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Common psycological cases in clinical practice
1. Common Psychological cases
in Clinical Practice
Common Psychological cases
in Clinical Practice
Dr Wafa Sheikh
Consultant Family Medicine
SBFM, ABFM,MRCGP (int)
Psychiatric clinic at PHC Al Harra AL Sharia
2. Clinical case 1 Depression and Anxiety among Adolescence
Clinical case 2 Depression Among Adult
Clinical case 3 Depression Among Elderly
Clinical case 4 Generalized Anxiety disorder and Panic Attack
Fluoxetine Drug indication Side effect Contraindication and Interaction
Serotonin Syndrome and Emergency management protocol
Anti Depressants using Special Conditions
Clinical case 1 Depression and Anxiety among Adolescence
Clinical case 2 Depression Among Adult
Clinical case 3 Depression Among Elderly
Clinical case 4 Generalized Anxiety disorder and Panic Attack
Fluoxetine Drug indication Side effect Contraindication and Interaction
Serotonin Syndrome and Emergency management protocol
Anti Depressants using Special Conditions
2
5. • Case scenario
• Faisal 15 years old school student came with irritability , insomnia and impulsive
behavior . Most of the time he feels lack of Energy and hopelessness
• During covid 19 he has to attend online lectures he is unable to concentrate for
his study .
• He did not enjoy with his life and social environment family and friends .
• Does not like to play foot ball any more (favorite game )and like to live alone.
• He is the youngest child of the family and he grown up since his child hood with
parental conflict his parents are too old to take care of his health and understand
his emotions and behavior .
• His brothers and sisters are married and busy in their life .
• He thinks no body care about him he is worth less
• He is feeling sick he just want to get rid of all issues He is unable to cope with
these circumstances so he smokes one packet per day .
• Case scenario
• Faisal 15 years old school student came with irritability , insomnia and impulsive
behavior . Most of the time he feels lack of Energy and hopelessness
• During covid 19 he has to attend online lectures he is unable to concentrate for
his study .
• He did not enjoy with his life and social environment family and friends .
• Does not like to play foot ball any more (favorite game )and like to live alone.
• He is the youngest child of the family and he grown up since his child hood with
parental conflict his parents are too old to take care of his health and understand
his emotions and behavior .
• His brothers and sisters are married and busy in their life .
• He thinks no body care about him he is worth less
• He is feeling sick he just want to get rid of all issues He is unable to cope with
these circumstances so he smokes one packet per day .
5
6. Depression among Adolescent and Children
Depression as not only adult , but Children – Especially Adolescents – commonly
suffer from depression.
The condition interferes with their ability to perform well in school and develop and
maintain relationships, and can have lasting repercussions, especially if it goes
unnoticed.
Children and Adolescents, depression is often accompanied by behavioral
problems, substance abuse, and/or other mental disorders.
Unfortunately, in children and adolescents, depression can manifest differently
than it does in adults, so parents are not always able to recognize the problem .
Depression as not only adult , but Children – Especially Adolescents – commonly
suffer from depression.
The condition interferes with their ability to perform well in school and develop and
maintain relationships, and can have lasting repercussions, especially if it goes
unnoticed.
Children and Adolescents, depression is often accompanied by behavioral
problems, substance abuse, and/or other mental disorders.
Unfortunately, in children and adolescents, depression can manifest differently
than it does in adults, so parents are not always able to recognize the problem .
6
7. One in six people are aged 10-19 years.
Mental health conditions account for 16% of the global burden of disease and injury in people aged 10-
19 years.
Half of all mental health conditions start by 14 years of age but most cases are undetected and
untreated(1).
Globally, depression is one of the leading causes of illness and disability among adolescents.
Suicide is the fourth leading cause of death in 15-19-year-old. Adolescent and mental health who 2020
In Saudi Arabia study conducted by Nada Al Yousefi in Riyadh 32.4 % found moderate to severe
depression among Saudi adolescent
In Abha Saudi Arabia Among Secondary school girls prevalence of symptoms of depression,
anxiety and stress was 41.5 %, 66.2% and 52.5% respectively as compare to adolescent boy
(38.2%) had depression, while 48.9% had anxiety and 35.5% had stress. .(al gublan )
7
8. Depression Risk Factors Among Adolescent
Media influence and gender norms can exacerbate the disparity between an adolescent’s lived reality and
their perceptions or aspirations for the future.
