Case question

[Zenman1]

From a doc in our dept:
I have a case that I'd like a little feedback on.

15 y/o who is clinically depressed. He has a history of a spontaneous brain
bleed about 2 years ago, no hx of trauma or other medical cause found.
Because of the bleed, providers have been hesitant to prescribe an
antidepressant. He also seems to have some cognitive dysfunction, which is
pending psychological testing to further eval. He's already done the
"therapy alone" route for treatment, which has not been sufficient.
I've looked on uptodate and through my textbooks already, but wanted to
bounce this off of my colleages as well. Typically I would start with
either Prozac or Zoloft in a teen, but I know SSRIs can have an effect on
platelet aggregation. I thought about Wellbutrin, but it can lower seizure
threshold (this young man has not had frank seizures that I know of). I
thought about Remeron, which would be great as he's having significant sleep
problems as well, but it also works partially on serotonin. I thought of
using a stimulant, but that could raise blood pressure.
Any input/ideas/suggestions??

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[Merovinge]

Do we know more about the location of the bleed and what workup was done (hes had the full heme workup I presume?). Also any idea what the specific cognitive dysfunctions are? While Id love formal neuropsych testing just a gross description of the deficits would help. Presuming that heme workup is negative for any known increased bleeding risks, I would think an SSRI would be medically appropriate if the likely cause of the bleed was a "1 of" small vascular abnormality. He should essentially be treated like any other teen if my supposition is close to what neurosurgery or heme said.

 

[nitemagi]

In the risk of recurring bleed vs. sz arena, I'd venture that the risk of sz is lower. Also agree to find out if the cause of the bleed was evaluated. Can also consider alternative Tx's if meds are really contraindicated, like TMS (I'm skeptical about it, but in this case maybe you could get insurance to pay for it).

 

[Psychobabbling]

My first question is has heme/onc ever seen this kid? If you have a "spontaneous brain bleed" the first thing I'm worried about is factor dysfunction/deficiency/etc

Secondly, in terms of treatment. Remeron and Wellbutrin are sound choices. I want to say Celexa could be an option too for some reason, but don't quote me on that. It's not just if it works on serotonin, but how strongly it works on serotonin.

If the kid is significantly depressed, it would be horrible to say "well, you had this bleed that no one really properly worked up, so we don't know, hope ya feel better!"

A stimulant wouldn't be my first choice. If it was a spontaneous bleed, especially in an adolescent, I doubt blood pressure played a role in the development of such.

I wouldn't delay treatment. If I was really concerned and he was in the hospital, I would make appropriate consults (Neuro, heme/onc, etc) to help figure out what medical problem the kid is dealing with....and I would treat him for his depression with his parents consent after reviewing risks/benefits/alternative options.

 

[smalltownpsych]

From a doc in our dept:
I have a case that I'd like a little feedback on.

15 y/o who is clinically depressed. He has a history of a spontaneous brain
bleed about 2 years ago, no hx of trauma or other medical cause found.
Because of the bleed, providers have been hesitant to prescribe an
antidepressant. He also seems to have some cognitive dysfunction, which is
pending psychological testing to further eval. He's already done the
"therapy alone" route for treatment, which has not been sufficient.
I've looked on uptodate and through my textbooks already, but wanted to
bounce this off of my colleages as well. Typically I would start with
either Prozac or Zoloft in a teen, but I know SSRIs can have an effect on
platelet aggregation. I thought about Wellbutrin, but it can lower seizure
threshold (this young man has not had frank seizures that I know of). I
thought about Remeron, which would be great as he's having significant sleep
problems as well, but it also works partially on serotonin. I thought of
using a stimulant, but that could raise blood pressure.
Any input/ideas/suggestions??

The therapy alone may not have been sufficient because of the provider. Most therapists don't have much experience working with patients with cognitive deficits. A good neuropsychologist might provide some solid treatment recommendations and a referral to a provider with experience in that area. Some might even provide the treatment for the deficits themselves which might be sufficient to alleviate some of the depression. I could be way off with this, but I see too many cases of therapists looking for the "deep rooted underlying cause" of the depression when it is as simple as "I can't do what I used to and it sucks."

p.s. If that's the case then medication might have less benefit, as well, since that won't "fix" his problem either.

 

[Armadillos]

Obviously a very different situation and probably not relevant to this patient, but do any of your various institution's stroke neurologists routinely start SSRIs post-stroke regardless of depression? I've heard there is decent evidence for it improving overall function and recovery even if patients aren't depressed. As far as I know they don't do it routinely where I am.

 

[smalltownpsych]

Obviously a very different situation and probably not relevant to this patient, but do any of your various institution's stroke neurologists routinely start SSRIs post-stroke regardless of depression? I've heard there is decent evidence for it improving overall function and recovery even if patients aren't depressed. As far as I know they don't do it routinely where I am.

Increased risk of bleeding verses improved recovery. My guess is that physician first do no harm wins out and neurologists would be wary of routine prescriptions of SSRIs. Am very interested in this as I occasionally work with patients who this could impact. I also love to hear about the cutting edge neurobiological stuff and is one reason I frequent this forum. This is where I first heard about the neuroprotective effects of stimulants in children with ADHD.

 

[Armadillos]

Haven't actually read these yet, so basing it mostly on the titles. But first a analysis highlighting possible risks because as you say first no harm.

http://www.jwatch.org/na36234/2014/11/25/ssris-stroke-and-mortality-should-we-be-concerned

Then an analysis showing probable benefits

http://www.jwatch.org/na32286/2013/10/02/ssris-after-stroke-should-they-be-used-routinely

 

[Shikima]

A good comprehensive evaluation with neuropsych, OT/PT/Speech and a TBI Neurologist is the direction I would go in first. There will be a fair amount of quarterbacking during this period of time, much like a PCP would.