Patient Management Exercise: Psychopharmacology
Abstract
This 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 information provided, making your decisions as you would with a real-life patient. Questions are presented at “consideration points” that follow a section 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 deducted 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. At the end of the exercise, you will add up your points to obtain a total score.
Case Vignette
Danielle Rawlings is a 25-year old female who was referred to you by her primary care physician for help with addressing issues of depressed mood, after being unable to tolerate treatment with two trials of antidepressant medication
She reported to you that she has been having trouble with her mood for much of the past year. “It started with feeling soooo negative and pessimistic. I couldn’t enjoy anything––not my job, not spending time with my friends, not sex with my boyfriend–– nothing.” She described that, in addition to pessimism and anhedonia, she also had been finding it difficult to get going in the morning and that she often slept 10 hours yet still felt exhausted. “My roommates learned to not even look at me until I’d had my first cup of coffee.”
Danielle described that she had gone to see her primary care physician about 10 months ago to try an antidepressant. “When I was in college, I had a bout of depression after my loser ex-boyfriend cheated on me and we broke up. I tried therapy with one of the intern psychologists at the Student Health Center. It didn’t help much, but probably because she spent a lot of time talking about herself and her problems. Their doc saw me for, like, 10 minutes and gave me a prescription for some generic Prozac. I tried it for a week, but I got all anxious and nervous and nauseated and gave up. I started doing some yoga, and that helped me pull out of it.”
Consideration Point A
At this point in the patient’s history, your differential diagnosis includes
| A.1_____ | Unipolar, major depressive disorder |
| A.2_____ | Hypersomnia not elsewhere classified |
| A.3_____ | Bipolar II depression |
| A.4_____ | Substance-induced disorder |
| A.5_____ | Obstructive sleep apnea |
Vignette Continues
You probed for more details of her current episode, and in addition to depressed mood, anhedonia, hypersomnia, and fatigue, she endorsed feeling hungry “all the time... craving comfort food,” with a 10 pound weight gain over the past year. She also felt worthless and guilty about being unable to “snap out of it.” She denied thoughts of suicide.
As you inquired more about her history, she denied any prior periods with obsessive thoughts or compulsive behaviors, hallucinatory experiences, or delusional thoughts. However, she endorsed that 2 years ago she had one occasion when she slept only 2 hours a night for 4 days while working on a big project for a course in her major, noting “I was ‘in the zone,’ with my creativity flowing and plenty of energy.” At that time, she was told by classmates “girl, you are on fire with creative ideas” and once the project was turned in, she impulsively dragged her boyfriend at the time to go on a trip to the mountains “for a weekend of pleasure to make up for my week of hell.” She reported that her thoughts came easily at that time, but were not “racing.” She had a similar bout about 14 months ago that lasted for 4 days in the wake of flying home from a trip to Hawaii, where she had been a bridesmaid. Both episodes had resolved spontaneously. She estimated that the second episode occurred about 2 weeks before her current depressed period began.
As you inquired about her early life history, you learned she had a fairly unremarkable childhood as the eldest of three sisters who grew up in an intact family of origin. Her dad was “a novelist who sometimes drank a little too much, but he was happy when he overdid it;” she denied that he ever was verbally or physically violent or sexually inappropriate with the patient or her siblings. She was a good student in high school and graduated from college with a BA degree in art and architecture. Currently, she worked doing graphic artwork for a web design company. She lived in a townhouse with two female roommates who had been good friends in college.
The patient reported never smoking tobacco or consuming alcohol to excess, but occasionally using marijuana while in college. She reported “I don’t smoke any weed now because it makes my mood worse. Plus, I don’t need the munchies.” She denies the use of other drugs of abuse, and notes that she will have a glass of wine with friends on the weekends but not during the week.
In reviewing her medical history, the patient denied having major medical conditions. When you evaluated her, she reported taking no routine prescription medications other than oral contraceptive pills.
You already had her complete a self-rated 30-item Inventory of Depressive Symptomatology (1) before coming to see you, and she had scored 31, comparable to a score of 17 on the 17-item Hamilton Depression Rating Scale (2), indicative of moderate symptom severity (3).
On examination, she was slender, pleasant, and cooperative with the interview, casually attired in shades of gray and black, with a nose ring and hair dyed jet-black with a few strands of pink. Moderate psychomotor slowing was noted. Eye contact was good. Speech was of slightly slowed rate and monotonous prosody, but of normal volume. Affect was fatigued. Mood was endorsed as “sometimes it all just seems so bleak.” Thought process was generally linear and coherent but slightly sluggish. Thought content was without hallucinations, delusions, or current suicidal or homicidal intent. Cognitively she was awake, alert, and oriented to self, place, date, and circumstances. Memory registration was intact with 3/3 stimuli, and recall after delay was 3/3 items. She recalled the prior five United States presidents without difficulty. Her similarities were abstract (apple/orange = “delicious fruit”; watch/ruler = “for measuring things”). Her insight was good in that she recognized she needed to receive professional help. Judgment currently was good in that she was open to considering all options for treatment. Neurologically, her gait stride length, arm swing, turning, and rapidly alternating movements were all normal. You detected no focal neurological deficits.
