Final Exam Questions Escitalopram

A 24-year-old-Caucasian female is being cared for in an integrated care setting. Originally, the patient was seeing their primary care physician for a high BMI and trouble sleeping. The physician referred the patient to the team's psychologist to address insomnia, fatigue, and low mood. During treatment, the psychologist administered the PHQ9 and the patient scored a 15, which indicates moderately severe depression. The patient reports still enjoying cooking and socializing with friends. The patient also denies psychosis or its associated symptoms and also reports never having been treated with any medication to treat their depression or its associated symptoms. The patient is now interested in starting a medication in addition to psychotherapy. What is the appropriate anti-depressant to start on this patient? Escitalopram A 23-year-old female patient is seen for an emergency follow up for MDD and presence of SI. The patient has anhedonia, low mood, no energy to get out of bed or spend time with friends. The patient is obese and has a history of difficulty with diet/weight management due to a previous diagnosis of binge eating disorder. An interdisciplinary team has met to determine the best approach to psychopharmacological treatment. Currently, ECT and ketamine have been refused. Which non-TCA SNRI medication is best suited for the patient? Venlafaxine A 24-year-old male presents for discussion of their mental health concerns. The patient has a past diagnosis of nonpsy1 / 14 chotic unipolar depression and has been receiving outpatient treatment for a year. They were prescribed sertraline at an adequate dose initially and have increased to the maximum dose for an adequate amount of time with no remission of symptoms. They have expressed concerns about the sexual side effects of sertraline and are wanting to explore other options. What medication is still classified as an antidepressant but uses a different mechanism of action AND has a lower potential for sexual side effects? Bupropion A 26-year-old female presents with non-psychotic unipolar depression while in an inpatient facility. She described experiencing extreme sadness for an extended period of time. However, the client does not present with severe suicidal ideations, therefore there are no indications for ECT at this time. Mirtazapine was historically administered for 6 weeks with only a partial response. Then venlafaxine was adequately tried for 8 weeks with no response. No other medications, beyond mirtazapine and venlafaxine, have been utilized for treatment. The client does have a history of seizures. What SSRI medication should now be prescribed? Sertraline Sandra B. is a 16-year-old non-binary patient with a history of major depression without any other comorbidities. Sandra has been historically treated with sertraline followed by venlafaxine, neither enabling Sandra to achieve remission nor an adequate response. Sandra was most recently prescribed and adherent to a 2 / 14 dosage of 300mg of bupropion for four months. Sandra reported that it helped with their sensitivity to social rejection, but she exhibited significant weight gain and demonstrated no mood improvements. Because Sandra has been resistant to treatment thus far, what alternative medication could be considered at this stage of her management? Phenelzine A 35-year-old adult male patient with a diagnosis of unipolar depression but without severe melancholy or atypical features is seen in an outpatient setting. The patient has no comorbidities or history of seizures. The patient tried an adequate trial of sertraline and subsequently switched to escitalopram with no response from either therapy. Then the patient was treated with an adequate trial of venlafaxine and the patient experienced some partial relief of symptoms but did not meet full remission. The patient reached venlafaxine's maximum dose and did not report any severe side effects. Although the patient reached venlafaxine's maximum dosage, the patient still has not reached full remission and reports experiencing difficulties with motivation and concentration. The patient reports interest in continuing with venlafaxine, but states interest in adding on a drug that enhances concentration as well as antidepressant effects. What would be your next course of action in treating this patient? Add bupropion A 30-year-old male is seeking treatment for unipolar major depression. The patient also has a comorbid diagnosis of 3 / 14 OCD. The patient was initiated on treatment with fluoxetine and reached a maximum dose of 80 mg a day after 2 months but showed little improvement of symptoms. The patient was switched to sertraline and reached a maximum dose of 200 mg a day with only partial remission of symptoms. What is a drug from a different drug class that can be used to augment treatment with sertraline? At your doctoral internship, you have been assigned a 32-year-old female patient named Sara. Sara has a diagnosis of type 1 diabetes mellitus and a history of experiencing persistent depressive symptoms interfering with her employment and interpersonal relationships. Sara has contracted for safety with no suicidal ideations, plan, intent, or