Case question

[Attending1985]

I have a 68 year old female patient. Reports starting on 50 mg zoloft for 20 plus years ago for mild depression. Stayed on it until about 3 years ago and her pcp switched her to Prozac after her Phq was elevated to moderate range. Was experiencing some phase of life issues. Got very anxious and dysphoric on the Prozac and has been switching antidepressants ever since. After a new med is started she will stabilize for around 2-3 months then experience severe depression and anxiety. This is much more severe than the mood change that got her on antidepressants initially. Nothing outside of ssri or snri has been used. I’m wanting to taper her off completely and give her some time off medication. I’ve never had a case like this before and wanted input.

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[Bartelby]

What about trying Zoloft again?

 

[Attending1985]

What about trying Zoloft again?

That was tried without success.

 

[psych_0]

How many more failed antidepressants until you try rTMS, Spravato or IV ketamine? If this is now a psychotic depression, could be worth it to have a conversation about ECT.

 

[Stagg737]

So meds were changed due to "phase of life issues" 3 years ago and changes in meds haven't seemed to help. Is she in therapy to address said issues? How has she been handling stressors? I find that meds fail splendidly when the issue involves existential questioning and that really just needs therapy and behavioral/social changes.

 

[Celexa]

So meds were changed due to "phase of life issues" 3 years ago and changes in meds haven't seemed to help. Is she in therapy to address said issues? How has she been handling stressors? I find that meds fail splendidly when the issue involves existential questioning and that really just needs therapy and behavioral/social changes.

In addition to this--what are her actual symptoms? 'depression' and 'anxiety' are uselessly vague terms. Is she having panic attacks? Constant running internal monolgue about what might happen next? Intrusive thoughts? Flashbacks or nightmares? What about physical symptoms--palpitations, fatigue, diaphoresis, shortness of breath? Is she suicidal for the first time in her life? What do other people in her family think? Sleep? Weight changes? Other medical diagnoses? Memory problems?....etc

The question as posed is unanswerable because the differential includes everything from simply a more severe episode of a prior MDD to new onset heart failure or COPD to being dumped by a boyfriend (being 68 doesn't preclude that) or having multiple people in your family die in a span of six months to dementia to a previously undiagnosed personality disorder or straight up loneliness--or multiple things in combination.

I'm not saying lay out every single detail on your patient in an internet forum but from the initial question all I can say is the answer isn't going to be spinning the antidepressant roulette wheel again.

 

[birchswing]

<Not a doctor or medical student>

I had some thoughts but won't share them due not being a HCP or student, but reading this one of my curiosities was how bad this initial episode that led to the change in medication was compared to the subsequent spells?

Was the Phq a fishing expedition that caused more harm than good?

 

[clausewitz2]

<Not a doctor or medical student>

I had some thoughts but won't share them due not being a HCP or student, but reading this one of my curiosities was how bad this initial episode that led to the change in medication was compared to the subsequent spells?

Was the Phq a fishing expedition that caused more harm than good?

No, it was screening in a particularly mindless way.

 

[clausewitz2]

In addition to this--what are her actual symptoms? 'depression' and 'anxiety' are uselessly vague terms. Is she having panic attacks? Constant running internal monolgue about what might happen next? Intrusive thoughts? Flashbacks or nightmares? What about physical symptoms--palpitations, fatigue, diaphoresis, shortness of breath? Is she suicidal for the first time in her life? What do other people in her family think? Sleep? Weight changes? Other medical diagnoses? Memory problems?....etc

The question as posed is unanswerable because the differential includes everything from simply a more severe episode of a prior MDD to new onset heart failure or COPD to being dumped by a boyfriend (being 68 doesn't preclude that) or having multiple people in your family die in a span of six months to dementia to a previously undiagnosed personality disorder or straight up loneliness--or multiple things in combination.

I'm not saying lay out every single detail on your patient in an internet forum but from the initial question all I can say is the answer isn't going to be spinning the antidepressant roulette wheel again.

