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Patient Management Exercise For Major Depressive Disorder
B. Harrison Levine, M.D., M.P.H.; Ronald C. Albucher, M.D.
FOCUS 2005;3:27-33.
View Author and Article Information

CME Financial Disclosure
B. Harrison Levine, M.D., M.P.H., Department of Psychiatry, University of Michigan Health System

No affiliations with commercial supporters.

Ronald C. Albucher, M.D., Clinical Assistant Professor of Psychiatry, University of Michigan Medical School, and Assistant Chief, Psychiatry Service, Ann Arbor VA Health System

No affiliations with commercial supporters.

Disclosure of Unapproved, Off-label or Investigational Use of a ProductAPA policy requires disclosure by CME authors of unapproved or investigational use of products discussed in CME programs. Off-label use of medications by individual physicians is permitted and common. Decisions about off-label use can be guided by the scientific literature and clinical experience.

Copyright 2005 American Psychiatric Association

This patient management exercise is designed to test your comprehension of material presented in this issue of FOCUS as well as your ability to evaluate, diagnose, and manage clinical problems. Answer the questions below, to the best of your ability, on the basis of the information provided, making your decisions as you would with a real-life patient.Questions are presented at "decision points" that follow a paragraph that gives information about the case. One or more choices may be correct for each question; make your choices on the basis of your clinical knowledge and the history provided. Read all of the options for each question before making any selections.You are given points on a graded scale for the best possible answer(s), and points are taken away for answers that would result in a poor outcome or delay your arriving at the right answer. Answers that have little or no impact receive zero points. On questions that focus on differential diagnoses, bonus points are awarded if you select the most likely diagnosis as your first choice. At the end of the exercise you will add up your points to obtain a total score.

Abstract Teaser
Figures in this Article

You are in private practice in adult psychiatry. You receive a phone call from Mr. D, who says he was referred to you by a colleague and asks if you are taking new patients. You ask him what he is hoping for, and he responds that he is "extremely depressed," that he just fired his previous psychiatrist because he "said some things that really bothered me" and "tried to force medications on me when he knows I’ve been able to manage my depressions with just therapy." You ask if this doctor also managed his psychotherapy. He says yes, they worked together for about 2 years, but Mr. D stopped meeting with him more than a year ago. You suggest that he make an appointment to come in and meet with you. His voice becomes angry. "I’m depressed," he says. "I’m not able to do my work. I can’t think. I can’t concentrate. I’ve been a mathematics professor for 22 years and for the first time I can’t tell if I’m making any sense to my students. I don’t think I can get myself to class today." You hear him crying. "I can’t bear the idea of not doing my best and you want me to make an appointment?"

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Decision Point A

Given this presentation, what is your next step? (Select the best answer. Points are taken away for incorrect answers.)

  • A1.____Tell Mr. D you would like to help him, but his anger will not allow you to do your evaluation efficiently.

  • A2.____Tell Mr. D you would like to help him, but you need more information. The only way to accomplish this is to meet with him in person to perform a thorough evaluation. Right now you do not have any available time, but you will gladly see him early next week.

  • A3.____Tell Mr. D you would like to help him, but you need more information. You are too busy to see him this week but you can refer him to a colleague who may have time in the next few days.

  • A4.____Ask Mr. D if he is thinking about hurting himself, or perhaps killing himself. If he answers in the affirmative, refer him to the psychiatric emergency room.

  • A5.____Ask Mr. D if he feels as though he needs to be seen immediately, and if so, refer him to the psychiatric emergency room.

  • A6.____Tell Mr. D that he still has a treatment relationship with his former psychiatrist and that he should contact him for a follow-up appointment.

Mr. D goes to the psychiatric emergency room. You are now the attending psychiatrist on duty and meet Mr. D for the first time. On evaluation you learn that he is 55 years old and has been feeling "depressed" for at least 3 years. He was elected president of his local teachers union about a year ago but had to quit the position 1 month ago because of "stress" and because he felt he was "not able to do the job the way it should be done." He is unable to sleep through the night; he has trouble initiating sleep and has middle insomnia. When he wakes up at night, which he does several times, he takes about a half-hour, sometimes more, to fall back asleep. Sometimes he stays up and tries to read or watch television, but, he says, "I can’t follow anything. I can’t stop my mind from running." His appetite is poor and he has lost 15 pounds unintentionally in the past month. His energy is low, and he feels as though he is "mired in muck." He is especially anxious about teaching. For the past 8 years he has consistently won the Teacher of the Year award at his college. Teaching mathematics is "automatic" at this point for him, but he feels as though he is not doing his best. Before he enters the classroom, he first has to convince himself that he can get through the lecture, but he still feels as though he is not making sense. He admits that it is possible that he may be doing a better job than he thinks, but he cannot help feeling as though he is letting his students down. He wonders if he should take time off.