Consideration Point B
At this point, your differential diagnosis includes
| B.1_____ | Unipolar, major depressive disorder |
| B.2_____ | Hypersomnia not elsewhere classified |
| B.3_____ | Bipolar II depression |
| B.4_____ | Substance-induced disorder |
| B.5_____ | Obstructive sleep apnea |
Vignette Continues
As you described your diagnostic impressions to the patient, she developed a slight smile and volunteered “my mom used to say that I was a lot like my great aunt because I was an ‘artiste’ as a kid. Great Aunt Robin was an artist who was so moody that she divorced my great uncle, moved to Spain, lived in a cave, and indulged her passion for painting. No one has heard from her in years.”
Consideration Point C
Given all the details of the case, your next therapeutic step(s) is/are
| C.1_____ | Retry fluoxetine monotherapy but at a low dose |
| C.2_____ | Trial of escitalopram plus bupropion |
| C.3_____ | Trial of quetiapine as monotherapy |
| C.4_____ | Electroconvulsive therapy |
Vignette Concludes
After a discussion of the options for treatment, the patient accepted quetiapine monotherapy, titrating up to 300 mg/d over 4 weeks. You asked her to leave you a voicemail message after 1 week, in order to let you know how things were going, either good or bad; she did so, and reported that she felt a little more tired the first 2 days than before starting the medication, but that had corrected. After 4 weeks of this regimen, she returned for a follow-up visit and reported that she was feeling markedly better—less pessimistic, more energetic, and “more like my well self.” After 6 weeks, she emailed you that she felt “really positive and solid, not moody or flighty at all.” At a follow-up visit after 8 weeks of quetiapine monotherapy, she reported that she was “pretty much a 10 out of 10” in terms of her recovery. Her self-rated IDS-30 score was 4, which is in the remission range.
Answers: Scoring, Relative Weights, and Comments
Consideration Point A
| A.1_____ | (+2) Unipolar, major depressive disorder. The patient endorsed several of the DSM-5 criteria for major depressive disorder (4), and you are struck by her symptom cluster with so-called reverse neurovegetative symptoms. |
| A.2_____ | (+1) Hypersomnia not elsewhere classified. In DSM-5, the conceptualization of primary and secondary insomnia has evolved into insomnia disorder, which may be accompanied by comorbidities (4). |
| A.3_____ | (+2) Bipolar II depression. The depressive-spectrum symptoms that the patient has reported at this point are consistent with a major depressive episode in either unipolar or bipolar disorder. |
| A.4_____ | (+2) Substance-induced disorder. Withdrawal from psychostimulants can be associated with excessive fatigue and sleepiness (4). |
| A.5_____ | (+1) Obstructive sleep apnea (OSA). Patients with obstructive sleep apnea experience periods when they stop breathing while asleep due to mechanical obstruction of the airway, and may experience symptoms including daytime sleepiness, headaches, and dry mouth or throat (5). |
Consideration Point B
| B.1_____ | (−2) Unipolar, major depressive disorder. The patient has given you evidence of hypomanic events, and treating her as if she had unipolar depression is not consistent with best practices (6, 7). |
| B.2_____ | (−2) Hypersomnia not elsewhere classified. There is evidence of a primary mood disorder of which the patient’s hypersomnia is merely a part. Neglecting the rest of the picture is not consistent with best practices. |
| B.3_____ | (+3) Bipolar II depression. The patient’s history includes periods of hypomania without frank manic episodes, most consistent with a bipolar II diagnosis. |
| B.4_____ | (0) Substance-induced disorder. The patient reports that she is not currently using any substances of abuse. |
| B.5_____ | (0) Obstructive sleep apnea (OSA). The patient’s exam and history do not lead to the likely presence of excess soft tissue involved with airway obstruction, the central pathophysiology of OSA. |
Consideration Point C
| C.1_____ | (−1) Retry fluoxetine monotherapy but at a low dose. According to the STEP-BD study and other research, selective serotonin reuptake inhibitor (SSRI) monotherapy does not appear to be the treatment of choice for bipolar II depression (cf. 8). |
| C.2_____ | (−2) Trial of escitalopram plus bupropion. While this combination may be quite helpful for unipolar depression (9), it has not been shown to be an evidence-based practice in bipolar II depression. |
| C.3_____ | (+3) Trial of quetiapine as monotherapy. This treatment approach is supported by double-blind randomized clinical trial data (cf 8) and the US Food and Drug Administration has allowed an indication for this drug for this condition. |
| C.4_____ | (−2) Electroconvulsive therapy. While ECT is an evidence-based practice for the treatment of depression, it is not the next step in the usual treatment algorithm for a patient like this, with bipolar II depression and without medication failures in the current episode (10). |
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