PSYCHOPHARMACOLOGY: ANTIDEPRESSANT CASE DISCUSSIONS

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PSYCHOPHARMACOLOGYANTIDEPRESSANTCASE
DISCUSSIONS

• Lloyda B. Williamson, M.D., Assist. Prof.
• Dept. of Psychiatry Behavioral Medicine,
• University of Alabama, School of Medicine,
• Tuscaloosa Campus
• April 10, 2007

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Case 1

• 21 yr old cauc F at U of A, depression, insomnia,
  poor appetite, no energy not going to classes,
  no time with activities/ friends, passive SI but
  no plan no medical prob.
• Dx Major Depresssion
• Discuss the following medication options
• 1) Remeron 15 mg
• 2) Effexor XR 150 mg
• 3) Amitryptylline 25 mg
• 4) Paxil CR 12.5 mg

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Case 1 Discussion

• 1) Remeron - sedating but increases appetite
• 2) Effexor- good choice but need to start at a
  lower dose (37.5 mg titrate up 75 mg then 150
  mg titrate q 4 days if side effects, meds left
  in samples to titrate downward)
• 3) Amitryptiline - sedating effective but
  causes dry mouth, blurred vision, constipation,
  weight gain, etc.)
• 4) Paxil - short half life for quick responseto
  improve function as a student

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Case 2

• 58 yr old AfAm M in management at a plant
  restless, fatigue, worries about family job,
  insomnia left work several times in past 6 mo.
  due to panic attacks unstable HTN DM
• Dx GAD Panic Disorder, no agorophobia
• Discuss the following medication options
• 1) Effexor XR 37.5 mg titration up to 225 mg
• 2) Lexapro 10 mg titration to 20 -30 mg
• 3) Wellbutrin XL 450 mg
• 4) Prozac 10 mg

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Case 2 Discussion

• 1) Effexor XR - now indicated for panic
  disorder but may further elevate high blood
  pressure
• 2) Lexapro - a good option, but will need to
  titrate upward to dose higher than for depression
• 3) Wellbutrin XL - not helpful for panic
  disorder
• 4) Prozac - a good option, long half-life will
  delay pts response to this acute problem

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Case 3

• 33 yr old hisp M atty, increased appetite
  sleep, low energy, not reading, irritable,
  sensitive to others comments, forgets to take
  meds daily disability for Seizure D/O
• Dx Atypical Depression
• Discuss the following medication options
• 1) Remeron 30 mg
• 2) Trazodone 100 mg
• 3) Prozac 10 mg
• 4) Wellbutrin XL 150 mg

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Case 3 Discussion

• 1) Remeron - sedating agent further complicate
  his sleeping will increase appetite
• 2) Trazodone - also sedating but not the most
  helpful antidepressant option either
• 3) Prozac - good option due to its long
  half-life it will remain in his system if he
  forgets to take a few days weekly
• 4) Wellubtrin - do not use will further lower
  his seizure threshold, leading to seizures

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Case 4

• 35 yr old Cauc F paralegal with tearful episodes,
  irritability, decreased concentration, insomnia
  also has Chronic Fatigue Syndrome
• Dx Major Depression with Chronic Fatigue
  Syndrome
• 1) Celexa 20 mg
• 2) Paxil 20 mg
• 3) Effexor 75 mg
• 4) Cymbalta 30 mg

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Case 4 Discussion

• 1) Celexa - reasonable option, however this is
  most likely a sub-therapeutic dose in need of
  titration up to at least 40 mg
• 2) Paxil - reasonable option but will need to
  monitor for weight gain
• 3) Effexor - this will need to be TID dosing,
  often inconvenient to remember
• 4) Cymbalta - a good option may help with pain
  symptoms

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Management of Sexual Side Effects of SSRIs

• Dose reduction
• Anorgasmia addition of 1 of following
• -yohimbine -presynaptic alpha2-adrenergic
  receptor blocker
• -bethanachol -cholinergic agent
• or cyproheptadine (Periactin)- antihistamine 1 -
  2 hrs before sexual activity
• Decreased libido - addition of Wellbutrin

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REFERENCES

• Liberman, J. A, Tasman, A. Handbook of
  Psychiatric Drugs, John Wiley Sons, Ltd.,
  2006.
• Lexi-Comps Drug Information Handbook, 13th
  Edit., 2005.