Which one of the following statements is true regarding the use of light therapy to treat seasonal affective disorder?
Correct Answer A:
Light therapy generally is most effective when administered in the morning. Early morning light helps regulate the circadian pattern of melatonin secretion, whereas light in the evening can delay the normal melatonin phase shift. The dosage of light therapy most often found to be effective is 5000 lux daily. This can be given as 2500 lux for 2 hours or 10,000 lux for 30 minutes. Like drug therapy for depression, light therapy does carry a risk of precipitating mania. Patients should be instructed to use light therapy units that are specifically designed for treatment of seasonal affective disorder. Other light sources may not provide adequate brightness or ultraviolet light filtration.
A 43-year-old female secretary is followed by her psychiatrist for recurrent annual depressive episodes. She recently watched a special on the local public television channel about seasonal affective disorder (SAD) and is inquiring what causes this condition.
The correct response would include each of the following, except:
Correct Answer D: Diminished appetite is not typical of SAD. In fact, carbohydrate craving is common for winter SAD. The theories regarding SAD are numerous, emanating from observation, clinical research, and patient intuition. The incidence of pure SAD is much higher in the northern latitudes, resulting in an interest in the seasonal variations of sunlight exposure and temperature as possible causes. The administration of melatonin can cause relapses in patients with SAD. The most accepted theory as to the etiology of SAD involves serotonin. The more common successful treatments for SAD affect serotonin in some way. These include the selective serotonin reuptake inhibitors (SSRIs) and light therapy.
Which one of the following is least likely to cause discontinuation syndrome if stopped abruptly?
Stopping an SSRI, or forgetting doses, can cause a discontinuation syndrome with a range of symptoms including asthenia, anxiety, agitation, GI distress, myalgias, or a sensation of “electrical shocks” through the arms and legs. The likelihood of the discontinuation syndrome occurring is inversely proportional to the half-life of the medication and the presence of active metabolites.
Fluoxetine is the least likely of the drugs to produce a discontinuation syndrome on abrupt cessation of use, due to both its long half-life (4-6 days) and a long-acting metabolite (t1/2: 4-16 days). Paroxetine has the shortest half-life (21 h) and therefore is most likely to cause symptoms.
Sertraline and citalopram have intermediate half-lives (26 h and 35 h respectively) and sertraline has an active metabolite (t1/2: 21/2-41/2). These agents have an intermediate likelihood of precipitating discontinuation symptoms.
At a routine follow-up visit, a 30-year-old male with depression that has been well-controlled for 12 months on extended-release paroxetine (Paxil) discusses stopping the medication because of delayed ejaculation that has become more problematic. He calls your office 5 days later because of a 3-day history of influenza-like symptoms, insomnia, nausea, and dizziness, which were moderately severe initially but are now improving.
Which one of the following would be most appropriate at this time?
This patient has developed antidepressant discontinuation syndrome. Proposed criteria for SSRI discontinuation syndrome include the presence of anxiety, diarrhea, dizziness, fatigue, gait/balance disturbance, gastrointestinal upset, hyperarousal, insomnia, instability, lightheadedness, paresthesia, tremor, vertigo and visual disturbance. Two or more of these must be present within 7 days of discontinuation of an SSRI after at least 6 weeks' use.
→ Because this patient’s symptoms are resolving quickly, it is unlikely to be influenza and does not warrant hospitalization.
→ The patient could restart the SSRI, but if this were a relapse of his depression the symptoms would not be resolving.
→ Doubling the dosage of the medication is inappropriate because the patient was doing well on the original dosage, and the symptoms do not indicate worsening depression (no need for hospitalization).
A 23-year-old man who is struggling with finishing college is diagnosed with schizophrenia. He eventually drops out of college and loses contact with his family. He is found 5 years later living in a homeless shelter.
This illustrates the concept of:
The downward drift hypothesis is based on the belief that persons with mental illness tend to drift into a lower socioeconomic class because their illness interferes with skills needed to maintain a higher socioeconomic status. There is a slow drift downward as living skills become more and more impaired.
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