access. While her depression has interfered with her daily living, she has never self harmed, is able to make it to her appointments on time, and is actively engaged in adherence to treatment. Sara was initially treated for MDD with venlafaxine. She tried this treatment for three months and the dose was increased every four weeks until reaching the maximum dosage. Sara experienced minimal reduction in her symptoms while taking venlafaxine. When advised by her previous prescribing physician, Sara was tapered off of venlafaxine and slowly increased on a dose of mirtazapine. Sara increased the dose of this medication until reaching and maintaining a steady state for three months. Sara did not experience a reduction of her symptoms after taking mirtazapine. Sara opted to 4 / 14 Resperidone taper off of mirtazapine, and bupropion was introduced to her therapy by her previous prescriber as a "kick in the pants" for treatment resistant depression. Sara experienced a small reduction in her depressive symptoms, however, the side effects of bupropion were intolerable per her report. Sara tapered off of bupropion and opted to accept therapy with lithium, despite having unipolar depression. The dose of lithium was increased until her true trough lithium serum concentration was recorded at 0.89 mcg/mL. While taking lithium she experienced insatiable thirst, frequent urination, and worsening symptoms associated with her diabetes. She is frustrated that her attempts to reduce her depressive symptoms with medications have been unsuccessful. At the first session, Sara presents with a new diagnosis of diabetic neuropathic pain, in addition to their symptoms of major depressive disorder. Given the previous medication regimens and failed psychopharmacological attempts at treating the patient's depression, which medication would be appropriate for treatment resistant depression in patients with a comorbidity of chronic peripheral neuropathic pain associated with diabetes? Madison is a 35-year-old female with a history of Major Depressive Disorder. After years of experiencing depressive symptoms without psychiatric treatment, Madison has developed auditory hallucinations. Her diagnosis was updated to Major Depressive Disorder with psychotic features. ECT was considered but determined not to be appropriate for this 5 / 14 Carbamazepine patient at this time. As a result, her psychiatrist introduced an augmentation with an adequate dose and trial of sertraline with aripiprazole to address the depressive and psychotic symptoms. Madison's symptoms did not alleviate, and she has titrated off these medications. The next recommended step, as outlined by the Harvard South Shore Program, is to introduce a TCA in conjunction with an antipsychotic. Name a drug combination that applies to this recommendation. Imipramine & Lurasidone P.J. is a 34-year-old non-binary patient with a medical history of MDD who now presents with recurrent and worsening auditory hallucinations and delusions of grandeur. The patient has become less able to show up for work, either on time or at all, and is missing deadlines set by their employer. The patient is becoming less effective at maintaining hygiene, with family and friends becoming very worried the patient will lose their job and resultantly loose their ability to pay their portion of the rent thereby losing their apartment. The patient has been historically treated with 6 different pharmacotherapies for MDD by several different physicians, including primary care and psychiatrist physicians, with little to no sustained remission or recovery. Most recently the patient was titrated up on their dosing with sertraline and paliperidone. Based on the evidence-based algorithm by the Harvard South Shore Program, what augmentation therapy should be considered at this stage of the patient's disease presentation? add ECT 6 / 14 Extracredit: Seizure medication known to be useful for a variety of pain syndromes Gabapentin Hannah was recently diagnosed with bipolar disorder, current episode manic. In addition to her episodes of increased energy, goal-directed activity, euphoria, and impulsivity, Hannah also periodically experiences depressive episodes. She is not currently taking any psychiatric medications and has no comorbid diagnoses. What is the first line of psychotropic treatment that Hannah should be prescribed? Quetiapine Nicole was diagnosed with bipolar mania. She exhibits mixed presentation with frequent bouts of depression. She was prescribed quetiapine at 600 mgs a day and noticed a partial reduction in manic symptoms. In attempts to reach full remission, her prescriber switcher her to Abilify. After an unsatisfactory response, which drug should be augmented to her list of medications? Valproate You are seeing a 40-year-old cisgender male with the diagnosis of bipolar I disorder. His most recent episode was manic, which led him to an inpatient hospitalization. The patient does not meet criteria for a mixed presentation. Therefore, he does not report a depressed mood or loss of interest. He does not have diabetes or chronic pain. He is not currently taking any medications. What should be the next step of treatment? Lithium A 35-year-old male, with a long-standing