History of depression in a parent or sibling
Quality of their home life Family dysfunction or conflict with a caregiver and relationships with peers.
Problems with friends or school
Violence (including harsh parenting and bullying) and socioeconomic problems .
Children and adolescents are especially vulnerable to sexual violence
Exposure to early adversity (such as abuse, neglect, the loss of a loved one in early life)
Negative outlook or poor coping skills
Previous bouts of depression
History of anxiety disorders, learning disabilities, attention deficit hyperactivity disorder, or significant
defiance or conduct problems ,history of brain injury or low birth weight , chronic medical illness .
8
9. Diagnostic criteria for depression
Major depression, a child or adolescent must have five or more of the following symptoms
present most of the day nearly every day for at least two consecutive weeks.
• For the diagnosis, at least one symptom must be either depressed mood or loss of interest or pleasure.
• Depression or irritable mood
• Diminish interest and pleasure
• Change in appetite or weight
• Sleep disturbances
• Psychomotor agitation or retardation (restlessness or sluggishness)
• Fatigue or loss of energy
• Feelings of worthlessness or guilt
• Impaired concentration and decision making
• Recurring thoughts of death or suicide
Depression in children and adolescents Uptodate 2021
9
10. Case continue…….
• Faisal is 15 years old school student came with irritability , insomnia and impulsive
behavior . Most of the time he feels lack of Energy and hopelessness .
• During covid 19 he has to attend online lectures he is unable to concentrate for his study
• Does not like to play foot ball any more (favorite game )does not want to see his friends
and like to live alone.
• He thinks no body care about him he is worth less .
• he did not enjoy with his life and social environment friends and family .
• He is the youngest child of the family and grown up with daily parental conflict his
parents are too old to take care of his health and understand his emotions and behavior .
• His brothers and sisters are married and busy in their life .
• He is feeling sick he just want to get rid of all issues He is unable to cope with these
circumstances history of smoking .
• Despite all this he think but never plan attempt or commit suicide
10
11. Case continue ……
Examination :
• BP :120/70mmhg Weight 70 height 150
• MMSE :
• Look Anxious , angry , irritable , sitting at the edge of chair no eye to eye contact
• Mood : Sad and Anxious Speech
• Tone : Angry
• Insight : present
• No Hallucination and delusion
• Conscious and alert
11
13. 13
Case continue…….
PHQ 9 24 GAD 7 14
As we have diagnosed Faisal
With severe Depression and Anxiety
Plan of Management
?
14. The Treatment of Adolescent Depression Study
•The largest study, involved subjects who were randomly assigned to receive
placebo, CBT alone, fluoxetine alone, or a combination treatment of CBT
with fluoxetine.
•Subjects assigned to receive combination treatment or fluoxetine alone showed
significantly greater improvement in their depressive symptoms and more rapid
initial response when medication is initiated first or in combination with therapy.
• The superiority of combination therapy is also demonstrated in adolescents with
anxiety.
Guidelines for Adolescent Depression in Primary Care (GLAD-PC): Part II. Treatment and Ongoing Management
14
15. Psychotherapy
• CBT (Cognitive Behavioral Therapy )
• Numerous meta-analyses and reviews have been conducted on CBT in the
treatment of adolescent depression and showed the effectiveness of CBT for
adolescents with moderate to moderately severe depression improved
outcomes for subjects treated with CBT. (Treatment of Adolescent Depression Study)
• IPT-A (Interpersonal Therapy – for Adolescent)
IPT-A was found to have significantly higher effects on reducing severity of
depression, suicidal ideation, and hopelessness compared with treatment as usual.
Guidelines for Adolescent Depression in Primary Care (GLAD-PC): Part II. Treatment and Ongoing Management
AMERICAN JOURNAL OF PEADRIATICS 2018
15
16. Pharmacotherapy
• SSRIs that have been studied and used in children and adolescents with
unipolar major depression include
• Fluoxetine (Prozac) drug of choice less sedative
• Citalopram (Celexa),
• Escitalopram (Lexapro),
• Sertraline (Zoloft).
• Fluvoxamine ( Luvox), side effect dose related
• Paroxetine ( Paxil), most sedative
• Fluoxetine has been more widely studied than other SSRIs
in children and adolescents.
