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Файл:Case Studies_ Stahl's Essential - Stephen M. Stahl.docx
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- •Table of Contents
- •Case Studies
- •Volume 2 Stephen m. Stahl
- •Thomas l. Schwartz
- •It furthers the University’s mission by disseminating knowledge in the pursuit of education, learning and research at the highest international levels of excellence.
- •Information on this title: www.Cambridge.Org/9781107607330
- •Illness – Chemotherapy – Examinations, questions, etc. |
- •Isbn 978-1-107-60733-0 Paperback
- •Introduction
- •Learning objectives
- •Accreditation and credit designation statements
- •Optional posttest and cme credit instructions (see p. 441) Peer review
- •Disclosures
- •Authors/developers
- •Disclosure of off-label use
- •Disclaimer
- •Cultural and linguistic competency
- •Provider
- •Support
- •Patient evaluation on intake
- •Psychiatric history
- •Psychotherapy history
- •Patient evaluation on initial visit
- •Current medications
- •Question
- •Attending physician’s mental notes: initial evaluation
- •Question
- •Attending physician’s mental notes: initial evaluation (continued)
- •Further investigation
- •Case outcome: first interim follow-up visit four weeks later
- •Question
- •Case outcome: second interim follow-up visit at two months
- •Attending physician’s mental notes: interim follow-up visit at three months
- •Question
- •Attending physician’s mental notes: second interim follow-up visit at three months
- •Case outcome: interim follow-up visits through six months
- •Question
- •Attending physician’s mental notes: interim follow-up visits through 12 months
- •Case outcome: interim follow-up visits through 24 months
- •Case debrief
- •Take-home points
- •Performance in practice: confessions of a psychopharmacologist
- •Tips and pearls
- •Psychotherapy moment
- •Psychopharmacology components
- •Psychotherapy
- •Documentation
- •Patient evaluation on intake
- •Psychiatric history
- •Attending physician’s mental notes: initial evaluation
- •Further investigation
- •Question
- •Attending physician’s mental notes: initial evaluation (continued)
- •Case outcome: interim follow-ups through six months
- •Question
- •Attending physician’s mental notes: nine months
- •Case outcome: interim follow-ups through nine months
- •Question
- •Attending physician’s mental notes: nine-month follow-ups
- •Question
- •Attending physician’s mental notes: interim follow-up through nine months (continued)
- •Case outcome and multiple interim follow-ups to 24 months
- •Case debrief
- •Take-home points
- •Performance in practice: confessions of a psychopharmacologist
- •Tips and pearls
- •Tardive dyskinesia
- •Tardive dyskinesia facts
- •Tardive dyskinesia treatments
- •Pretest self-assessment question (answer at the end of the case)
- •Patient evaluation on intake
- •Psychiatric history
- •Attending physician’s mental notes: initial evaluation
- •Further investigation
- •Question
- •Attending physician’s mental notes: initial evaluation (continued)
- •Case outcome: interim follow-ups through four months
- •Question
- •Attending physician’s mental notes: nine months
- •Case outcome: interim follow-ups through nine months
- •Question
- •Attending physician’s mental notes: 9–12 month follow-ups
- •Question
- •Case outcome: interim follow-ups through 12 months
- •Case outcome: multiple interim follow-ups through 16 months
- •Attending physician’s mental notes: 16-month follow-ups
- •Case debrief
- •Take-home points
- •Performance in practice: confessions of a psychopharmacologist
- •Tips and pearls
- •Abnormal Involuntary Movement Scale (aims)
- •Aims instructions
- •Case outcome: use of outcome measures
- •Posttest self-assessment question and answer
- •Patient evaluation on intake
- •Psychiatric history
- •Attending physician’s mental notes: initial evaluation
- •Attending physician’s mental notes: initial evaluation (continued)
- •Further investigation
- •Question
- •Case outcome: interim follow-ups through three months
- •Question
- •Attending physician’s mental notes: four months
- •Question
- •Case outcome: interim follow-ups through six months
- •Attending physician’s mental notes: interim follow-up, nine months (continued)
- •Case outcome and multiple interim follow-ups to 12–120 months
- •Case debrief
- •Take-home points
- •Performance in practice: confessions of a psychopharmacologist
- •Tips and pearls
- •Mechanism of action moment How does vns theoretically work?
