Mark E. Schneiderhan, Pharm.D.
Spring 1998
Mood Disorders
Mark E. Schneiderhan, Pharm.D.
Spring 1998
Mood Disorders
Overview:
This handout provides grading information, learning objectives and cases for Major Depressive Disorder, and Bipolar Disorder. The case examples and formats will be similar to the examination.
The Student will be held responsible for reading and understanding the related book chapters of the required text: The newly released 3rd edition (1997) of Dipiro’s, Pharmacotherapy: A Pathophysiologic Approach.
The student will be responsible for the preworkup, intervention goals, problems, treatments, and follow-ups for each assigned case:
1. Assessment (20 percent of grade): This includes information that is necessary to solve the case but may not be included in the case description.
a. In order to proceed you must first address the information that you feel is needed (i.e. previous medication use history, allergies, family psychiatric history, current medications use history)
b. Provide an answer as if you actually interviewed the patient. You may answer (The patient has no allergies, no previous psychiatric history, no medical conditions). For example in some situations, it may be important to assess the severity of insomnia in a patient presenting with major depression. (i.e. The patient sleeps only 2 hours per night for the last week.)
c. I will be looking for how you assess the case before solving the patients problems.
2. Problems (20 percent): This includes identifying problems that contribute to the patient’s condition. For example, Insomnia is a treatable problem in a person who is depressed. IMPORTANT: List problems in the order of severity) The patient usually can tell you what is the most important problem that needs to be treated. (i.e. patient presents with the complaint of insomnia)
3. Intervention goals (Outcome) (20 percent): This includes describing the desired outcome of your interventions. For example: The patient’s insomnia should be significantly less after 1 day of treatment. To receive credit for this section you must have the outcome and time course for each listed problem.
4. Treatment (20 percent): This includes describing the treatment and reasoning for the above listed problems. (For example: Temazepam 15mg po q hs for insomnia for 5 days. Temazepam is longer acting to prevent multiple awakenings during the night) Note: spelling and medication doses are important.
5. Follow-up (20 percent) This includes describing how you will follow-up with each problem and treatment. (For example, If the insomnia is not improved after 3 days please contact me or your doctor. If severe day-time sedation occurs from the Temazepam please contact me or your doctor.
A.W. is a 61-year-old WM admitted to the inpatient psychiatry unit on 4/10/91. The Axis I diagnosis was Major Depression. This is the patient’s first psychiatric admission; he is a widower and unemployed. A.W. was sent to the ER by his local MD after expressing suicidal ideation ¥ 3 days. He had thoughts of a Tylenol overdose or driving his car into an underground garage and suffocating with CO poisoning. (+) Hx of feeling depressed ¥ 1 year, with worsening in the past few weeks. A.W.’s father, who died 5/90, was a millionaire, treated his son poorly, and left him out of the will. A.W. declared bankruptcy a few weeks PTA and is suing his father’s estate. On MSE, the patient displays depressed affect, and continues to express suicidal ideation. He has difficulty falling asleep with mid-night awakening. There has been a 10-lb. loss of weight 2° decreased appetite. A.W. has frequently had crying spells, and shows poor concentration. PMHx is significant for mild hypertension, which was treated with SerApEs (reserpine-hydralazine-hydrochlorothiazide). FHx is positive for a maternal grandfather who died by suicide. The patient denies use of ETOH or illicit substances. He smokes 1 to 2 ppd times 40 years. Medication Hx is significant only for the use of diazepam 3 years ago for nerves, and B12 shots, which he hasn’t had in 1 year. ROS and PEx are noncontributory.
Assessment:
1. Why is the patient on SerApEs? Have other antihypertensive agents been tried? (Reserpine has a fairly high incidence of depression.). No other antihypertensive agents have been tried.
2. Is the patient allergic to any medications? Patient is not allergic to medications.
3. Has any base-line work-ups been performed? The patient was treated with B12 in the past. (Thyroid profile, Urinalysis/toxicology, CBC with differential, Chemistry profile). Laboratory work-ups are normal and EKG was normal.
4. Has A.W. experienced other mood symptoms such as racing thoughts, irritability or euphoria, excessive planing or participation in multiple activities? Upon, interview patient denies such symptoms (no history of a manic episode).
5. Was the maternal grandfather treated with medications for depression? It was determined that the grandfather was not treated.
Problems:
1. Elderly patient with depressive symptoms including suicidal ideation, insomnia, crying, poor appetite, poor concentration, and weight loss for greater than 2 weeks.
2. Depression may be exacerbated by Resperpine.
3. Patient has increased stressors such as being unemployed and bankrupt. Patient may not be able to obtain or afford medications after leaving the hospital.
Intervention goals:
1. In the first week, observe decrease in the symptoms of insomnia, crying, poor appetite and poor concentration. Also, monitor for side effects of the antidepressant. In the next 2 - 4 weeks monitor for decreases in depressed mood, anxiety and suicidal ideations.
2. Over the next 1 - 2 week, the patients blood pressure should be well controlled on new medication
3. Over next week, determine the patient’s ability to obtain medications after discharge.
Treatment:
1a. Recommend an antidepressant such as: Nortriptyline 10mg bid for 3 days, then increase to 25mg bid for 3 days, then increase to 50mg po bid. Recommend a serum nortriptyline level (50 - 150 mcg/mL) in 5 - 7 days after dose titration.
Secondary Amine: Nortriptyline or Desipramine tends to be more sedating than the SSRI’s and may help with the insomnia and anxiety related to depression. Unlike the Tertiary Amines (Amitriptyline) which produce more cardiovascular, and anticholinergic side effects.
1b. Recommend an antidepressant such as: Paroxetine 10mg po q hs. and hypnotic Zolpidem 10mg po q hs for insomnia for 5 days.
