General Questions:
1. in a person with psychotic depression, where you can't tell which is causing which, do you treat the psychosis or the depression?
Both. Clinical studies are pretty clear that patients with psychotic depression need both antidepressants and antipsychotics. Alternatively, ECT is an option.
2. if a person has some mild side effects from a drug, should you consider decreasing the dose before switching the class of drug or v.v.?
depends on how mild and how beneficial the drug as been (i.e., risk-benefit ration). In general, if the drug has been effective, but the side effects are not tolerable, it would make more sense to use another drug within the same class, in the hopes that the benefits will be cross class, but the side effects may not be as bad.
3. if you're not sure whether alcoholism is causing depression or if the person was self-medicating, do you wait x number of days or do you immediately give antidepressants?
This is a complicated issue, and once again implies another risk benefit ratio (how bad the depression, etc.) Of relevance in answering this questions: 1. There is very little evidence for the "self-medication" hypothesis. 2. Some studies have suggested that it makes sense to wait at least 4 weeks post detox, as most secondary alcoholic related depressions spontaneously improve by then.
4. a person presents at a hospital and says they're suicidal from depression but then says they aren't serious. do you start them on antidepressants or give them a list of support groups just in case? these were separate answers, but both seemed logical conclusions.
Sorry, there is inadequate information here for a meaningful answer. In general, both decisions about treating depression, as well as assessing suicidality involve more than single statements of a chief complaint. You would have to make a full assessment as you would for any disease, which would include patient statements but also other factors from the history and exam in making a final decision on what to do in either case.
5. What is the central difference between substance dependence and substance abuse? (i.e., what is the difference between adverse clinical consequencesand clinical significant impairment)?
"Substance abuse" is meant to define problem drinking (or drugging) that hasn't reached the level of substance dependence. Dependency trumps abuse: first decide if the patient meets the criteria for dependence, and if not, yet still is having problems as a result of drinking, think of abuse.
6. If an elderly woman who has been successfully treated for major depression with nortriptyline has another episode (her fourth), how would she be treated? (question 11 from last year's exam) Mirtazapine, SSRI, venlafaxine, or SSRI + diazepam?
Wow, that was sort of picky, but it makes more sense if you read the whole question:
A 72-year-old woman has been successfully treated for major depression. This is the fourth episode of depression during her adult life. During the previous episode, 10 years prior, she responded well to a regimen of nortriptyline (a TCA) 75 mg a day, and recalls no significant adverse effects from the drug. Now the patient presents with dysphoria which began about a month ago, and has worsened since. During the same time, she has noticed increased irritability and anxiety, with poor sleep and appetite. Regarding the latter, she estimates she has lost 10 pounds in the last month (she is 5'6", 160 lbs.).
Current medications include cardizem and lipitor. Physical examination is significant for a blood pressure of 170/95.
The most appropriate management at this point would be to
A. Start mirtazapine, which has similar action to nortriptyline, but may also help appetite.
B. Consider use of an SSRI, as an elderly patient should no longer receive a TCA.
C. Start venlafaxine, as it has similar action to nortriptyline but also might help her blood pressure.
D. Start nortriptyline at a dose of 25 mg and gradually increase a therapeutic level.
E. Start an SSRI, but also add diazepam to help with her anxiety and insomnia.
The answer hinges on understanding the side effects of the drugs. Changing straight to an SSRI (though many might do) doesn't make sense if the patient respondedwell to a TCA, and it is not true that TCAs are contraindicated in the elderly. Venlafaxine actually causes hypertension, so wouldn't be a good idea in someone who already has it. Adding Diazepam makes no sense at all. Mirtazapine might make sense, but since we have a choice here of using nortriptyline, I see no reason not to just give her that one again. In general, one of the few reliable predictors of current response is past response.
7. from last year's exam, question 24, is the most likely diagnosis psychotic depression since the woman has the symptoms of depression over the past two months (anhedonia, anergia, sleep problems, decreased concentration) with the psychotic symptom of hearing voices? Would ECT be the most effective treatment?
