case Study 1 - Anxiety And Depression Association Of · CASE STUDY 2. ADAA, Miami, FL ... Emory...

Charles B. Nemeroff, M.D., Ph.D.

Leonard M. Miller Professor and Chairman

Department of Psychiatry and Behavioral Sciences

Director, Center on Aging

University of Miami Miller School of Medicine

Miami, Florida 33136

CASE STUDY 2

ADAA, Miami, FL

9 April 2015

W. Edward Craighead, Ph.D.

J. Rex Fuqua Professor and Vice Chair

Emory University

Psychiatry/Psychology

CASE STUDIES

CHARLES B. NEMEROFF, M.D., PH.D.DISCLOSURES

• Research/Grants: National Institutes of Health (NIH), Agency for Healthcare Research and Quality (AHRQ)

• Speakers Bureau: None

• Consultant: Xhale, Takeda, SK Pharma, Shire, Roche, Lilly, Allergan

• Stockholder: CeNeRx BioPharma, Inc., PharmaNeuroBoost, Revaax Pharma, Xhale

• Other Financial Interest: CeNeRx BioPharma, PharmaNeuroBoost

• Patents: Method and devices for transdermal delivery of lithium (US 6,375,990B1), Method of assessing antidepressant drug therapy via transport inhibition of monoamine neurotransmitters by ex vivo assay (US 7,148,027B2)

• Scientific Advisory Board: American Foundation for Suicide Prevention (AFSP), CeNeRx BioPharma, National Alliance for Research on Schizophrenia and Depression (NARSAD), PharmaNeuroBoost, Anxiety Disorders Association of America (ADAA), Skyland Trail

• Board of Directors: AFSP, Gratitude America, Skyland Trail, ADAA

Financial DisclosuresW. Edward Craighead

Dr. Craighead receives support from the

NIH for his research, and he receives book

royalties from John Wiley & Sons. He is a

Senior Fellow, Center for the Study of Law

and Religion, Emory University. He is an

officer of Hugarheill ehf, an Icelandic

company dedicated to prevention of

depression. His participation is supported

by the Mary and John Brock Foundation

and the Fuqua Family Foundations.Arnarson & Craighead

CASE STUDY 3

A 64-year-old male, CFO of a large

health care company is referred to you

for evaluation of depression after

discharge from a step-down cardiology

unit. He had suffered his first myocardial

infaction 10 days ago and was admitted

to the CCU for 3 days followed by a

week long stay in a monitored hospital

unit. Family history is positive for both

depression and heart disease. He

admits to consuming 2 packs per day of

cigarettes and “moderate” daily alcohol

intake.

CASE STUDY 3 (cont.)

He had a stent placed in his left anterior

descending coronary artery after

treatment with a thrombolytic in the

Emergency Room. He is discharged on

ASA, Plavix, an ACE inhibitor, nifedipine

and propranolol. On MSE he fills criteria

for severe non-psychotic MDD. He is

hopeless and anhedonic with almost

delusional thoughts of his imminent

demise. He wants to return to work

immediately, but is concerned about

whether his concentration or energy level

is sufficient.

CASE STUDY 3: Question 1

Of the medications he is currently being

treated with by his cardiologist, the most

likely contributors to his depression are:

A. ACE inhibitor and Plavix

B. Nifedipine and propranolol

C. ASA and ACE inhibitor

D. All of these drugs can cause

depression

E. None of the above


You discuss with your patient’s

cardiologist the likelihood that nifedipine

and propranolol may be contributing to

the severe depression. Together you

agree that a β-blocker that does not

cross the blood-brain barrier is less likely

to produce depression. He is switched to

naldolol. The patient insists that he has

no time for psychotherapy and prefers

pharmacotherapy for his depression.