He reports that he has suffered two previous bouts of major depression, 10 years ago after he and his wife separated, and 4 years ago after a job promotion. He overcame both episodes with psychotherapy alone. He and his wife are opposed to taking medications of any sort, including acet-aminophen. "I don’t know what you are going to propose to me, but I want you to know that I’m very skeptical of medications, especially fluoxetine." He tells you that his general practitioner gave him a prescription for fluoxetine 10 mg daily, but he did not fill it for fear that it would make him want to kill himself. He has been reading articles lately on the dangers of antidepressants, and he does not trust the drug companies, the government, or psychiatrists to level with him about the drugs’ true risks.

He explains that his current depression reminds him of his previous two episodes of major depression, but now with more hopelessness and with suicidal ideation. "I know I don’t want to do something stupid," he says, "but I can’t get the thought out of my head." He admits to thinking about cutting his wrists and lying in a bathtub, shooting himself (he does not own a gun), and lying on railroad tracks. When he thinks about killing himself he feels "an adrenaline rush" because, he says, "I might go through with it, but it would devastate my family." He has been married for 25 years, and his wife has accompanied him to the psychiatric emergency room today. They have a son, 18, and a daughter, 22. You perform a Mini-Mental State Examination, and he scores 29/30, requiring prompting for recall.

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Decision Point B

Given what you have learned so far, what would you most likely do next? (Select all that apply. Points are taken away for incorrect answers.)

  • B1.____Ask Mr. D where he heard about fluoxetine. What does he know about it? Then explain that it is a safe medication and that you’ll give him some samples.

  • B2.____Tell him that you understand he is going through a great deal of stress right now with the teaching, the extra job he quit, and his worries about performance. Ask if there are any other issues that may be bothering him right now. Then tell him he has a more severe depressive disorder and this time he would respond best to medication and psychotherapy.

  • B4.____Ask him about alcohol and drug consumption.

  • B5.____Explore the issue of ECT. Tell him this is probably his best bet if he wants a more effective, cheaper treatment than a lifetime on antidepressant medications.

  • B6.____Acknowledge that he felt some relief after psychotherapy with his previous bouts of major depression, but tell him you could have predicted he would be back for more intensive help, since psychotherapy is not a long-term solution to depression. Remind him that 15%–20% of cases of untreated depression end in suicide.

  • B7.____If the patient acknowledges that this bout is indeed different—especially more severe than before—or if he feels “helpless,” gently suggest the availability of medications that are very effective against major depression.

After long discussions, the patient and his wife agree that the severity of the current depression warrants a trial of pharmacological treatment. You discharge him with clonazepam 0.5 mg, which he should take twice daily, and 1 mg at bedtime as needed, and you tell him to fill the prescription for fluoxetine written by his primary care physician. Mr. D agrees to return in 1 week for a bridging appointment.

As agreed, Mr. D returns 1 week later. He tells you that he feels a little relief from the clonazepam but has been cutting your prescribed doses in half, as they were too sedating for him. He still feels depressed, hopeless, and worthless and still feels as though he is just going "through the motions" when he teaches and as though he is somehow letting his family down. His thoughts of suicide got worse for a few days at the beginning of the week, and he had some mild stomachache, but his overall feeling has improved by now. He wonders if this fluoxetine is really going to work. He is also anxious to get started with a therapist, but it will be another 4 weeks before he can be seen by a therapist. He will have an appointment with his new psychiatrist in another 10 days.

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Decision Point C

Given the above information, what would you do next? (Select all that apply. Points are taken away for incorrect answers.)

  • C1.____Tell him you are not going to give him any more clonazepam, because you do not want him to become addicted to it. He will need his regular psychiatrist to give him more than a week’s worth.

  • C2.____Ask him if he has any other symptoms or side effects from the fluoxetine, and if not, suggest going up to fluoxetine 20 mg/day for now and make a bridging appointment for 1 week from today to meet with him one more time before his appointment with his new psychiatrist.