Here's the actual question:
A 42-year-old woman is brought by her husband to the emergency department for increasing symptoms of anhedonia, which have increased over the past 2 months. She reports feeling down, and despondent, with little energy or motivation during the day. In addition, she wakes up frequently in the middle of the night and cannot fall back asleep. Of most concern is that she reports wishing she was dead, and feeling that her husband would be better of without her.
On examination, the patient appears as a physically healthy woman who is well dressed and groomed. She reports herself as feeling “miserable” and “sad” and is tearful through much of the interview. Often during the interview she appears to be distracted, and when asked, she says that she is hearing voices that are telling her to kill herself. She explains that the voices began about a week ago, and though she thinks they might be “in my head” she is beginning to question this belief, and wonders whether they might be “dead relatives trying to help me end this suffering.”
Physical exam and laboratory evaluation are unremarkable.
Her husband is consulted as well. He generally confirms her history. When asked about her voices, he seems surprised, but then says that for that past week he has noticed his wife to be talking to herself. He is not aware of any past history of similar problems.
24. The most likely diagnosis is:
A. Psychotic depression.
B. Schizoaffective disorder.
C. Schizophrenia, paranoid type.
D. Delusional disorder.
E. Melancholia.
The answer is psychotic depression: this is a hallucination and delusion which seems clearly associated, at least temporally, to her depression.
25. Which of the following would be the most effective treatment for this disorder?
A. Haloperidol.
B. Sertraline.
C. Electroconvulsive therapy.
D. Cognitive-behavioral treatment.
E. Sodium Valproate.
ECT would be the answer. As in the 1st question above, the only choices would be combined antipsychotic and antidepressant (not a choice here), or ECT.
8. For question 56 from last year's exam, what type of treatment decreases depression without stifling the hyper times--light therapy or sodium valproate?
Here's the complete question:
A 46-year-old woman presents for worsening depressive symptoms. She describes that she has been feeling increasingly down. She will become easily fatigued, and will suddenly break out into tears for no obvious reason. She says that this has been worsening over the last month, and is concerned as she is beginning to find it hard to concentrate, and she feels she it is beginning to affect her work.
She explains that this is a significant change from her usual level of functioning. She describes herself as usually being a “hyper” person, who is “always going” and usually very active. She says that at times her “hyper” nature may become more pronounced, and she describes periods of “about a week” in which she will become productive. During those periods she is sleep very little (she estimates about 3 hours a night), and will be able to complete a large number of projects. She says that, at the time, people sometimes will comment that she is talking very fast. She believes that her current depressive symptoms only occur during the winter months, and that she generally begins to become productive again by the spring.
The patient works as a professor of religious studies at a large university. She explains that she tends to depend on her periods of “high activity,” and is able to write most of her papers and complete her research during these periods.
Physical examination and laboratory evaluation reveals an adult woman who is in the low normal range of weight. On questioning, she says she has always been on the thin side, but in the past month she has “entirely lost my appetite.” Otherwise, she appears to be in good physical health.
56. The most likely diagnosis is:
A. Major depression, seasonal type.
B. Manic depression
C. Generalized anxiety disorder
D. Bipolar disorder type II
E. Bulimia nervosa.
Bipolar type II is the correct answer.
In discussing a course of treatment, pharmacotherapy is discussed. The patient is clear that she will only start therapy if it can be guaranteed that “you stop what's happening now, but don't stifle my hyper times–I need those, otherwise I'll never get promoted.
57. You suggest:
A. An antidepressant from the serotonin reuptake inhibitor group.
B. Beginning a trial of light therapy.
C. Sleep deprivation as an alternative treatment.
D. That a strategy based on her request may be too risky.
E. The anticonvulsant sodium valproate at a low therapeutic dose.
SSRI's, Sleep deprivation, and, light therapy all can treat the depressive part but may worsen the mania (though sleep deprivation is not usually used clinically, as it stops working after you do fall asleep). Sodium Valproate would help, but would not fulfil her desire to not stifle the hyper times, as it treats both the depressive and manic parts of bipolar disorder. The most reasonable answer is D--to sit this patient down and have a realistic talk about this.
This is a picky question which I asked last year as I discussed this case in detail during one of the lectures last year.
