Question

Which of the following would be your next step?

Try a new SSRI for both of these patients

Switch to an SNRI for both of these patients

Switch to an NDRI for both of these patients

Insist upon psychotherapy for both of these patients

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

Case outcome: first interim follow-up visit four to six weeks later

Patient #1 was placed on an SSRI, citalopram (Celexa) 20 mg/d, to which he had never been exposed, and advised strongly to stick with a full-dosed trial

• – He returns no better

• – He has mild fatigue as a side effect

• – Patient #2 was placed on an SSRI, escitalopram (Lexapro), which was novel to her, but at a low 5 mg/d dose to avoid the acute side effect of agitation

  • Patient and family are fully educated about side effects and suicide monitoring

  • She returns with slightly improved affective range and energy, and is having no side effects

Question

Would you increase their current medications or change strategies?

Yes, continue both patients at higher SSRI doses

Continue Patient #1 at higher dose but keep Patient #2 at current dose

Continue Patient #2 at higher dose but keep Patient #1 at current dose

No, continue both patients at current dose and wait for full clinical effect to occur

Attending physician’s mental notes: interim follow-up visits through three months

Two rashes, two patients, two different drugs

All drugs carry risk of rashes and allergies

Patient #2 seems more severe, given the facial edema

Likely have to stop both drugs in both patients despite some early clinical improvement

Case outcome: interim follow-up visits through three months

Patient #1

• – Citalopram (Celexa) was increased to 40 mg/d for better effect

• – It caused minor increase in fatigue, but he had less dysphoria and mood lability

• – He developed a drug rash on his arms and legs

Patient #2

• – Escitalopram (Lexapro) was increased to 10 mg/d with some initial improvement, but then a regression toward anhedonia, failure to thrive, and inability to attend school

• – She was hospitalized for the first time

  • She was placed on bupropion-IR (Wellbutrin-IR) 75 mg twice a day by her inpatient psychiatrist, and her SSRI discontinued

  • She showed initial improvement in her depressive symptoms globally

  • She developed a rash and facial swelling a few days after discharge