diagnosis of bipolar mania, presents for a follow-up appointment. The patient has noted no recent drug use and no traumatic medical history. He has previ7 / 14 ously been treated with several SSRIs with no success due to manic symptoms. In an attempt to treat manic symptoms, the patient was treated with lamotrigine, then valproic acid and subsequently with lithium without reaching full remission at adequate dosage and duration of each of these medications. What second generation antipsychotic should next be tried? Aripiprazole A 34-year-old female has been diagnosed with bipolar mania. They are currently not on any antidepressant, are not pregnant, and deny any history of substance use. The individual's presentation does not demonstrate any evidence for a mixed presentation. Lithium was administered with an unsatisfactory response. The prescriber then added quetiapine which also resulted in an unsatisfactory response. What would be an appropriate second-generation antipsychotic for the prescriber to administer next? Aripiprazole A 27-year-old male, who has never been on antidepressants, presents for a follow up visit. He has no history of substance use or any co-morbid anxiety disorders. In the past six months the patient's family has expressed concerns about impulsive sexual and gambling behaviors. The client spent all of his savings on a new model motorcycle and has barely been sleeping. The patient reports that he feels like he is on top of the world. After exploration, this patient does not have a history of depressive episodes. This patient was initially prescribed lithium with no response. The physician then augmented therapy with quetiapine with no Resperidone 8 / 14 response. He then was treated with valproate, but again no response. All previous treatments have been discontinued. Which of these antipsychotics would be the most appropriate 1st tier treatment? Jane has a history of flight of ideas, increased goal-directed activity, decreased need for sleep, mood disturbances not attributable to the physiological effects of a substance, and risky behavior. She was non-responsive to previous medication which consisted of adequate trials of quetiapine, valproate, and lithium. What long acting injectable that is also a recommended second tier therapy could be prescribed? Aripiprazole Stefen is an in-patient with repeated suicidal ideation and Bipolar Disorder I without mixed presentation. An intern physician treated the patient with lithium, and the response was partial. Next, the intern added quetiapine which was unsatisfactory in its effects. This adjustment was followed by changing quetiapine to aripiprazole. Stefen reported aripiprazole as ineffective, so the intern treated the patient with ziprasidone. The intern found that ziprasidone was also ineffective. With these results, what is the best third-tier SGA option the intern could try alongside lithium? Clozapine Stefen is an in-patient and has severe bipolar depression. His treating psychiatrist recommended ECT, but the patient refused. Stefen was then started on IV ketamine but the therapy was unsuccessful. What medication should doctors try next? Lithium 9 / 14 Jane comes in with concerns for bipolar depression which includes symptoms of anhedonia, withdrawal and isolation, and insomnia. There is not an urgent need for ECT and she is currently not on any mood stabilizers. What medication should be suggested for Jane that is not a mood stabilizer? Quetiapine The patient is a 27-year-old male with bipolar 1 current episode depressed. There is no indication that ECT is needed. They are currently prescribed lithium and have had a partial response. Their serum level was taken and found to be at 0.4mEq/L after reaching a steady state. What should be done to the dosage to see if lithium will be an effective treatment? Double the dose A 25-year-old male was recently diagnosed with bipolar depression. His current presentation demonstrates no urgent need for ECT. He has not taken any mood stabilizers at this point. What anticonvulsant would be most appropriately recommended? Carbamazepine A 35-year-old male with a diagnosis of bipolar depression presents for a follow up visit. The patient showed no response to initial treatment with quetiapine prescribed at a minimal dosage of 150 mg/day for 6 weeks. What is the most appropriate next step with the therapy? Increase the dose of quetiapine You are a psychologist that is certified to prescribe psychiatric medications in an inpatient psychiatric hospital. A 25- year-old cisgender female patient is meeting with the treatment team for the 10 / 14 first time and reports symptoms characteristic of an acute bipolar disorder, with her most recent episode being depressive. Her symptoms are not currently severe or treatment resistant. Nonetheless, in the community she was diagnosed with major depressive disorder and prescribed fluoxetine. However, the patient disclosed that she was not asked about her history of mania and hypomania; thus, not being prescribed with a mood stabilizer. What should the next step with therapy be? Taper off fluoxetine and add lithium A 34-year-old male patient who was recently diagnosed with bipolar 2 (current episode depressed) was