|
Case contributed
by: Mark J. Berber,
MD, FRCP(C), MRCPsych, MRCGP After completion
of this case, participants will be able to:
Patient Presentation: Questions
to Consider:
Gathering further history, you learn that Ms. T.’s mother was recently diagnosed with Alzheimer’s disease, although the family physician had reassured her that it was mild. Further functional inquiry reveals that this recent episode of depression was insidious in onset, with gradual worsening over the past year. Ms. T. is not currently experiencing suicidal ideation. Woven into her dysphoria are anxiety, apprehension and tension with muscle aches and pains. She does not experience panic attacks, phobias, obsessions or compulsions and does not endorse a current or past history of mania, hypomania, delusions or hallucinations. Two months ago, she missed a couple of days at work because of "stress". Ms. T. reports healthy interpersonal relations, naming her husband as her primary support. Sexual relations prior to the onset of this depressive episode were mutually satisfying. Her medical history is unremarkable and menstrual cycles are normal. There is no personal history of seasonal mood episodes and no family history of any psychiatric illnesses. Questions to Consider:
You diagnose major depression of moderate severity and determine that there is no comorbid condition. You discuss treatment options with Ms. T., who expresses to you her urgent wish to return to feeling well as soon as possible. You select venlafaxine XR 75 mg daily and discuss the possible side effects that may occur with this antidepressant. You inform Ms. T. that her baseline bloodwork was normal. Questions to Consider:
You reassure
Ms. T. that antidepressants are not addictive and will not change
her personality. You advise her that the antidepressant effects
are not instantaneous and that it may take three to six weeks before
full antidepressant effects are seen. You arrange a follow-up appointment
for two weeks hence, but ask Ms. T. to telephone your office earlier
should her condition deteriorate or should side effects cause distress. Ms. T. returns two weeks later stating she has been fully compliant with her medication. She noticed a slight improvement in her mood, but still feels quite depressed. She had mild nausea at the start of treatment but this side effect did not persist beyond the first week of therapy. Question to Consider:
Ms. T. is advised to increase the dose of venlafaxine XR to 150 mg daily. As you are keen to achieve full remission and promote recovery, you arrange an appointment to see her again in two weeks. At that time, she returns to see you, looking much better. She tells you that there has been a marked improvement in her mood since the dose of venlafaxine XR was raised. Sleep, energy level, concentration, self-esteem and libido have all improved and Ms. T. expresses her wish to return to teaching. You recommend that she continue to take venlafaxine XR 150 mg daily and ask that she return in four weeks to monitor her progress. At this next follow-up appointment, Ms. T. tells you that she feels great, fully back to her former happy self. Questions to Consider:
Discussion: Undertreatment
is a common cause of chronic depression. There are many reasons
for undertreatment, including unawareness of optimal therapeutic
dosing, selection of inadequate antidepressants, inadequate dose,
inadequate duration, concerns about safety and side-effects. It
usually requires several weeks to observe clinically significant
effects with antidepressants. Unfortunately, the side effects occur
early, and often lead to discontinuation of treatment. Patient education
regarding adverse events and time course to response is essential
in order to increase compliance and acceptance of transient adverse
events. Patients with comorbid conditions and those who have difficulty
metabolizing psychotropic agents (e.g. older or medically compromised
patients) are more often sensitive to drug-related adverse events.
In these situations, the clinician should begin at the lowest possible
dose, and titrate upward slowly. If a fully compliant
patient has no antidepressant response after six weeks on an adequate
dose of medication, a new antidepressant strategy should be considered.
If there is partial remission, the clinician should consider optimization
to the highest tolerated dose: dose optimization is critical in
antidepressant therapy. The majority
of depressive patients are undertreated, and up to half will discontinue
their antidepressant within about three months. Inadequate optimization
of any antidepressant increases the risk of residual symptoms which,
in turn, heightens the risk of relapse, recurrence and chronicity. Once the patient achieves remission, continuation treatment lasting six to nine months is generally recommended in order to prevent relapse. The goal of maintenance therapy is to ensure continued recovery; maintenance therapy should always be considered in those patients who are at higher risk of recurrence. Discontinuation of the antidepressant medication should be gradual in order to avoid a discontinuation syndrome. Proceed to Section IV - "Clinical Cases - Case #2"
|