9. On page 180 of the syllabus, it says under personality disorders that "only antisocial cannot be diagnosed" but "core symptoms include antisocial, psychosis, affect". What does this mean?
These short phrases are obviously taken from the slides used by Dr. Grapentine for that lecture. Antisocial personality disorder is not diagnosed in children, only adults (though conduct disorder is a likely prequel). The second part is simply listing some of the core symptoms found in childhood personality disorders.
Mid Term Specific:
Question 1. How does this meet the criteria for Major depressive episode?
It doesn’t. I merely asked which disorder were the symptoms most consistent with. The patient displays problems with concentration and attention, decreased motivation and energy, and he implies that he is feeling badly. The time course also is more consistent with a depressive illness than some of the other choices.
Question 24. Why can't the patient's thought be considered pressured? ("My thoughts acquire such momentum, they rush out of my head")
"pressured" usually refers to a pattern of speech, not of thought. Usually pressured speech implies rapid thoughts, but it is the nature of the speech--fast, continuous without pause--that defines it as pressured.
Question 32. I feel that the prognosis for this schizophrenic 15 yr. old is a poor one (B), and not the answer of "relatively good" (A). The syllabus lists, as predictors of poor outcome, family history of psychiatric illness (depression), poor premorbid functioning (quiet, shut-in, few friends), poor psychosocial functioning (difficulty in getting along at camp), and assaultive behavior(violent outbursts). The textbook also includes on p.228. a never married status and younger age at onset (in this case, 15 yrs). The patient does have some predictors of good outcome absent psychiatrichistory, high social class, negative family history of schizophrenia, acute onset, and present mood symptoms, though I feel that the patient's physical state supersedes these positive factors. To tell you the truth, I feel that the answer can swing either positive or negative, and that this question is very subjective.
This question was probably too picky, and I have thrown it out. I think that the good prognostic factors narrowly beat out the bad ones. Keep in mind that it is primarily a family history of psychotic illness that is bad, not of mood disorders (that’s really picky I know) and the premorbid history isn’t entirely bad–psychosocial functioning might have been bad but other areas (school performance) was good. Will let the not being married thing slide. I’m not sure what it is meant by the physical state superceding the positive factors.
Question 33 - Page 60 of the syllabus lists "personal and/or family history of psychiatric illness" as one predictor of poor outcome for a person with schizophrenia. Why did you choose "social history" as being more predictive?
see above.
Question 42. About the medication that has the best likelihood of helping Kevin recover quickly, I don't understand why the affect of the drug on the neurotransmitter most affected wouldn't be the best predictor for response? Isn't the neurotransmitter system the most important criteria for drug prescription? I was thinking that family history to drug response might not be the best because perhaps the family member was depressed many years ago when medication was different vs. current SSRI or third generation drugs that are currently available and may have better response.
I think this point was adequately stressed in class. All the antidepressants have approximately equal efficacy, and there is no evidence that one can use this information to predict individual response. The only clinical predictors are personal and family history.
Question 43. I chose perseveration (B) and not neologism (A) as my answer. I feel that they're both correct, but I felt that you were emphasizing the perseveration aspect in that you write that the patient kept repeating the same word in a conversation, and then went on to describe the meaning in detail, which means that she was stuck on the same idea throughout the interview and couldn't change her train of thought. Neologisms don't have that repetitive aspect.
I think the fact that the word was so bizarre and so obviously not a real word makes this as good an example of a neologism as I’ve heard. I don’t really see an perseveration in the paragraph–she is logically defining the word at the request of the psychiatrist, and her explanation would otherwise seem a good one if it weren’t for the word itself.
Question 44 - How is a disorder of "thought process" different from one of "thought organization" (see page 29 syllabus).
Disorders of thought process may include organizational problems, but thought process is the overarching term I made up for the test, and the one we have been using in class.
Question 45. Why is a disorder of thought process most consistent with bipolar disorder and not schizophrenia
The choices were between bipolar disorder, and schizophrenia, paranoid type. Paranoid schizophrenia involves disorders of thought content, not process. Disorganized schizophrenia (not included as a choice) can involve disorders of thought process.