- •Vns side effects
- •Neurostimulation and neuromodulatory devices other than vns
- •Patient evaluation on intake
- •Psychiatric history
- •Attending physician’s mental notes: initial evaluation
- •Further investigation
- •Question
- •Attending physician’s mental notes: initial evaluation (continued)
- •Case outcome: interim follow-ups through one month
- •Question
- •Case outcome: interim follow-ups through two months
- •Case outcome: interim follow-ups through three months
- •Question
- •Attending physician’s mental notes: four-month follow-ups
- •Question
- •Case outcome: interim follow-ups through four months (continued)
- •Attending physician’s mental notes: interim follow-ups through four months
- •Case outcome and multiple interim follow-ups to six months
- •Case debrief
- •Take-home points
- •Performance in practice: confessions of a psychopharmacologist
- •Tips and pearls
- •Is quetiapine (Seroquel) an antipsychotic, anti-manic, antidepressant, anxiolytic, or a hypnotic?
- •Pharmacodynamics of quetiapine and norquetiapine
- •Pretest self-assessment question (answer at the end of the case)
- •Patient evaluation on intake
- •Psychiatric history
- •Attending physician’s mental notes: initial evaluation
- •Further investigation
- •Attending physician’s mental notes: initial evaluation (continued)
- •Case outcome: interim follow-ups through one month
- •Case outcome: interim follow-ups through two months
- •Attending physician’s mental notes: two months
- •Question
- •Case outcome: interim follow-ups through two months
- •Case outcome: interim follow-ups through three months
- •Question
- •Case outcome and multiple interim follow-ups up to six months
- •Case debrief
- •Take-home points
- •Performance in practice: confessions of a psychopharmacologist
- •Pharmacodynamic moment
- •What is worse in causing escalated mania or mixed features, antidepressants or stimulants?
- •Should unipolar antidepressants be used in bipolar disorder?
- •Does clonazepam (Klonopin) work in bipolar mania?
- •Posttest self-assessment question and answer
- •Patient evaluation on intake
- •Psychiatric history
- •Question
- •Case outcome
- •Case debrief
- •Take-home points
- •Tips and pearls
- •Patient evaluation on intake
- •Psychiatric history
- •Attending physician’s mental notes: initial evaluation
- •Further investigation
- •Question
- •Attending physician’s mental notes: initial evaluation (continued)
- •Case outcome: interim follow-ups through three months
- •Question
- •Attending physician’s mental notes: four months
- •Case outcome: interim follow-ups through six months
- •Case outcome: interim follow-ups through nine months
- •Question
- •Attending physician’s mental notes: nine-month follow-ups
- •Attending physician’s mental notes: interim follow-up, nine months (continued)
- •Case outcome and multiple interim follow-ups to 24 months
- •Case debrief
- •Take-home points
- •Performance in practice: confessions of a psychopharmacologist
- •Tips and pearls
- •Treating aawg with metformin
- •Posttest self-assessment question and answer
- •Patient evaluation on intake
- •Psychiatric history
- •Attending physician’s mental notes: initial evaluation
- •Further investigation
- •Question
- •Attending physician’s mental notes: initial evaluation (continued)
- •Case outcome: interim follow-ups through six months
- •Attending physician’s mental notes: six months
- •Case outcome: interim follow-ups through nine months
- •Case outcome: interim follow-ups through 18 months
- •Attending physician’s mental notes: through 20 months
- •Question
- •Case outcome: interim follow-ups through 24 months
- •Question
- •Attending physician’s mental notes: 24-month follow-ups
- •Case outcome: interim follow-up, 36 months
- •Attending physician’s mental notes: 48-month follow-ups
- •Question
- •Case outcome and multiple interim follow-ups to 48 months
- •Case debrief
- •Take-home points
- •Performance in practice: confessions of a psychopharmacologist
- •Tips and pearls
- •Techniques for switching antipsychotics
- •Pretest self-assessment question (answer at the end of the case)
- •Patient evaluation on intake
- •Psychiatric history
- •Question
- •Case outcome
- •Case debrief
- •Clozapine sialorrhea statistics and etiology
- •Possible antidotes for cis
- •Posttest self-assessment question and answer
- •Patient evaluation on intake
- •Psychiatric history
- •Further investigation
- •Question
- •Attending physician’s mental notes: initial evaluation (continued)
- •Case outcome: interim follow-ups through three months
- •Attending physician’s mental notes: six months
- •Case outcome: interim follow-ups through nine months
- •Case outcome: interim follow-ups through 12 months
- •Case outcome: interim follow-ups through 12 months (continued)
- •Question
- •Attending physician’s mental notes: 12 month follow-ups
- •Case outcome: interim follow-up, 24 months
- •Attending physician’s mental notes: 36-month follow-ups
- •Case outcome and multiple interim follow-ups to 60 months
- •Case debrief
- •Take-home points
- •Performance in practice: confessions of a psychopharmacologist
- •Tips and pearls
- •A pharmacodynamic moment
- •Antihistamine and the sleep–wake switch
- •Serotonin receptor antagonism and sleep
- •What about 5-ht1d receptor antagonism?
