A 42 year old man is diagnosed by his primary care physician as having major depressive disorder. The patient tells his physician that he is extremely concerned about his sexual performance, as he is worried that he is getting older and that he is having some marital difficulties with his wife.
Which of the following antidepressants would be the best choice for initial treatment?
Correct Answer A:
Bupropion is the antidepressant of the choices listed that has the fewest adverse sexual side effects. Selective serotonin reuptake inhibitors, such as fluoxetine, paroxetine , and sertraline are all known to be associated with erectile and orgasmic disturbances, such as delayed ejaculation and anorgasmia. Because imipramine also has effect on the serotonin levels in the brain, it too has sexual side effects, although to a somewhat lesser degree than the SSRIs.
A 25-year-old woman with a several year history of binging and purging presents to a psychiatrist complaining of a lack of energy, poor sleep, and decreased ability to concentrate. She is very concerned about weight gain.
Which of the following medications would be the most appropriate to initiate?
Correct Answer B:
This patient appears to have symptoms of major depression in the context of bulimia. She should therefore be treated with an antidepressant medication, and a selective serotonin reuptake inhibitor (SSRI), such as fluoxetine, would be most appropriate.
→ Bupropion is contraindicated in patients with a current or prior diagnosis of bulimia or anorexia nervosa because of a higher incidence of seizures.
→ Haloperidol is a typical antipsychotic agent, which is used primarily to treat schizophrenia.
→ Lithium is prescribed for bipolar disorder.
→ Valproic acid is an anticonvulsant and mood stabilizer, and is used to treat epilepsy, bipolar disorder, migraine headaches, mania, and behavioral problems associated with Alzheimer's disease or dementia.
Which of the following is correct about depression in children?
Depression among children and adolescents is common but frequently unrecognized. It affects 2 percent of prepubertal children and 5 to 8 percent of adolescents. The clinical spectrum of the disease can range from simple sadness to a major depressive, bipolar disorder or antisocial disorder. Risk factors include a family history of depression and poor school performance. Evaluation should include a complete medical assessment to rule out underlying medical causes. A structured clinical interview and various rating scales such as the Pediatric Symptom Checklist are helpful in determining whether a child or adolescent is depressed.
Psychotherapy appears to be useful in most children and adolescents with mild to moderate depression. Tricyclic antidepressants and selective serotonin reuptake inhibitors are medical therapies that have been studied on a limited basis. The latter agents are better tolerated but not necessarily more efficacious. Because the risk of school failure and suicide is quite high in depressed children and adolescents, prompt referral or close collaboration with a mental health professional is often necessary.
A 53 year old housewife presents with depression marked by early morning wakening, diminished energy and poor concentration. She is treated with supportive psychotherapy and Celexa (Citalopram) 20 mg. After two weeks she says she feels more energetic with no change in her mood.
You would next:
Depressive disorders are characterized by sadness severe enough or persistent enough to interfere with function and sometimes by decreased interest or pleasure in activities.
Treatment usually consists of drugs, psychotherapy, or both, and sometimes electroconvulsive therapy. Some people respond to antidepressant medication after about two weeks, but for most, the full effect is not seen until four to six weeks or longer.
By six to eight weeks after starting an antidepressant medication, it is usually possible to determine if the medication is effective. If the symptoms have improved somewhat during this time, the dose of the medication may be increased, or a second medication may be started. If there has been no improvement in symptoms, an alternate antidepressant medication may be recommended.
Celexa should be administered at an initial dose of 20 mg once daily, generally with an increase to a dose of 40 mg/day. Dose increases should usually occur in increments of 20 mg at intervals of no less than one week. Although certain patients may require a dose of 60 mg/day, the only study pertinent to dose response for effectiveness did not demonstrate an advantage for the 60 mg/day dose over the 40 mg/day dose; doses above 40 mg/day are not recommended because of risk for QT prolongation.
Which one of the following statements regarding antidepressant drug therapy is true?
Correct Answer C:
An adequate trial of antidepressant therapy is 4-6 weeks. Patients who are unresponsive to treatment may respond to another antidepressant with a different mechanism of action. Patients who are partially responsive may benefit from dosage titration or the addition of a second antidepressant in combination. Electroconvulsive therapy is the most effective treatment in patients with severe resistance to medical antidepressant therapy or those with psychotic depression.
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