Uptodate 2021 Depression in children and adolescents
16
17. Case continue ……..
• With the agreement of Faisal
• Combination Therapy CBT And pharmacotherapy
• CBT refer the patient CBT clinic psychiatric hospital
• About the drug we will start with (SSRI )Fluoxetine
Now Faisal question about drug duration side effect and for how long I
will take the medication to improve ?
17
18. Patient Education about drug therapy
recommendation
An antidepressant medication for a child or adolescent's depression, the following issues
should be discussed before treatment begins:
The expected benefits and possible risks and side effects
The instructions for the dose and timing
The expected length of time to response
Potential interactions with other prescription or non-prescription medications
Alternatives to medication (eg, continued psychotherapy)
Depression in children and adolescents Uptodate 2021
18
19. Fluoxetine (Prozac)
Indications:
• Major Depressive Disorder , Bulimia
Nervosa , Obsessive-Compulsive Disorder, Panic
Disorder, and Premenstrual Dysphoric Disorder (PMDD).
Fluoxetine and Olanzapine (Zyprexa) to treat manic
depression caused by bipolar disorder.
• Fluoxetine should be started at least 14 days after
stopping an MAO inhibitor .(such as Isocarboxazid,
Rasagiline, Selegiline, Phenelzine, or Transcypromine).
• Thioridazine or an MAOI should be started 5 weeks
after stopping fluoxetine .
19
20. Common fluoxetine side effects :
• Sleep problems insomnia strange
dreams
• Headache, dizziness, drowsiness,
vision changes;
• Tremors or shaking, feeling anxious
or nervous;
• Pain, weakness, yawning, tired
feeling;
• Upset stomach, loss of appetite,
nausea, vomiting, diarrhea;
• Dry mouth, sweating, hot flashes
• changes in weight or appetite;
• Stuffy nose, sinus pain, sore throat,
flu symptoms; or
• Decreased sex drive, impotence or
difficulty having an orgasm.
20
21. • The updated treatment review for antidepressant safety and efficacy included
randomized controlled trials (RCTs) of antidepressants in youth with depression.
• In this GLAD-PC review, we identified 27 peer-reviewed articles in this area, including
trials with fluoxetine, sertraline, citalopram, paroxetine, duloxetine, and venlafaxine .
• Available evidence from RCTs Adverse effects ( nausea, headaches, behavioral
activation, etc) were found to occur in most adolescents treated with antidepressants,
with duloxetine, venlafaxine, and paroxetine as the most intolerable.
• Therefore, routine monitoring of the development of adverse events is critical for
depressed youth treated with antidepressants.
Guidelines for Adolescent Depression in Primary Care (GLAD-PC): Part II. Treatment and Ongoing Management
21
22. Time required for a response — Some people respond to antidepressant medication after about 2 weeks, but
for most, the full effect is not seen until 4-6 weeks or longer.
During the first few weeks, the dose is usually increased gradually.
The patient usually follow up by the prescribing clinician once per week for the first four weeks, then every
two weeks for the next four weeks, and then every one to three months
By six to eight weeks after starting an antidepressant medication, it is usually possible to determine if the
medication is effective. If symptoms have improved somewhat during this time, the dose of the medication
may be increased.
Duration — In most cases, the antidepressant medication is continued for at least 6 to 12 months
after the symptoms of depression improve.
Maintenance therapy may last from one year to indefinitely, depending upon the individual's
situation and personal history of depression.
Depression in children and adolescents Uptodate 2021
22
23. FLUOXETINE Drug interaction
• Any other antidepressant MOI , SNRI
• Amitriptyline Nortriptyline Desipramine
buspirone
• lithium
• St. John's Wort
• Tryptophan
• Warfarin Coumadin
• Medicine to treat ADHD - Amphetamine ,
Methylphenidate , atomoxetine
• Narcolepsy Modafinil
• Migraine headache medicine - Rizatriptan
Sumatriptan Zolmitriptan
• Metoclopramide
• Narcotic pain medicine - fentanyl
tramadol
FLUOXETINE should be
used with CAUTION
• Cirrhosis of the liver
• Urination problems
• Narrow-angle glaucoma
• Seizures or epilepsy
• Bipolar disorder (manic
depression)
• Drug abuse or suicidal
thoughts
23
24. Case continue…….
Management
Clarification , Reassurance ,Prevalence and Prognosis of his problem .
