The Case: The man whose antidepressants stopped working

The Impact of Ethnicity on Antidepressant Therapy

The Case: The man whose antidepressants stopped working

The Question: Do depressive episodes become more difficult to treat and more recurrent over time?
The Dilemma: When can you stop antidepressant treatment and what do you do if medications that worked in the past no longer work?
When should antidepressant maintenance become indefinite?
63-year-old man with the worst depression and anxiety he has ever felt

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Psychiatric History: First Episode The Case: The man whose antidepressants stopped working

• Age 42, became depressed and anxious after his episode of atrial
fi brillation
• Felt vulnerable and afraid of death
• After his hospitalization for atrial fi brillation, which resolved with medications, he felt depression, anxiety, “butterfl ies in his stomach” and felt like his whole body was “plugged into an electrical circuit”
• Began having suicidal thoughts
• This episode also coincided with the death of his mother
• Treatment with alprazolam (Xanax) and clonazepam (Klonopin): no improvement
• Sertraline (Zoloft) treatment 100 mg/day and he was much improved within 2–3 months, functioning normally at work but had sexual side effects
• Felt totally normal after 6 months and discontinued sertraline Social and Personal History
• Married 33 years, 3 children
• Non smoker
• No drug or alcohol abuse

Review the patient intake documentation, psychiatric history, patient file, medication history, etc. As you progress through each section, formulate a list of questions that you might ask the patient if he or she were in your office.

Based on the patient’s case history, consider other people in his or her life that you would need to speak to or get feedback from (i.e., family members, teachers, nursing home aides, etc.).
Consider whether any additional physical exams or diagnostic testing may be necessary for the patient.
Develop a differential diagnoses for the patient. Refer to the DSM-5 in this week’s Learning Resources for guidance.

Review the patient’s past and current medications. Refer to Stahl’s Prescriber’s Guide and consider medications you might select for this patient.
Provide the case number in the subject line of the

List three questions you might ask the patient if he or she were in your office. Provide a rationale for why you might ask these questions.

Identify people in the patient’s life you would need to speak to or get feedback from to further assess the patient’s situation. Include specific questions you might ask these people and why.
Explain what physical exams and diagnostic tests would be appropriate for the patient and how the results would be used.

List three differential diagnoses for the patient. Identify the one that you think is most likely and explain why.
List two pharmacologic agents and their dosing that would be appropriate for the patient’s antidepressant therapy based on pharmacokinetics and pharmacodynamics. From a mechanism of action perspective, provide a rationale for why you might choose one agent over the other.
For the drug therapy you select, identify any contraindications to use or alterations in dosing that may need to be considered based on the client’s ethnicity. Discuss why the contraindication/alteration you identify exists. That is, what would be problematic with the use of this drug in individuals of other ethnicities?

If your assigned case includes “check points” (i.e., follow-up data at week 4, 8, 12, etc.), indicate any therapeutic changes that you might make based on the data provided.
Explain “lessons learned” from this case study, including how you might apply this case to your own practice when providing care to patients with similar clinical presentations, The Case: The man whose antidepressants stopped working.