EXAM- Anxiety and Depression cases Flashcards
Chloe is a 23 yo F coming to you for 8 months of increasing anxiety. She states that she feels on edge and anxious about everything, and that it is negatively impacting her relationships with her friends and her partner. Her academic performance has also been decreasing. She often feels nauseous and like her heart is racing, but attributes this to how much coffee she drinks to “keep up with” school. What resources will you use to approach Chloe’s case?
I used
-Rx Files (p. 181)
-Mental health ppt
-Katzman et al. 2014 (Canadian clinical practice guidelines for management of anxiety- posted on brightspace)
How will you approach your visit with Chloe?
Start with assessment
-History, physical, assessment of anxiety and specific characteristics (?any depression), screening for suicidality)
-Review of medications- only on oral contraceptives. No previous rx for anxiety. Drinks at parties on weekends- usually 8 drinks or a bottle of wine friday and saturday nights. Has only used recreational drugs at a club once- not sure which.
-Consider labs (i.e., CBC, TSH, glucose, lytes…)
What is your approach to non-pharm treatment for Chloe?
-Counselling, CBT
-Lifestyle: exercise (cardio), health diet, cutting back on coffee and alcohol intake- could be contributing to anxiety, sleep hygiene, etc.
Should you start pharm treatment for Chloe? If so, what would you start with?
I probably would- increasing anxiety x8mo interfering with her life. Could consider trial of CBT first, if patient was amenable to it- per Katzman guideline, as effective as pharmacotherapy.
I don’t think she needs BZDs for acute tx (going on for months)
First line tx for GAD (per Katzman guideline) are SSRIs and SNRIs.
Sertraline 25mg by mouth, take daily in the morning.
Rationale: per Rx files, of the SSRIs, escitalopram, paroxetine, and sertraline are the best for anxiety/ GAD ( depression: antidepressant colour comparison chart). Ruled out paroxetine (caution in pregnancy- pertinent for F of childbearing age, particularly if she will be on it for a while), inc anticholinergic effects and worse withdrawal. Escitalopram and Sertraline have a similar profile; sertraline may have fewer DIs, is safer in OD, and does not affect QT. I think Escitalopram 10mg PO daily is what Susan would choose, because she loves it. Thoughts?
Teaching- AE (GI, HA, tremor), don’t stop med suddenly (withdrawal symp), s&s serotonin toxicity (concern if pt did use recreational drugs), importance of lifestyle/ non pharm management.
Reassess in 2 weeks (may need to increase dose, change to another agent, consider adjunct)
You see Chloe again in 2 weeks. What do you want to reassess?
Assess for early response (indicative of therapy efficacy).
If no response, increase dose (i.e., sertraline 50mg po qam)
Assess for side effects- may require different medication in same or different class
Treatment adherance
Reassess suicidality, insomnia, substance abuse. etc.
Chloe is wondering how long she will be on medication for anxiety for?
Minimum 1 year (flow chart in lecture slides with orange background).
New case! Albert is a 67 yo male with obesity, HTN, dyslipidemia, and T2DM. He is on Ramipril 5mg PO daily, Atorvastatin 10mg PO qhs, and Metformin 500mg BID. No other meds. His chief complaint today is depression that has been increasing over the last 6 months. You have been working with Albert for a while on non- pharmacological approaches, and he feels like they are not helping him. What to do?
Assess- history, physical, review meds, re- assess depression, screen for suicidality. Fun fact- ACEI can contribute to drug induced depression! p. 185 RxFiles.
It is probably time to prescribe an antidepressant for Albert if non-pharm approaches aren’t working and he is still depressed.
Consider clinical factors in selecting antidepressant, potential med interactions, and side effects to avoid (i.e., weight gain).
What do you prescribe for Albert?
Recall:
67 yo M, obesity, HTN, dyslipidemia, T2DM
On ramipril, atorvastatin, and metformin
Probably escitalopram (10mg po daily)? Does not cause OH, beneficial impact on CV risk, fewer DIs.
I initially was thinking fluoxetine as it can help decrease weight and doesn’t affect QT, but it has a ton more drug interactions- while Alberts meds weren’t on the list on p. 187, chances are (as an older adult with cv and metabolic comorbidities) this could be problem in the future.
Checking interactions on lexicomp- escitalopram can increase hypoglycemic effect of metformin (unclear mechanism). May require dose adjustment.
When would you use an SNRI over an SSRI?
I’m not sure… All I could come up with was:
-May be less sedating
-May be better for neuropathic pain and migraines
Colin is 25 year old M with symptoms of anxiety increasing over the last 5 months. He describes multiple episodes of “panic attacks” and an underlying sense of unease, dread, and worry about his relationships, work, and family. He regularly sees a counsellor and has been trying to go to the gym regularly to help manage his symptoms. What do you prescribe?
1) BZD with plan to taper. I.e., lorazepam 0.5mg SL, take 1 tab prn at onset of increasing anxiety/ signs of panic attack (???), dispense 7 tabs (follow up in one week). I have no idea how to prescribe this- the guidelines and Rx files are not super useful. Rx files says as adjunct, reassess in q4-6 wks. Chose lorazepam as balance between fast onset but not an insanely long half life (i.e., diazepam has a faster onset, but t1/2 is 100 hours). Teaching re: risk of dependance, disinhibition, drowsiness, do not combine with etoh, do not drive after. Contract w pt.
2) SSRI- i.e., escitalopram 10mg po daily. This will be maintenance therapy.
3) Reassess after 1 week. May require another 1-3 weeks of BZD while SSRI kicks in (Rx files p. 181)
