Match each patient's clinical presentation with the most appropriate next step in psychopharmacologic or procedural management.
- A 72-year-old man with major depressive disorder refuses to eat or drink for 4 days, resulting in acute kidney injury. He is actively hallucinating that his internal organs are rotting.Schedule for immediate electroconvulsive therapy
- A 58-year-old man presents with depressed mood, anhedonia, and insomnia 4 weeks after an acute anterior wall myocardial infarction. He is clinically stable on his current cardiac medications.Initiate sertraline monotherapy
- A 24-year-old man with newly diagnosed major depressive disorder reports severe insomnia and weight loss. He has a history of epilepsy on levetiracetam and requests a treatment lacking sexual side effects.Initiate mirtazapine monotherapy
- A 45-year-old woman on escitalopram 20 mg daily for 8 weeks reports only partial improvement in her depressive symptoms. She continues to struggle with profound daytime fatigue and poor concentration.Add bupropion to the current regimen
- A 62-year-old woman with breast cancer presents with major depression. She recently started tamoxifen therapy. She requests medication to improve her mood and manage severe concurrent hot flashes.Initiate venlafaxine monotherapy
Answer
The 72-year-old man with food refusal requires electroconvulsive therapy. The 58-year-old man post-myocardial infarction requires sertraline. The 24-year-old man with epilepsy requires mirtazapine. The 45-year-old woman with residual fatigue requires bupropion augmentation. The 62-year-old woman on tamoxifen requires venlafaxine.
Each patient requires a highly specific intervention based on their medical comorbidities and symptom profiles. Electroconvulsive therapy is required for life-threatening psychotic depression. Sertraline is chosen for post-myocardial infarction safety. Mirtazapine is selected to avoid sexual dysfunction in a patient who cannot take bupropion due to epilepsy. Bupropion is added to an SSRI for partial response with residual fatigue. Venlafaxine is chosen to avoid CYP2D6 interactions with tamoxifen while also effectively treating concurrent hot flashes.
Step-by-Step Solution
Key Concept
Management of major depressive disorder must be strictly tailored to the patient's specific symptom profile, medical comorbidities, concurrent medications, and the acuity of the clinical situation.
Estimated Time:3m 0s