• Cognitive Behavioral Therapy ( refer to CBT clinic and advice for online CBT session for depression
and anxiety)
• Life Style modification (Diet and Exercise)
Pharmacological Therapy (Combination therapy )
Patient education about Drug therapy
• Cap Fluoxetine 10 mg po od in the morning first week then cap Fluoxetine 20 mg po od from next
week
• Tab lorazepam 2 mg po od for two weeks
• Follow up weekly 1st month ( side effect , drug response via scale/symptoms)
• Biweekly 2nd month 8-12 week (Remission )
• Monthly for 3 month then every 2-3 month ( maintenance ) 6-12month
24
25. • Faisal was Follow up after one week (No suicidal ideation or side effect )
• Then weekly for one month Stable feeling better
• Follow-up was done biweekly for second month showing good improvement .
• Faisal Came after 3 month with Anxious ,restlessness, disorientation , agitated , high temperature, high
blood pressure, vomiting , diarrhea ,Tremors, hyperreflexia.
Rapid history raveled that he took drug for nausea and vomiting along with his antidepressant after
this start these symptoms.
What is diagnose how do you managed this situation
?
25
Case continue …….
26. Serotonin syndrome
• Clinical presentation :
• Anxiety ,restlessness, disorientation , agitated, delirium,
• Diaphoresis, hyperthermia, hypertension, vomiting , diarrhea
• Tremors , myoclonus, hyperreflexia, bilateral bikinis sign
• Management Emergency call for Ambulence
• ABC
• Stabilize the patient
• Discontinue serotonergic agent
• lorazepam1-2 mg IV /dose
• Provide oxygen IV fluids continues cardiac monitoring
• If benzodiazepine and supportive treatment fails give Cyproheptadine (4-20 mg)12
mg orally or NGT
26
27. Course of illness — Studies indicate that In adolescents, After recovery, depression might last
4 to 9 months, and 20 to 50 percent might relapse.
Case continue ……….
• Faisal came after 3 month looks depressed he admit he stopped his medication
for one month as he was assuming he is improve and no longer need further
treatment .
• Plan with agreement to restart medication same dose without stopping himself .
• After one year of regular follow up now plan to stop the medication gradually
• With close follow up continues observation of symptoms .
27
29. Case scenario …..
38 years old female referred from general physician to Family Medicine clinic with complaint of
chronic headache since long time which is not relieving from Analgesics .
Patient has an episodes unilateral headache throbbing pain that is associated with nausea ,pain
was lasting for 2-3 days 3-4 times in a month and she also complaints of difficulty in sleep and
unrefreshed sleep and feeling tired after getting up in the morning .
No history of chronic illness
History of Analgesic prescribed frequently by physician Tab paracetamol and Tab Ibuprofen
History of OCP since 4 years
Other history is unremarkable
Examination : Stable BP 130/90
Our First plan to Stop the OCP and refer her for alternative non hormonal method of
contraception . (Migraine with Aura , hypertension, depression )
Patient came after 2 weeks BP was improved 110/70 mmHg .
Still complaining of headache . …………
29
30. 5- steps protocol for providing mental healthcare in primary health
care(WHO)
30
33. STEP 1-Suspect patient had some hidden agenda frequency of visit an chronic pain
STEP 2- Screen The patient Depression and Anxiety (positive)
Explore idea concern and expectation
Does the patient has Stress ?
• Sleep pattern disturbed sleep unrefreshed sleep (moderate severe)
• Performance markedly declined she is hardly to do daily home duties
• (Moderate severe)
• Relationship She is married with 4 kids she is not happy with social life
(her family and friend lives in another city) She is sad and depressed
• Daily conflict with his husband and she had an aggressive behavior with her kids
(severe ).
33
5- steps protocol for providing mental healthcare in primary health care(WHO)
34. • STEP 3 -Scoping some time she had an suicidal ideation but she never attempt
or either think to attempt .
• No history of hallucination or delusion
• No history of substance abuse
• No history of episode of high mood or low mood
• Reason for referral no
• STEP 4-Diagnosis based on m GAP version 2.0 (WHO 2016)
• Sad mood and loss of interest (screening depression positive)
• Level of disorder Moderate Severe Depression PHQ :9 16
Chronic Migraine Headache
34
5- steps protocol for providing mental healthcare in primary health care(WHO)
36. • Migraine is linked both with Depression and Anxiety people with migraine 5 times
more likely to develop depression then without migraine .
• Migraine Depression and Anxiety
• About 25 % of patient with Migraine have depression and 50% have Anxiety .
