HuBio 564: Principles of Pharmacology II
Case Study 1
Ms Q, a 48 year old single woman presents with a 2 month history of depressed mood, decreased appetite (but weight has gone up 4 pounds), poor sleep with both initial and terminal insomnia. She is very fatigued, especially in the morning. She is single; her previously active social life has declined dramatically. She smokes 5-8 cigarettes per day. She has type II diabetes, is mildly overweight. Recently she has developed some neuropathic pain in her left leg, which may be contributing to her sleep disturbance. She has a crummy job with lousy insurance coverage. She is missing work almost one day per week due to various minor complaints (e.g. headache). She reports at least one prior episode of depression.
1. What are the important questions to ask about her long term psychiatric history?
2. What further questions would you ask about her current status?
The patient has no psychotic symptoms, history of mania, suicide attempts. She was hospitalized once for severe depression. She does have a history suggestive of mild panic disorder and has had a few panic attacks recently. What are the advantages and disadvantages of each of the following medications in this situation? Note that venlafaxine and duloxetine are expensive at your hospital, while the short acting preparations of most other antidepressants are cheap. She was tried on Mirtazepine in the past, she can't remember if it helped or not.
3. Please list the advantages and disadvantages of each of the following medications in this situation.
| Medication | Advantages | Disadvantages |
|---|---|---|
| Bupropion | ||
| SRIs | ||
| Mirtazepine | ||
| Venlafaxine/duloxetine | ||
| Tricyclics |
4. You prescribe venlafaxine and taper it up to 225 mg per day. After 4 weeks at this dose, the patient calls you stating the venlafaxine didn't work at all, she stopped it two days ago and now she is "worse than ever" and thinks she has the flu. What is going on? What other symptoms should you ask about? How should this problem be managed?
5. Next, you prescribe citalopram 10 mg every day. The patient calls you in three weeks. She is tolerating it well, states "my boyfriend says I'm a little better" but is still quite bothered by her symptoms and wants to know if she can take more citalopram. What would you do next?
Eight weeks later, now on a dose of 40 mg of citalopram, she reports no panic attacks and a considerably better mood. She can enjoy herself a bit more, but is still troubled by very low energy, poor concentration, and poor self esteem. She reports feeling discouraged about the prospects of getting better. She fears she may get worse and need hospitalization again. She has occasional loose stools that she attributes to the citalopram, but is otherwise tolerating it well and "likes it".
6. Name at least four reasonable adjunctive treatment strategies at this point.
After she has been on two medications for eight weeks, she is improved but is still quite fatigued and is gaining weight. She is not sexually active.
7. What endocrine disorder should you consider?
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