Pretest self-assessment question (answer at the end of the case)
How much different can a generic drug be from its brand name counterpart, based upon individual regulatory tests of bioequivalence?
A. 0%
B. 5%
C. 15%
D. 25%
Patient evaluation on intake
Patient #1
– 60-year-old man with a chief complaint of “being angry and down”
Patient #2
– 15-year-old girl with a chief complaint of “everything sucks”
Patient #1 states that he was involved in a fracas at work, was pushed down the stairs, and was in a coma for a week
Patient #2 states that she has been having a difficult time at home and at school
Psychiatric history
Patient #1 had been without any psychiatric issues until his head injury. He states his symptoms developed after this
Patient #2 states that she has gradually become more emotionally labile, depressed, and anxious over the last one to two years
Patient #1 has not been able to go back to work at all due to his depression, amotivation, and anger management problems
Patient #2 has been absent from school due to her inability to get up and get ready for school
Patient #1 admits to full syndrome MDD
He states that little things make him angry quickly
– Experiences road rage and followed fellow drivers after incidents
He states that he was never like this prior to his accident
– Denies PTSD-related avoidance, flashbacks, or nightmares as he does not remember the accident due to his head injury and coma
– Is tense and hyperaroused most of the time
He has relatively few friends as most were colleagues at his previous job. He is at home more and not motivated to leave his home
Patient #2 admits to full MDD symptoms
She states that “little things make her angry quickly”
– She is afraid that going to school puts her in situations where she may strike out and get into fights, even though this has never been her social pattern
– She has friends but feels disenfranchised from them
– She gets along with her grandmother but not her parents
Medication history
Patient #1
– Has had a few treatments so far while in the care of his PCP
– He failed to respond to a low-dose SSRI
– SNRIs as well
– Additionally, an NDRI
– He stopped his medication several weeks ago due to lack of clinical improvement
Patient #2
– A few subtherapeutic treatments so far while in the care of her PCP
– Failed to respond
To a low-dose SSRI (fluoxetine [Prozac]) 10 mg/d due to agitation side effects
To an SNRI (venlafaxine-XR [Effexor-XR]) 75 mg/d due to agitation side effects
Each of these treatments lasted less than one week
Psychotherapy history
Patient #1 has never been involved in psychotherapy
Patient #2 has just started supportive psychotherapy on a weekly basis
Social and personal history
Patient #1
– Graduated high school
– Worked in law enforcement for many years and now is a disabled delivery driver since his accident
– Does not use drugs or alcohol
Patient #2
– Attends high school, and despite her symptoms, is passing her classes for the most part
– However, her grades have dropped from their usual levels
– She only attends school 50% of the time
– She does not use drugs or alcohol
Medical history
Patient #1 has suffered a head injury, is overweight but otherwise in good health
Patient #2 is healthy and has no history of eating disorder or epilepsy
Family history
Patient #1 denies any known psychiatric illness in any family member
Patient #2 has a family history of
– MDD and GAD in her mother
– AUD and questionable bipolar illness in her father
Patient evaluation on initial visit
Patient #1
Patient #2
– Gradual onset of symptoms as she entered her teenage years
– There is no single stressor identified that predates her symptoms
– She is gradually getting worse and is at risk of failing her classes and her grade level
– She has been compliant with her medication but may have become more symptomatic with its use, and has only taken subtherapeutic doses as such
Current medications
Question
In your clinical experience, which patient has a worse prognosis?
Not sure, it is too early to tell
Patient #1 is older, has failed more antidepressant trials, and has a worse prognosis
Patient #1 has more comorbidity and has a worse prognosis
Patient #2 is younger and cannot tolerate her medications and may be activated by them and has a worse prognosis
Not sure as this is like comparing apples and oranges as they are both depressed, but for very different reasons, and both have different phenomenology for their depressive symptoms
Attending physician’s mental notes: initial evaluation
Patient #1
– This patient has his first MDE now with associated anxiety features (subsyndromal PTSD likely)
– It is acute and triggered by the psychosocial stressor but complicated by a traumatic brain injury (TBI)
– It seems more than an adjustment disorder as it is pervasive, lasting over time, and clearly disabling at this point
– His prognosis is likely fair but made worse by his medication resistance and non-adherence
Patient #2
– This patient is relatively untreated due to medication intolerance but psychotherapy and family interventions should be helpful
– The reported activation and escalation is concerning on her current SSRI
Will need to work with the patient and family regarding safety planning, given FDA suicidal warnings associated with antidepressants in her age group
There is no clear family history of bipolarity, but “mood swings, alcoholism, and possible bipolar illness” have been noted in a first-degree relative
The SSRI activation may be a precursor of true bipolarity
Question
Which of the following would be your next step?
Attending physician’s mental notes: initial evaluation (continued)
Both patients are currently undertreated and have not had a fair, therapeutic full dose and full duration SSRI trial
– Patient #1 should be advised about the remaining SSRI medications
– Patient #2 and her parents should be specifically advised about the two approved SSRIs for treatment of depression in adolescents (fluoxetine [Prozac] and escitalopram [Lexapro]) as her failing sertraline (Zoloft) is actually approved for pediatric OCD
Further investigation
Is there anything else you would especially like to know about these patients?
What about details concerning Patient #1’s brain injury?
– He was injured one and a half years ago
– He was in a coma for several days
– His brain has likely healed to its fullest extent possible by now
– His head was impacted on the right side, and according to the patient, he sustained bruising to his cortex in the right parietal area and also to a lesser degree on the left side (contrecoup injury)
– He did not suffer any brain hemorrhage as a result
What about details concerning Patient #2’s previous antidepressant side effects?
– The patient and family report that with low-dose SSRI and then an SNRI, she had to stop them due to acute behavioral changes
She became more mood labile, angry, and irritable
There was no evidence of insomnia, grandiosity, hyperactivity, or impulsivity
Further questioning also suggests that the patient has these types of “mood swings” often and regardless of medication being used
This activation was not accompanied with any increase in suicidal symptoms
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