This is the way.

I will add a possible involutional melancholia developing given the age and the apparent severity that is out of proportion to what she has experienced previously. But all these other possibilities are very much live.

If you are inclined to prescribe antidepressants again at some point escalating to TCAs straight off the bat would probably be ideal.

 

[Sushirolls]

Sleep Medicine consult; OSA

 

[comp1]

Well, another person harmed by inappropriately broad use of the PHQ... Anyways, even without any additional information, if she can talk, she needs to be in therapy. Ideally that therapy would be with a psychiatrist since there is some sort of medication focus here, but if not, the therapist needs to be in regular contact with a prescriber to figure out what is really going on.

 

[Attending1985]

In addition to this--what are her actual symptoms? 'depression' and 'anxiety' are uselessly vague terms. Is she having panic attacks? Constant running internal monolgue about what might happen next? Intrusive thoughts? Flashbacks or nightmares? What about physical symptoms--palpitations, fatigue, diaphoresis, shortness of breath? Is she suicidal for the first time in her life? What do other people in her family think? Sleep? Weight changes? Other medical diagnoses? Memory problems?....etc

The question as posed is unanswerable because the differential includes everything from simply a more severe episode of a prior MDD to new onset heart failure or COPD to being dumped by a boyfriend (being 68 doesn't preclude that) or having multiple people in your family die in a span of six months to dementia to a previously undiagnosed personality disorder or straight up loneliness--or multiple things in combination.

I'm not saying lay out every single detail on your patient in an internet forum but from the initial question all I can say is the answer isn't going to be spinning the antidepressant roulette wheel again.

She’s experiencing low mood, anhedonia, executive dysfunction, feeling consistently on edge, still sleeping ok. What’s different about her case is what she reports and her husband supports is that she has consistently been stable in her personality and not terribly stress reactive throughout her life. She worked full time and functioned well at work and in relationships. Based on what they’re telling me she never met criteria for a psychiatric disorder. As other people have said the rating scales at once yearly pcp appointments are not that helpful. I’m wondering if this is an iatrogenic response to medications.

 

[Attending1985]

Well, another person harmed by inappropriately broad use of the PHQ... Anyways, even without any additional information, if she can talk, she needs to be in therapy. Ideally that therapy would be with a psychiatrist since there is some sort of medication focus here, but if not, the therapist needs to be in regular contact with a prescriber to figure out what is really going on.

She is in therapy with a good therapist. She finds the coping skills helpful but this doesn’t to me or her therapist appear to be mainly psychological in nature.

 

[clausewitz2]

She’s experiencing low mood, anhedonia, executive dysfunction, feeling consistently on edge, still sleeping ok. What’s different about her case is what she reports and her husband supports is that she has consistently been stable in her personality and not terribly stress reactive throughout her life. She worked full time and functioned well at work and in relationships. Based on what they’re telling me she never met criteria for a psychiatric disorder. As other people have said the rating scales at once yearly pcp appointments are not that helpful. I’m wondering if this is an iatrogenic response to medications.

To the extent you're comfortable with details, what exactly constitutes executive dysfunction here? Also, when did she stop working. I have definitely seen this pattern before in people who worked fairly demanding jobs and did well at them having a tremendously difficult time adjusting to no longer having a professional identity to ground them.

 

[Attending1985]

To the extent you're comfortable with details, what exactly constitutes executive dysfunction here? Also, when did she stop working. I have definitely seen this pattern before in people who worked fairly demanding jobs and did well at them having a tremendously difficult time adjusting to no longer having a professional identity to ground them.

Difficulty with everyday decisions, planning meals, preparing for social events. We have a new check in system that was difficult for her. This is a stark departure from baseline. What’s different about her case is these changes are very abrupt when they occur. It doesn’t appear to be a chronic problem related to adjustment.