American migraine foundation 2018
36
37. Depression and chronic migraine prevention
Class/agent Psychiatric use Migraine
prevention
TCA(amitriptyline) Effective for
depression at higher
doses with more
side effect
Effective for
Migraine prevention
at low doses with
minimal side effects
SNRI (Venlafaxine) Effective for
depression and
anxiety
Only Venlafaxine
has a grade B
evidence of efficacy
for Migraine
prevention
37
• Venlafaxine (SNRI)
• Side effect
• Headache (25-38%)
• Nausea (21-58%) insomnia (15-24%)
• Dizziness (11-24%)
• Ejaculatory dysfunction (2-19%)
• Dry mouth (12-22%)
• Weight loss (1-6%)
• Abnormal vision (4-6%)
• Hypertension(2-5%)
38. STEP 5 : management
Non- pharmacological
Diet (Mediterranean ) and Exercise (BMJ, up to date )
Cognitive Behavioral Therapy , Supportive and Narrative therapy
Pharmacological
Tab venlafaxine 37.5 mg po od first week (*Choose with caution patient should not be on
SUMITRPTAN ) risk of serotonin syndrome
Second week Tab venlafaxine 75 mg po od
Follow up after 2 week
Patient response no side effect Feeling better continue the same dose
After 4 weeks patient came improves still sad PHQ 9: 10
This time plan to increase the dose of Tab Venlafaxine 150 mg follow up after 4 weeks
Patient came after 4 weeks she was happy no complaint of headache PHQ 9 was 0 (Remission
period) now follow up every 2-3 month
Plan to continue same dose for 6-9 month (Maintenance therapy )
38
40. •Case scenario…………
• 68 years old Syeda frequently visited to physician clinic she is not satisfied with her previous visits
every time she has a new complaint although she had been requested all investigation which is
requested for her complaints all investigation are normal .
• On this visit anxious and looks sad no eye to eye contact on further exploration it is revealed that
she is suffering from sleep disturbances . She is alone at home
• His husband died few years ago and she had a one daughter she lived for her study in another city .
• She is known case of Hypothyroidism , Gout and Osteoarthritis .
On further exploration of hidden addenda because her frequent visits and sleep disturbance she is
in STRESS .
SUSPECT ? Depression
Depression in older adults diagnosis and management BMJC vol 19
40
41. Depression in elderly
•PHQ 2 screening PHQ 9 diagnostic criteria
Depression Geriatric scale
Criteria: Questions (abnormal or positive answers in parentheses)
1.
Are you basically satisfied with your life? (No) Yes
2.
Do you often get bored? (Yes)
3.
Do you often feel helpless? (Yes)
4.
Do you prefer to stay at home rather than going out and doing new things? (Yes)
5.
Do you feel pretty worthless the way you are now? (Yes)
• III. Interpretation
1.
Two positive answers suggests depression Syeda score 4
•IV. Efficacy
1.
Test Sensitivity: 97%
2.
Test Specificity: 85%
3.
As effective as the Fifteen-Item Geriatric Depression Scale
Hoyl (1999) J Am Geriatr Soc 47(7): 873-8 [PubMed]
41
42. • Prevalence of depression among the elderly DGS indicated
45% of the studied population having depressive symptoms
(36% moderate, 9% severe), (AlShammri Al subaie)
• Depression, regardless of its severity, was recorded among
63.7% of elderly patients.
• Mild and moderate depression was reported by 47.5% and 14.5% of elderly
patients respectively while severe depression was reported by only 1.8% of them.
Eisa Y. Ghazwani (1) Hassan M. Al-Musa (2).
42
43. Predisposing factors include previous clinical depression, physical and chronic disabling illnesses
(e.g., cerebrovascular illness, multiple medications and persistent sleep difficulties.
Psychosocial predisposing risk factors include female gender, personality traits such as dependency,
being widowed or divorced, being socially disadvantaged, lacking social support, and having
caregiving responsibilities for others with significant illness.
Precipitating risk factors for LLD include recent bereavement, change of residence (e.g., from house
to nursing home), and adverse life events (e.g., loss, separation, financial crisis, declining health,
marital problems).
Recently bereaved patients should be screened for LLD and a clinical determination should be made
regarding depression based on the patient’s history and the cultural norms for the expression of
distress after loss.
Depression in older adults diagnosis and management BMJC vol 19
43
44. Help-seeking behaviors
Suggestive of LLD include persistent complaints of
pain, headache, fatigue, insomnia, gastrointestinal
distress, weight loss, and multiple diffuse symptoms.