  • C3.____Tell him to finish out the prescription of clonazepam as you directed and say that you wouldn’t give him too much on purpose.

  • C4.____Tell him to take as little clonazepam as he likes. He won’t be hurt by taking smaller amounts. If he wants to take larger amounts, he should check with you first.

  • C5.____Agree with him that fluoxetine may not be working for him and tell him that there are many other antidepressants on the market. Provide him with literature on escitalopram and venlafaxine so he can make an informed decision.

  • C6.____Tell him to take some time off from work, as he probably will not be functioning at 100% until he makes a more complete recovery from his depression.

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Decision Point D

The patient’s therapist has many psychotherapeutic modalities from which to choose that may be useful in the treatment of major depressive disorder. The techniques and theories are individually defined for various purposes, including research and discussion. In practice, clinicians typically use a combination of techniques, depending on the patient’s individual situation and coping capacities. Choose which psychotherapy modality is most closely identified with the following concepts. Each concept may have one or more answers.

 
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Decision Point E

Which of the following drugs are required to carry a black box warning urging families and physicians to monitor patients for "clinical worsening, suicidality, or unusual changes in behavior"?

  • Clomipramine

  • Trazodone

  • Venlafaxine

  • Amitriptyline

  • Paroxetine

  • Fluoxetine

  • Buproprion

  • Sertraline

High positive scores (+3 and above) indicate a decision that would be effective, would be required for diagnosis, and without which management would be negligent. Lower positive scores (+2) indicate a decision that is important but not immediately necessary. The lowest positive score (+1) indicates a decision that is potentially useful for diagnosis and treatment. A neutral score (0) indicates a decision that is neither clearly helpful nor harmful under the given circumstances. High negative scores (−3 and above) indicate a decision that is inappropriate and potentially harmful or life-threatening. Lower negative scores (−2) indicate a decision that is nonproductive and potentially harmful. The lowest negative score (−1) indicates a decision that is not harmful but is nonproductive, time-consuming, and not cost-effective.

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Decision Point A

  • A1.−5 The patient is clearly angry and frustrated by his depression and his inability to work as he had done previously. Try to support his coming to you for help rather than adopting a paternalistic or defensive stance.

  • A2.−2 This response acknowledges the patient’s need for an appointment and his desire for help but not his frustration or his clearly fragile state.

  • A3.+2 As in answer A2, this response acknowledges the patient’s need for an appointment, and it also includes an attempt to facilitate an urgent appointment. However, since the patient is so emotionally labile, you should first explore whether he is in danger of hurting himself or others.

  • A4.+5 This is a totally appropriate next step given the patient’s frustration, his emotional lability, and his own acknowledgment that his mood and intentions are unpredictable.

  • A5.+3 A similar response to A4 without closed questions that define his safety level.

  • A6.−5 This is clearly not what Mr. D wants, and by brushing him off in this way you may harm the chances of other psychatrists’ forming a therapeutic alliance with him. You could later explore what went wrong in his previous treatment relationship, once the safety issues were properly managed.

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Decision Point B

  • B1.+1 You address one of his major concerns, but in your explanation of the safety of fluoxetine you may come across as forcing medications on the patient, which is precisely what drove him away from his previous psychiatrist.

  • B2.+3 This answer contains a wonderful reflection of the patient’s key stressors and current mental state, which helps establish and strengthen the therapeutic alliance. Before announcing that “the other doctor was right,” you should explore how nonpharmacological treatments were effective for the patient and how previous episodes differ from the current presentation.

  • B3.+5 Always a good question. If the patient is alone and does not have good social supports, his prognosis is much worse. His wife accompanied him, but it is never safe to assume a supportive marriage, especially given the history of a separation.

  • B4. +5 Always ask. Both illnesses need treatment, as one certainly affects the other.

  • B5.−5 ECT is known to have a higher rate of response in major depression than any other antidepressant treatment, especially in cases of moderate to severe depression that have not responded to pharmacological intervention. Approximately 50% of pharmacologically resis-tant depression will respond to ECT. The current method of applying this treatment is safe and effective. For this patient, because pharmacotherapy has not yet been tried and because the patient is still able to function, albeit with difficulty, ECT is not yet indicated—and even less so given his resistance to pharmacotherapy, which is somatically less invasive.