previous- Taper off sertraline and add lumateperly treated with sertraline with little reone sponse. What should the next step in treatment be for this patient? Paige, a 31-year-old female, was diagnosed with bipolar depression 2 years ago. Her treatment team determined no urgent need for ECT. The patient has had adequate trials of lithium and quetiapine with no remission in spite of an adequate dosage and length of therapy. After these trials, the psychiatrist utilized lamotrigine, lurasidone, and cariprazine individually but unfortunately remission was not reached. Paige does not experience rapid cycling and presents in a depressive state while not on an SSRI. SSRI's are not an option as they increase manic symptoms. After reviewing the drug history, which medication should be considered? The patient has received a diagnosis of bipolar I disorder, current episode de11 / 14 Valproate pressed. His providers determined he is not a candidate for ECT or IV ketamine. The patient was successfully tapered off of a previously prescribed SSRI after it induced a manic episode. The patient was given cariprazine to treat his presenting symptoms, followed by a variety of other options, including appropriate doses and durations of therapy using quetiapine, lamotrigine, lurasidone, and lithium, all of which were unsuccessful. Which pharmacological class of medications should continue to be avoided? Antidepressants Patrick was recently voluntarily hospitalized for intense auditory and visual hallucinations and the clinical psychologist diagnosed him with schizophrenia. Patrick expressed interest in being prescribed medication to treat these symptoms but reported being concerned about the side effects of weight gain. The physician should prescribe a second-generation antipsychotic as the first line of treatment. Name one SGA that should be avoided due to its known side effect of weight gain. Olanzapine Tim is a 21-year-old male who was recently diagnosed with schizophrenia after experiencing symptoms since age 18. After meeting with a psychiatrist, the first step was to prescribe aripiprazole at a minimum dose. Tim was on aripiprazole for 6 weeks with an increasing dosage every 2 weeks. Once he reached the maximum dose with poor tolerance, the psychiatrist is considering switching to another SGA. What SGA could be prescribed? Asenapine 12 / 14 A 77-year-old male patient who was diagnosed with schizophrenia has reached the maximum dose of lurasidone after a 6-week trial with little response. The patient has muscular dystrophy and has expressed concern regarding extrapyramidal-type side effects. Of the following, which medication would be the most appropriate next step? Resperidone You are seeing a 40-year-old male patient who is at an inpatient facility with auditory hallucinations, flat affect, and persecutory delusions. In his first trial, the patient was prescribed ziprasidone for approximately 6 weeks. The patient was still observed to respond to unseen others, therefore, the dosage was slowly increased but led to no relief of psychotic symptoms. After completing the adequate trial, which led to an unsatisfactory treatment response, the patient was then prescribed haloperidol. However, during his medication trial the patient was reporting sustained muscle contraction, constant leg movement and restlessness, and parkinsonism. What should the next step be in treatment? Resperidone A 35- year-old male with a diagnosis of schizophrenia presents for a follow up visit. He's tried an appropriate dose of aripiprazole for 4-6 weeks with an unsatisfactory response. He followed this up by trying on appropriate dose of olanzapine for an additional 4 weeks with unsatisfactory response. Due to continued symptoms of schizophrenia what medication should be tried next while gradually removing his current medications? Clozapine 13 / 14 A 45-year-old male has been recently diagnosed with schizophrenia. Aripiprazole was administered for five weeks with no response. Risperidone was then prescribed with no reduction in symptoms. After the patient was taken off risperidone, they were prescribed clozapine. The patient demonstrated an unsatisfactory improvement on this therapy. At this stage of therapy, what mood stabilizer should be recommended in conjunction with clozapine? Lamotrigine The patient is a 27-year-old male diagnosed with schizophrenia. He has previously been appropriately treated with asenapine, olanzapine, and clozapine. They are no longer taking asenapine or olanzapine, but are still taking clozapine. They gave each medication an adequate trial but received an unsatisfactory response. They most recently tried augmenting therapy with lamotrigine but did not tolerate the treatment. What is another option they could try next in combination with the clozapine? ECT Jane has been diagnosed with schizophrenia. She was initially started on risperidone and had an unsatisfactory response. She was then sitched to treatment with lamotrigine which still resulted in unsatisfactory improvement. The patient was then treated with adequate dose and trial of clozapine and achieved partial response. In addition to clozapine continuation, what subsequent therapy could be utilized? Add ECT 14 / 14