 

[Celexa]

To the extent you're comfortable with details, what exactly constitutes executive dysfunction here? Also, when did she stop working. I have definitely seen this pattern before in people who worked fairly demanding jobs and did well at them having a tremendously difficult time adjusting to no longer having a professional identity to ground them.

Agree--some high functioning people react very poorly to retirement (expectation: tons of free time and fun! Reality: lack of purpose and too much time to focus on regrets). And if they had dysfunctions kept in check by a rigorous schedule, it can get all the more disorienting.

Another significant possibility being the beginnings of a neuro cognitive disorder.

 

[Celexa]

Difficulty with everyday decisions, planning meals, preparing for social events. We have a new check in system that was difficult for her. This is a stark departure from baseline. What’s different about her case is these changes are very abrupt when they occur. It doesn’t appear to be a chronic problem related to adjustment.

This case is screaming to be assessed for age related neuro cognitive issues.

 

[Sushirolls]

Well, another person harmed by inappropriately broad use of the PHQ... Anyways, even without any additional information, if she can talk, she needs to be in therapy. Ideally that therapy would be with a psychiatrist since there is some sort of medication focus here, but if not, the therapist needs to be in regular contact with a prescriber to figure out what is really going on.

Wasn't the PHQ-9 fault.
We all have patients whose PHQ or GAD or whatever mismatch to their subjective symptoms and even the MSE.

It's the clinicians job to ignore "data" that isn't pertinent.
I'm a fan of running PHQ/GAD and billing for it.

 

[comp1]

If the therapist doesn't find the depression or anxiety "psychological" in nature...then I think all that's left is neurocognitive stuff.

 

[aim-agm]

Seconding the recommendation for investigating a neurocognitive disorder. Mood disorders are not infrequently the initial presentation of a neurocognitive disorder, even if the cognitive symptoms themselves are still not apparent.

This is by no means diagnostic, but the pattern I have noticed with anxiety as a product of incipient cognitive impairment is that it tends to be vague. In a primary anxiety disorder the patient is usually able to describe specific event/eventuality (or many specific ones) they are worried about and its (series of) consequences, e.g. "I am worried I'll fail this course...because then my GPA would drop...and then I'd lose my scholarship...and I'd have to drop out of college" (although this might take prodding and specific questioning to elucidate). In people with anxiety as product of impairment, the anxiety is vague; they feeling they describe is consistent with anxiety, but they aren't able to say what they are anxious will occur, or if they can, they can't describe the negative consequence they are worried about.

 

[Candidate2017]

She is in therapy with a good therapist. She finds the coping skills helpful but this doesn’t to me or her therapist appear to be mainly psychological in nature.

What do you mean "good" therapist? What are the therapist's credentials and experience? The only good therapists I've met are usually old psychiatrists who don't split treatment. Or PsyDs in their 70s and 80s.

Other than "coping skills", whatever that means (usually avoidance and/or stasis), what is she actually doing in and out of therapy sessions?

If the therapist psychiatrist doesn't find the depression or anxiety "psychological" in nature...then I think all that's left is neurocognitive stuff.

This case is screaming to be assessed for age related neuro cognitive issues.

Also, substance history and UDS result? It's not far fetched that retirees with more time on their hands blaze up quite a bit as a form of "coping mechanism".

 

[Merovinge]

What do you mean "good" therapist? What are the therapist's credentials and experience? The only good therapists I've met are usually old psychiatrists who don't split treatment. Or PsyDs in their 70s and 80s.

Other than "coping skills", whatever that means (usually avoidance and/or stasis), what is she actually doing in and out of therapy sessions?






Also, substance history and UDS result? It's not far fetched that retirees with more time on their hands blaze up quite a bit as a form of "coping mechanism".

You've never met a clinical psychologist (PhD) who does psychotherapy all-day everyday that was good?

 

[Candidate2017]

You've never met a clinical psychologist (PhD) who does psychotherapy all-day everyday that was good?

Whoops, PhD. Yes, I know some who are very good.