Selective Serotonin reuptake inhibitor (SSRI): I would recommend starting at a lower dose because of the patients age. This may also avoid some of the side effects such as insomnia, nausea, restlessness, and diarrhea associated with it. The hypnotic agent was chosen because of it’s rapid onset of action and less day-time sedation.
2. Recommend an antihypertensive such as: Procardia SR 30mg po qd. The once a day dosing will ensure compliance. Other agents such as beta-blockers may also increase depressive symptoms.
3. Consult with case-management or a social worker about the patient’s financial status.
Follow-up:
1a. If no observable decrease in depression symptoms (especially insomnia) is seen in 1 - 2 weeks. Check nortriptyline serum levels and adjust dose accordingly. Because the patient is a smoker, this may lower the nortriptyline serum levels.
1b. If no observable decrease in depression symptoms is seen in 2 - 4 weeks. Consider increasing paroxetine to 20mg po q hs. Continue to monitor for side effects.
Follow-up:
2. Monitor blood pressure and side effects over next 3 - 6 months.
3. If the patient is considered indigent, attempt to enroll the patient in an indigent program to supply medications until the patient has resources to acquire medications.
T.S. is a 23 y.o. WF brought to the walk-in clinic by her father after several days of "bizarre behavior," which included episodes of sexual promiscuity. One month PTA, the patient impulsively went on a trip to California. While there, she spent a considerable amount of money on clothes and entertainment. Recently, on the patient’s birthday, she was drinking and may have been using illicit substances. One admitted to the psychiatry unit, the patient became uncooperative, eventually requiring 4-point restraints. On MSE, T.S.’s mood was elated and euphoric, and her affect was extremely labile; thought content - delusions of reference and paranoid ideation; thought process - flight of ideas; behavior - pressured speech, very distractible; judgment/insight - poor. FHx is positive for a father with a bipolar disorder and paternal grandfather who is an alcoholic. T.S. is currently an undergraduate student in her senior year. Medication Hx reveals that the patient uses diuretics and ibuprofen during menses. She denies allergies to food or legend drugs. In the past, T.S. has used ethanol, marijuana, cocaine, and "mushrooms." Urine tox screen on admission was negative. ROS was not performed. PEx showed a questionably irregular pulse. Dx: Bipolar disorder, manic.
Assessment:
1. Is this the first psychiatric hospitalization for T.S.? Does she have a history of depression or mania in the past? Was she ever treated before? Apparently, this is the patients first psych visit.
2. Was the patient’s father treated for bipolar illness? If so, what medications and how did he respond? The father responded to lithium and is currently asymptomatic.
3. Were baseline labs done on admission? Yes, CBC, Chemistry, UA, Thyroid and EKG were normal. The HCG was positive.
4. Had the patient slept in the past week? The patient has been without sleep for 4 days. (I have found that this is an important symptom to treat rather aggressively in the bipolar patient. Patients who are able to sleep are most often less irritable and agitated.)
5. Because of the patient’s sexual promiscuity, has the patient missed her last menses? The patient had her period last month before these events took place.
Problems:
1. The patient is agitated and dangerous with delusions of paranoia and reference. The patient had to be placed into restraints.
2. The patient is elated and euphoric with pressured thoughts and speech. Also the patient in not sleeping at night and disturbing other patients.
3. The patient is in her first trimester of pregnancy.
Intervention Goals:
1. Within 24 - 48 hours, the patient will be 50% calmer and no longer requiring restraints.
2. Within 24 - 48 hours, the patient will be sleeping at least 4 hours at night and will be less elated and euphoric. After 1 week, the patient’s manic symptoms should be significantly improved to allow the patient to attend and participate appropriately in groups. After 2 weeks the patient should have improved enough to be discharged.
3. Within one week, the patient needs prenatal follow-up.
Treatment:
1. Since the patient is in her first trimester of pregnancy, I would consider a high potency antipsychotic such as haloperidol or prolixin. This agents lack the anticholinergic and cardiovascular side effects of the low potency agents. Haloperidol is category B for fetal risk. Haloperidol 5mg po tid and Haloperidol 5mg po/IM q 4 hours prn agitation. Consider using Benztropine 1mg po bid if the patient develops extrapyramidal symptoms.
2a. Since the patient is in her first trimester of pregnancy, I would continue the antipsychotic agent.
2b. If the patient was in her second or third trimester, I may consider using lithium if: 1) the patient did not respond to haloperidol, 2) the patient continues to be dangerous to herself or her fetus, and 3) the patient and family understands the risks of lithium during pregnancy. Lithium 300mg po tid.
3. Recommend OB/GYN consultation and discuss medication therapy with the physician.
Follow-up:
1. Continue to monitor for side effects and effectiveness of antipsychotic therapy.
2. If patient is started on Lithium, monitor serum levels in 5 - 7 days after initiating dose. Maintain a lithium level of 0.8 - 1.2 mEq/mL. Monitor for increased extrapyramidal side effects when combining with antipsychotic. Lithium may increase the serum levels of haloperidol. Also, the patient should avoid ibuprofen and diuretics because these may elevate the lithium levels. This should not be an issue because the patient is pregnant.
3. Reassess the safety of continuing the antipsychotics. Attempt to lower haloperidol to 5mg po bid if patient is no longer acute and monitor for increases in symptoms. If the patient is on Lithium and antipsychotics, attempt to lower and possibly discontinue the antipsychotic agent if the patient has satisfactorily responded to lithium. Continue to consult with OB/GYN if changes in medication treatment.
4. After the patient delivers the baby, the patient should not nurse while on Lithium.
5. If the patient does not respond to lithium and the patient is not pregnant, consider carbamazepine or divalproex.
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