There may be frequent calls and visits to
the family practitioner and high utilization
of services
44
45. DSM-5 Diagnosis criteria of LLD (Late Life Depression)
The criterion “markedly diminished interest or pleasure” may overlap with or be confused with the
apathy of dementia (classified as major neurocognitive disorder in DSM-5) .
Loss of weight or appetite
Sleep disturbance ( physical illness, chronic pain, or the use of substances such as opioids).
Psychomotor retardation, fatigue, and anergia
Feelings of worthlessness and suicidal ideation (to end-of-life issues. )
45
47. A complete assessment for Late Life Depression :
Reviewing DSM-5 diagnostic criteria for late-life depression and assessing the patient for
depression using appropriate screening tools.
• Performing a physical examination and ordering laboratory investigations to identify (e.g.,
hypothyroidism, anemia).
• Determining severity of condition, including presence of psychosis or catatonia.
• Assessing suicide risk.
• Identifying any comorbid psychiatric and medical illnesses.
• Identifying any personal or family history of mood disorder.
• Reviewing current medications, allergies, and substance use.
• Reviewing current stresses and life situation.
• Assessing level of functioning/disability.
• Considering support system, family situation, and personal strengths.
• Reviewing results from Mini-Mental State Exam and any other tests for cognitive function.
• Reviewing collateral information.
47
48. Management late-life Depression
There is good evidence to support the use of Psychotherapy or Pharmacotherapy alone, and the
two in combination.
For Milder forms of LLD, psychotherapy may be recommended as a stand-alone treatment, with the
addition of pharmacotherapy if required.
For Moderate severity LLD, antidepressant treatment is recommended, with the addition of
psychotherapy if required.
For Severe LLD, antidepressant treatment and referral to mental health services are recommended.
48
49. Case continue …..
• Syeda has help seeking behavior with frequent visits and has multiple predisposing and
predisposing psychological risk factors
• persistent sleep difficulties
• Geriatric depression score positive 4
• Mini Cog screening for cognitive impairment 3-5 negative screen for dementia
Diagnosed her Moderate depression
Plan of management
?
• Depression Geriatric scale
• Depression Geriatric scale
49
50. pharmacotherapy
SSRIs (e.g., Citalopram, Escitalopram, Paroxetine, Sertraline)
SNRI ((e.g., venlafaxine), bupropion, moclobemide, and mirtazapine are all
commonly used and well tolerated by older patients. 2014 guideline update from the Canadian
Coalition for Seniors’ Mental Health
In General, Drugs side effect constipation, diarrhea, nausea, insomnia,
somnolence, and sexual dysfunction
Depression in older adults diagnosis and management BCMJ vol 59 2019
50
51. While response rates to antidepressants are similar in younger and older patients, physiological changes with aging,
polypharmacy, and comorbidities all increase the risk of adverse drug reactions occurring.
“start low, go slow” but go
with the understanding that older patients may require full adult doses in order to
Achieve Response (a 50% reduction in symptoms on a validated depression scale) or
Remission (absence of depression on a validated depression scale) since many older adults receive
subtherapeutic doses or are treated for inadequately short periods.
Depression in older adults diagnosis and management BCMJ vol 59 2019
51
Guide line for Management late-life Depression
52. Guide line for Management late-life Depression
Antidepressant medications for LLD should be started at half the normal adult dose and then increased within 1 week
if tolerated.
Subsequently, doses should be titrated up regularly until there is a noticeable clinical response, maximum dose is
reached, or side effects limit further increases. The aim should be to reach average therapeutic dose within 4 weeks.
A change of medication should be considered if there is no response after 4 weeks on maximum dose.
If there is only partial response after 8 weeks, options include switching to or adding on an alternative therapy.
Augmentation include lithium, methylphenidate, another antidepressant (preferably of a different class), an
atypical antipsychotic, or psychotherapy.
Physicians without comfort or experience using multiple agents should consider referral to a specialist or use the
strategy of switching.
When adding on a second serotonergic antidepressant, clinicians must monitor for serotonin syndrome.
Depression in older adults diagnosis and management BCMJ vol 59 2019
52
53. Full remission of symptoms should be the goal of treatment.
Following remission of a first episode of LLD, patients should be maintained on a full therapeutic
dose of medication for at least 1 year.
