of the following?
Activated charcoal is widely used for gastrointestinal decontamination following drug overdose. There is no evidence to support or exclude its use more than 1 hour after the ingestion, however, and potential complications such as aspiration should be weighed against benefits. It is given orally or via nasogastric tube at a recommended dose of 1 g/kg body weight. Charcoal absorbs >90% of most toxins in vitro if the amount used is ten times the amount of the toxin. The charcoal-toxin complex is later evacuated in the stool. However, charged (ionized) chemicals and dissociated salts such as iron, lithium, fluoride, cyanide, mineral acids, alkalies, and some other inorganic compounds are poorly absorbed by charcoal. Even multiple-dose therapy is not effective in the treatment of poisoning due to these agents. For toxic iron ingestions useful treatments include gastric evacuation with ipecac or lavage, whole bowel irrigation with polyethylene glycol, and chelation with deferoxamine.
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