Your recommendation for antidepressant

therapy is:

A. St. John’s wort

B. Bupropion

C. Paroxetine

D. Escitalopram

E. Venlafaxine


Your recommendation for concurrent

psychotherapy is:

A. Intensive daily CBT

B. Interpersonal Psychotherapy

C. Short term supportive therapy

D. Group therapy with other cardiology

patients with depression related

disorders

E. No Psychotherapy until the

delusional thoughts are significantly

decreased


The patient is treated with escitalopram

10 mg po q am. After 3 weeks, he is only

approximately 20% improved. He has

been unable to return to work and is

ruminating about his cardiac status and

his longevity, which he perceives is

markedly reduced. He has no interest in

usual activities and is also fearful of

engaging in sexual activity for fear of

inducing another cardiac event.


At this point you decide to:

A. Add bupropion 150 mg XL q am

B. Switch to duloxetine 30 mg po q am

C. Add olanzapine 10mg po qhs

D. Increase the escitalopram dose to

20 mg

E. Add aripiprazole 5 mg po qhs


His dose of escitalopram was increased

to 20 mg and 2 weeks later little

improvement is noted; the dose is

increased to 30 mg per day. Two

weeks later, he is approximately 40%

improved, but still anxious, back at work

but fatigued, and still ruminating about

his health. He has had 2 episodes of

sexual activity in which he failed to

perform adequately in his view – unable

to ejaculate.


He has now been treated for 7 weeks with

escitalopram and is somewhat improved, but has

not achieved a clinical response (<50%

improvement). You discuss the options with him

and:

A. Increase the escitalopram dose to 40 mg q am

B. Discontinue escitalopram and begin bupropion

XL 150 mg po q am

C. Taper escitalopram and begin venlafaxine 75

mg po q am

D. Taper escitalopram and begin mirtazapine 15

mg po q am

E. Reduce escitalopram to 30 mg q am and add

bupropion XL 150 mg q am


You chose to reduce escitalopram to 30

mg po qhs and add bupropion XL 150 mg

po q am. After 3 weeks the patient shows

no improvement. In fact, he seems more

agitated and ruminative and complains of

insomnia. He admits to thoughts of

suicide and is having extreme difficulty at

work. His wife who accompanies him, for

the first time, expresses her concerns

about his pervasive depressed mood and

negative thoughts.


At this point you recommend:

A. rTMS after taper and discontinuation of

both escitalopram and bupropion

B. Clomipramine 75 mg po qhs after taper

and discontinuation of escitalopram and

bupropion

C. ECT after taper and discontinuation of

both escitalopram and bupropion

D. Aripiprazole 10 mg po qhs

augmentation after bupropion

discontinuation

E. Quetiapine 100 mg po qhs after

bupropion discontinuation


At this point you also recommend:

A. CBT to focus on his cognitive

distortions and his underlying schema

B. Behavior Therapy for his addictive

patterns of behavior

C. IPT to focus on his work situation

D. Group supportive therapy for other

patients who have had similar post MI

interpersonal problems


Together with the patient and his wife,

you opt for the aripiprazole

augmentation strategy. After 2 weeks on

escitalopram (30 mg po q am) and

aripiprazole (10 mg po qhs), he reports

an absolute inability to sit still. He finds

this particular curious in that he believes

that his depression is finally getting

better. He has renewed interest in

hobbies and is now more sexually active.


You now recommend that he:

A. Add alprazolam 0.25 mg po bid

B. Add buspirone 5 mg po tid

C. Discontinue all meds and begin

ECT

D. Discontinue all meds and refer for

VNS

E. Reduce the aripiprazole dose to 5

mg po qhs


You also recommend that he:

A. Continue CBT and focus on his

underlying schema

B. Add Behavior Therapy to address

addictive behaviors

C. Refer to a sex therapist to assure

continuation of adaptive intimacy

D. Both A & B

E. Both A & C


With the reduction in aripiprazole dose,

the akathisia disappears and he continues

to improve attaining remission 16 weeks

after initiation of treatment.

Questions or comments.

CASE STUDY 3

case Study 1 - Anxiety And Depression Association Of · CASE STUDY 2. ADAA, Miami, FL ... Emory...

Documents

Transcript of case Study 1 - Anxiety And Depression Association Of · CASE STUDY 2. ADAA, Miami, FL ... Emory...