If pharmacotherapy is discontinued, it should be done gradually over months with close monitoring.
Patients who respond but do not achieve full remission should be maintained on therapy indefinitely
with ongoing effort to achieve full resolution.
Patients who have had more than two episodes of LLD or had particularly severe episodes should
also continue on indefinite antidepressant treatment if tolerated.
Depression in older adults diagnosis and management BCMJ vol 59 2019
53
Guide line for Management late-life Depression
54. Patient follow-up visit…….
• After the patient agreement clarification
• Combination therapy CBT + Pharmacotherapy
• We start with Syeda Tab Escitalopram 5 mg po od 1st
2 week
• After 2 week patient came she is feeling better and her sleep has been improved .
She is giving good response follow up after one month
• Next visit patient came she is fine but still restless plan to increase the dose tab
Escitalopram 10 mg po od
• After 8 week patient came she is improved sleeping well feeling happy .
• Continue same dose for 6-9 month . Thank you
54
56. Case scenario ………..
• 40 years old female came with excessive worries and anxiety her symptoms has been
increased after the death of her close relative .
• She feels anxious and nervous and unbale to concentrate on her work and feel tired all the
time
• She has a disturbed sleep and started to have an episodes of dyspnea palpitation chest pain
and at every night especially at the time of sleep her symptoms associated with gastritis
flatulence abdominal pain .
• She had an similar episode 6 years ago for which she has been treated for one year with SSRI
for her Anxiety after which she completely improved .
• No history of chronic illness
• No family history of psychiatric illness
• She is married with 3 children her youngest child is 3 years old
• She has a good relation with her husband family
• She on OCP
56
57. Case continue ……..
• Her concern is about SSRI might cause interaction with OCP and the same
time she is worrying if she conceive these medication affect on her
pregnancy whether this drug is safe for her future pregnancy ?
• Examination vital are BP 110/70 mmHg
• Weight 78 kg
• Mini Mental State Examination : Well behaved and well dressed looks tense
irritable anxious nervous
• Speech tone normal mood not sad but anxious
• Good memory
• Insight
• No hallucination or delusion
57
61. The presence of excessive anxiety and worry about a variety of topics, events, or
activities. Worry occurs more often than not for at least six months and is
clearly excessive.
The anxiety and worry are accompanied by at least three of the following physical
or cognitive symptoms
• Edginess or restlessness
• Tiring easily; more fatigued than usual
• Impaired concentration or feeling as though the mind goes blank
• Irritability (which may or may not be observable to others)
• Increased muscle aches or soreness
• Difficulty sleeping (due to trouble falling asleep or staying asleep, restlessness at
night,
• or unsatisfying sleep)
61
DSM- 5 diagnosis of GAD
62. A panic attack is a sudden and intense feeling of terror, fear, or apprehension, without the presence of actual
danger. Symptoms of a panic attack usually happen suddenly, peak within 10 minutes, and then subside.
• Chest pain or discomfort
• Chills or hot sensations
• Feeling of choking
• Feeling dizzy, unsteady, lightheaded, or faint
• Fear of dying
• Fear of losing control or going crazy
• Feelings of unreality (derealization) or being
detached from oneself (depersonalization)
• Nausea or abdominal distress
• Numbness or tingling sensations (paresthesia)
• Palpitations, pounding heart, or accelerated heart
rate
• Sensations of shortness of breath or smothering
• Sweating
• Trembling or shaking
According to the (DSM-5) A Panic
attack is characterized by a “surge of
intense fear or intense discomfort that
reaches a peak within minutes” and
includes four or more of symptoms.
62
63. Generalized anxiety disorder (GAD)
and panic disorder (PD) are among
the most common mental disorders
in the United States, and they can
negatively impact a patient's quality
of life and disrupt important
activities of daily living.
Evidence suggests that the rates of
missed diagnoses and misdiagnosis
of GAD and PD are high, with
symptoms often ascribed to
physical causes
Diagnosing GAD and PD requires a
broad differential and caution to
identify confounding variables and
comorbid conditions.
Screening and monitoring tools can
be used to help make the diagnosis
and monitor response to therapy.
The GAD-7 and the Severity
Measure for Panic Disorder are free
diagnostic tools.
Successful outcomes may require a
combination of treatment
modalities tailored to the individual
patient.