  • B6. −5 It is true that 15%–20% of untreated depression ends in suicide, but the patient was being treated with psychotherapy, so this statistic does not apply. Additionally, telling him you could have predicted that he would require more treatment is inappropriate and untrue, and it could hurt your therapeutic alliance. The patient already said he was put off by his previous physician’s being paternalistic.

  • B7.+5 Good approach to the patient, acknowledging his current severe and perhaps very different presentation than in previous depressions as a means of “gently” broaching the subject of medications. The next step would be a brief psychopharmacology education, since this is an intellectually motivated individual.

  • B8.+5 Again, this is appropriate once the patient is convinced that he should abandon the belief that he can overcome his depression without medications.

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Decision Point C

  • C1.−2 Since your disposition for this patient from the psychiatric emergency department included a bridging appointment to provide ongoing treatment and evaluation until he was able to make an appointment with a psychiatrist, you must be sure to refill his prescriptions as needed until another psychiatrist can take over the case. In this instance, you should find out how much clonazepam the patient has left and, if necessary, provide enough additional medication for another week. He is unlikely to become addicted to clonazepam with regular use during the first 2 weeks. Explain the potential for addiction, what the side effects of withdrawal are, and how withdrawal is treated.

  • C2.+2 This is a reasonable option with the caveat that his clonazepam prescription must also be covered as mentioned in C1.

  • C3.−2 If the clonazepam is helping him at the smaller dose, he should be encouraged to continue. He will not develop an addiction in such a short period given clonazepam’s long half-life and the small dose. However, insisting that a patient “trust you” because “you are his doctor” is paternalistic. While some patients respond well to this approach, this patient already stated that he does not like it when a physician pressures him to take medication, so this should be avoided. You should react to the patient’s questions as one who is allied with him such that you are working together in treatment.

  • C4.+3 Discuss the pros and cons of smaller versus larger doses of clonazepam. Find out precisely what symptoms he is experiencing, and make specific suggestions about how to adjust the dose so that he has a firm understanding of how to proceed. Educating him will help him make his own decisions and subsequently feel empowered in his own treatment. He made it clear to you that he prefers not to take medications if possible. In this case he is likely to feel more confident about pharmacotherapy if he understands the concrete evidence you provide, and he will probably be comforted by your obvious understanding of his concerns.

  • C5.−3 An adequate trial of an antidepressant, if there are no intolerable side effects, is 6 to 12 months. The onset of symptom relief will likely take 2 to 4 weeks in most individuals. Once you select an agent, you should stick with it unless the patient cannot tolerate it or it is clearly not effective.

  • C6.0

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Decision Point D

 
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Decision Point E

As of October 15, 2004, all antidepressants prescribed in the United States are required by the Food and Drug Administration to carry the warning. The labeling also states that "although a causal link between the emergence of such symptoms and either the worsening of depression and/or the emergence of suicidal impulses has not been established, there is concern that such symptoms may represent precursors to emerging suicidality." (2 points for each correct answer.)

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Your total

 
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American Psychiatric Association: Practice Guidelines for the Treatment of Psychiatric Disorders Compendium 2004. Arlington, Va, American Psychiatric Association,  2004
 
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington DC, American Psychiatric Association,  2000
 
Rosack J: FDA issues controversial black-box warning. Psychiatric News, Nov 5,  2004
 
Sadock BJ, Sadock VA: Synopsis of Psychiatry, 9th ed. Philadelphia, Lippincott Williams & Wilkins,  2003
 
Shea SC: The Practical Art of Suicide Assessment. New York, Wiley,  2002
 
World Health Organization: World Health Report 2001: Mental Health: New Understanding, New Hope. Geneva, World Health Organization,  2001
 
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References

American Psychiatric Association: Practice Guidelines for the Treatment of Psychiatric Disorders Compendium 2004. Arlington, Va, American Psychiatric Association,  2004
 
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington DC, American Psychiatric Association,  2000
 
Rosack J: FDA issues controversial black-box warning. Psychiatric News, Nov 5,  2004
 
Sadock BJ, Sadock VA: Synopsis of Psychiatry, 9th ed. Philadelphia, Lippincott Williams & Wilkins,  2003
 
Shea SC: The Practical Art of Suicide Assessment. New York, Wiley,  2002
 
World Health Organization: World Health Report 2001: Mental Health: New Understanding, New Hope. Geneva, World Health Organization,  2001
 
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