Charles B. Nemeroff, M.D., Ph.D.
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1 CASE STUDY 1 Charles B. Nemeroff, M.D., Ph.D. Leonard M. Miller Professor and Chairman Department of Psychiatry and Behavioral Sciences Director, Center on Aging University of Miami Miller School of Medicine Miami, Florida 33136
2 CASE STUDIES ADAA, Miami, FL 9 April 2015 W. Edward Craighead, Ph.D. J. Rex Fuqua Professor and Vice Chair Emory University Psychiatry/Psychology
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4 CHARLES B. NEMEROFF, M.D., PH.D. DISCLOSURES Research/Grants: National Institutes of Health (NIH), Agency for Healthcare Research and Quality (AHRQ) Speakers Bureau: None Consultant: Xhale, Takeda, SK Pharma, Shire, Roche, Lilly, Allergan Stockholder: CeNeRx BioPharma, Inc., PharmaNeuroBoost, Revaax Pharma, Xhale Other Financial Interest: CeNeRx BioPharma, PharmaNeuroBoost Patents: Method and devices for transdermal delivery of lithium (US 6,375,990B1), Method of assessing antidepressant drug therapy via transport inhibition of monoamine neurotransmitters by ex vivo assay (US 7,148,027B2) Scientific Advisory Board: American Foundation for Suicide Prevention (AFSP), CeNeRx BioPharma, National Alliance for Research on Schizophrenia and Depression (NARSAD), PharmaNeuroBoost, Anxiety Disorders Association of America (ADAA), Skyland Trail Board of Directors: AFSP, Gratitude America, Skyland Trail, ADAA
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6 Financial Disclosures W. Edward Craighead Dr. Craighead receives support from the NIH for his research, and he receives book royalties from John Wiley & Sons. He is a Senior Fellow, Center for the Study of Law and Religion, Emory University. He is an officer of Hugarheill ehf, an Icelandic company dedicated to prevention of depression. His participation is supported by the Mary and John Brock Foundation and the Fuqua Family Arnarson & Craighead Foundations.
7 CASE STUDY 1 A 24-year-old female medical student is brought to the ER after ingesting 20 Tylenol and 10 aspirin in a suicide attempt. After an ICU admission because of rising liver enzymes, she is medically cleared, and admitted to the inpatient psychiatric service. A diagnosis of major depression is made. By history she has had two previous depressive episodes, both untreated. Family history is positive for depression in her mother and alcohol abuse in her paternal grandfather.
8 CASE STUDY 1: Question 1 The antidepressant you begin treatment with is: A. Bupropion B. Sertraline C. Mirtazapine D. Desipramine E. Tranylcypromine
9 CASE STUDY 1: Question 2 In terms of adjunctive treatments at this point, which Psychotherapy would you recommend? A.Psychodynamic based psychotherapy to provide insight into unconscious wish to die B. Rogerian Non-directive therapy C. CBT focused on suicidal ideation D. IPT focused on prior losses and developing better social skills
10 CASE STUDY 1 (cont.) She is discharged after 7 days in the hospital on sertraline (100 mg) having also received cognitive-behavior therapy (CBT). She is seen in the outpatient setting 2 weeks later. She is improved with fewer crying spells and improved appetite, but she is still quite depressed and has passive suicidal ideation.
11 CASE STUDY 1: Question 3 In terms of her antidepressant therapy, you opt to prescribe: A. An atypical antipsychotic B. Add lithium C. Switch to mirtazapine D. Switch to nortriptyline E. Increase dose of sertraline
12 CASE STUDY 1 (cont.) The dose of sertraline is increased to 150 mg for 2 weeks, and 4 weeks later to 200 mg. The patient is now 65% improved, but not yet euthymic and clearly not in remission.
13 CASE STUDY 1: Question 4 At this point you decide to: A. Switch to fluoxetine B. Switch to venlafaxine or duloxetine C. Augment with thyroid hormone D. Augment with an atypical antipsychotic E. Add mirtazapine
14 CASE STUDY 1 (cont.) Because the patient has had a persistent problem with sleep continuity, mirtazapine (30 mg) is added to the Sertraline. The patient responds very well and is euthymic for the ensuing 3 months. However, she gains 27 pounds and is seeking a change in her medication regimen.
15 CASE STUDY 1: Question 5 Which of the following options do you choose?: A. Discontinue mirtazapine B. Reduce mirtazapine dose from 30 mg to 15 mg C. Discontinue mirtazapine and increase sertraline dose to 300 mg D. Discontinue mirtazapine and add buspirone E. Discontinue mirtazapine and add thyroid hormone
16 CASE STUDY 1: Question 6 Which of the following options do you also choose?: A. Add Behavior Therapy for weight loss B. Refer her to a nutritionist for dietary counseling C. Refer her to Group Therapy for support regarding weight and eating issues D. None of the above
17 CASE STUDY 1 (cont.) The patient has now been euthymic for 3 additional months treated with sertraline (200 mg) and thyroid hormone (T3, 25 mcg). She is in a new relationship and is concerned about her unacceptably low libido.
18 CASE STUDY 1: Question 7 Which course of action do you take?: A. Discontinue sertraline abruptly B. Taper sertraline from 200 mg/day to 100 mg/day C. Add sildenafil 50 mg qhs D. Add buspirone 15 mg po tid E. Refer her to an expert in the treatment of sexual dysfunction
19 CASE STUDY 1 (cont.) The reduction in the sertraline dose to 100 mg is associated with an improvement in her libido without any return of depressive symptoms.
20 CASE STUDY 1 Questions or comments.
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Charles B. Nemeroff, M.D., Ph.D.
CASE STUDY 2 Charles B. Nemeroff, M.D., Ph.D. Leonard M. Miller Professor and Chairman Department of Psychiatry and Behavioral Sciences Director, Center on Aging University of Miami Miller School of Medicine
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