63
64. Clinical recommendation for GAD and Panic Attack(aafp)
Clinical recommendation for GAD and Panic Attack
64
Treatment
SSRI are first line of therapy for GAD and PD .
SSRI/psychotherapy, both of are highly
effective. B
Medication should be continued for 12 months
before tapering to prevent relapse. C
Psychotherapy is as effective as
medication for GAD and PD cognitive
behavior therapy has a best level
evidence . A
Benzodiazepines are effective in
reducing anxiety symptoms, but their
use is limited by risk of abuse and
adverse effect profiles. B
Physical activity is cost effective for
GAD and PD and can reduce
symptoms of GAD and PD. B
65. Medication for Generalized Anxiety Disorder and panic disorder
First line
SSRI
2nd
line
Tricyclic
Antidepressants
Escitalopram
(Lexapro) Fluoxetine (Prozac) Fluvoxamine for PD Paroxetine Sertraline (Zoloft)
Amitriptyline Nortriptyline
Imipramine
(Tofranil)
Antiepileptics
Pregabalin (Lyrica)
for GAD
3rd
line
Monoamine
oxidase inhibitors
Quetiapine
(Seroquel) for GAD
Hydroxyzine
(Vistaril)
Augmentation
Benzodiazepines
Isocarboxazid Phenelzine Tranylcypromine
Alprazolam (Xanax)
Clonazepam
(Klonopin)
Diazepam (Valium)
for GAD
65
66. OCP with depression and antidepressants
•Association of Use of Oral Contraceptives With Depressive
Symptoms Among Adolescents and Young Women
•Although oral contraceptive use showed no association with depressive
symptoms when all age groups were combined, 16-year-old girls reported
higher depressive symptom scores when using oral contraceptives.
•In double blind treatment there was no difference between OCP users and non user in
response to SSRI (sertraline and fluoxetine)
•Another study women taking fluoxetine for major depression and OCD and bulimia found no
interaction with OCP .
AMA Psychiatry. 2020;77(1):52-59. doi:10.1001/jamapsychiatry.2019.2838
66
67. Which antidepressants are safe to use during pregnancy?
Evidence-Based Answer
There are no studies that have shown any antidepressant to be absolutely safe for use during
any stage of pregnancy. The use of (SSRIs) or tricyclic antidepressants (TCAs) during pregnancy
does not increase the risk of congenital malformations or miscarriage. (B )
The use of SSRIs or TCAs during pregnancy may increase the risk of preterm birth, low birth
weight, respiratory distress, and neonatal convulsions, without obvious subsequent adverse
neurodevelopmental outcomes. ( B)
(ACOG) recommends avoiding paroxetine use during pregnancy. Fetal echocardiography
should be considered if a woman takes paroxetine in early pregnancy.
ACOG also recommends the use of a single medication at higher dosages over the use
of multiple psychotropic medications.
American academy family physician FPIN Clinical queries
67
68. ACOG Guidelines on Psychiatric Medication Use During Pregnancy and Lactation
• Ten to 16 percent of pregnant women meet diagnostic criteria for depression,
and up to 70 percent of pregnant women have symptoms of depression.
• Studies have shown a relapse rate of 68 percent in women who discontinue
antidepressant therapy during pregnancy.
• Untreated maternal depression is associated with increased rates of adverse
outcomes (e.g., premature birth, low birth weight, fetal growth restriction,
postnatal complications), especially when depression occurs in the late second
to early third trimesters.
68
69. ACOG Guidelines on Psychiatric Medication Use
During Pregnancy and Lactation
• There is limited evidence of teratogenic effects from the use of
antidepressants in pregnancy and adverse effects from exposure during
breastfeeding.
• Exposure to selective serotonin reuptake inhibitors (SSRIs) late in pregnancy
has been associated with transient neonatal complications; however, the
potential risks associated with SSRI use must be weighed against the risk of
relapse if treatment is discontinued.
• Treatment with SSRIs or selective norepinephrine reuptake inhibitors during
pregnancy should be individualized.
69
70. Which antidepressants are safe to use during
pregnancy?
• SSRIs In Pregnancy
• Fluoxetine C less sedative
• Citalopram C
• Escitalopram C
• Sertraline C
• Fluvoxamine C
• Paroxetine D most sedative
Amitriptyline case control study no increase risk of congenital malformation
Little evidence is available on the use of duloxetine (Cymbalta),
escitalopram (Lexapro), or bupropion (Wellbutrin) during pregnancy.
70
