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By Neuroscience Education Institute

ISBN-10: 1422500128

ISBN-13: 9781422500125

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Risk of depression is highest for women during: A. Pregnancy and postpartum B. Postpartum and perimenopause C. Perimenopause and menopause D. Pregnancy and menopause 7. Alan and Henry are identical twins who both suffer from major depressive disorder. They were both started on the same antidepressant; Alan achieved remission with this first medication trial, while Henry achieved remission with his third medication trial. What is true regarding the risk of relapse for these two patients? A. Alan has a greater risk of relapse C.

If you think you know what you’re looking for, think again. Am J Nursing 2006;83(2):372-89. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed. Text rev. Washington, DC: American Psychiatric Association; 2000. Stahl SM. Stahl’s essential psychopharmacology. 3rd ed. New York, NY: Cambridge University Press; 2008. Stahl SM. Stahl’s essential psychopharmacology: the prescriber’s guide. 3rd ed. New York, NY: Cambridge University Press; 2009. Steinman LE, Frederick JT, Prohaska T et al.

Lithium (to boost mood and mitigate the risk of cycling) Monoamine oxidase inhibitor (MAOI) (to boost mood) Mirtazapine (to boost mood and possibly treat anxiety) Quetiapine (to boost mood and possibly treat anxiety) Aripiprazole (to boost mood) None of these Clinician’s Notes • Lithium • Could help boost her mood and mitigate the risk of future relapse • If added, it may not be necessary to give her a full dose, as she is already on other mood-stabilizing medications • MAOI • May help boost mood, as this has been effective for patients with anxious depression • However, this could also be activating for some patients and could cause problems with sleep and anxiety • If added, a MAOI would require the discontinuation of bupropion • Transdermal selegiline does not require dietary restriction and may be a preferable formulation • Mirtazapine • May boost mood and potentially treat anxiety • Quetiapine • May boost mood (recently approved for the depressed phase of bipolar disorder and as an adjunct for unipolar depression) • May also be helpful for anxiety (anecdotal reports as adjunct) • If added, it may require careful dosing to avoid daytime sedation • Aripiprazole • May boost mood (recently approved as an adjunct for unipolar depression) • Can be activating and can cause problems with anxiety Case Outcome • 24 The patient is encouraged to switch from bupropion to mirtazapine, but she opts instead to try aripiprazole augmentation of her current medications (bupropion, lamotrigine, gabapentin, methylphenidate) while switching off of ziprasidone The Case: 44-Year-Old Woman With Treatment-Resistant Anxious Depression and Comorbid Sleep Disorder • • • • • • Aripiprazole is titrated from 2 mg/day to 5 mg/day while ziprasidone is discontinued; over the course of one month, there are no changes, good or bad Aripiprazole is increased to 10 mg/day and there is some improvement over the next four weeks After a second month on aripiprazole, there is no further improvement in depression or anxiety and overall results are not satisfactory She is switched from aripiprazole to quetiapine; she does not experience improvement in mood or anxiety, but her sleepiness worsens She is offered a trial of mirtazapine or a MAOI, but she says she would rather consider TMS or another round of ECT Her insurance does not cover TMS, so she will go for another round of ECT and consider a MAOI afterwards Case Debrief • • • • The patient has a 25-year history of recurrent anxiety and depression that appears unipolar in nature and has been somewhat responsive to antidepressants and very responsive to ECT in the past Her current relapse is causing her disability and is not fully responsive to the various medication regimens that have been tried Because of her prior response to ECT, she may be an excellent candidate for VNS or TMS, but insurance coverage is preventing the use of these options She may experience benefit from this next course of ECT; additional adjustments to her medications may also be helpful, including trial of a MAOI Take-Home Points • • • It can be difficult to determine whether sleep-related problems (insomnia or anxiety at night, daytime sleepiness) are due to a sleep disorder, an anxiety disorder, a mood disorder, or the side effects of medications Simplifying a complicated medication regimen may help determine whether some of the symptoms are due to medications In addition to medications, there are alternative options for patients with resistant depression, but it may be difficult to get insurance approval for some of the more novel approaches Performance in Practice Assessment • What could have been done better here?

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