- •What about 5-ht7 receptor antagonism?
- •Patient evaluation on intake
- •Psychiatric history
- •Current medications
- •Question
- •Attending physician’s mental notes: initial evaluation
- •Question
- •Attending physician’s mental notes: initial evaluation (continued)
- •Further investigation
- •Case outcome: first interim follow-up visit four weeks later
- •Question
- •Case outcome: second interim follow-up visit at two months
- •Attending physician’s mental notes: second interim follow-up visit at two months
- •Question
- •Case outcome: interim follow-up visits through seven months
- •Question
- •Attending physician’s mental notes: interim follow-up visits through seven months
- •Case outcome: interim follow-up visits through 24 months
- •Case debrief
- •Take-home points
- •Performance in practice: confessions of a psychopharmacologist
- •Tips and pearls
- •Mechanism of action moment
- •Patient evaluation on intake
- •Psychiatric history
- •Psychotherapy history
- •Patient evaluation on initial visit
- •Current medications
- •Question
- •Attending physician’s mental notes: initial evaluation
- •Question
- •Attending physician’s mental notes: initial evaluation (continued)
- •Further investigation
- •Case outcome: first interim follow-up visit eight weeks later
- •Question
- •Case outcome: second and third interim follow-up visits at three months
- •Attending physician’s mental notes: second interim follow-up visit at three months
- •Question
- •Attending physician’s mental notes: second interim follow-up visit at three months (continued)
- •Case outcome: interim follow-up visits through five months
- •Question
- •Attending physician’s mental notes: interim follow-up visits through nine months
- •Case outcome: interim follow-up visits through 12 months
- •Attending physician mental notes
- •Case outcome: interim follow-up visits through 15 months
- •Question
- •Case debrief
- •Take-home points
- •Performance in practice: confessions of a psychopharmacologist
- •Tips and pearls
- •Pharmacoeconomic and regulatory moment
- •How many ways can a drug be turned into a slow-release preparation?
- •Pretest self-assessment question (answer at the end of the case)
- •Patient evaluation on intake
- •Psychiatric history
- •Medication history
- •Psychotherapy history
- •Social and personal history
- •Medical history
- •Family history
- •Patient evaluation on initial visit
- •Current medications
- •Question
- •Attending physician’s mental notes: initial evaluation
- •Question
- •Attending physician’s mental notes: initial evaluation (continued)
- •Further investigation
- •Case outcome: first interim follow-up visit four to six weeks later
- •Question
- •Attending physician’s mental notes: interim follow-up visits through three months
- •Case outcome: interim follow-up visits through three months
- •Question
- •Attending physician’s mental notes: interim follow-up visits through three months (continued)
- •Case outcome: interim follow-up visits through six months
- •Attending physician’s mental notes: interim follow-up visits through six months
- •Case debrief
- •Take-home points
- •Performance in practice: confessions of a psychopharmacologist
- •Tips and pearls
- •Overview
- •Classification
- •Clinical manifestations
- •Therapy and management
- •Posttest self-assessment question and answer
- •Pretest self-assessment question (answer at the end of the case)
- •Patient evaluation on intake
- •Psychiatric history
- •Current medications
- •Question
- •Attending physician’s mental notes: initial evaluation
- •Question
- •Attending physician’s mental notes: initial evaluation (continued)
- •Further investigation
- •Case outcome: first interim follow-up visit six weeks later
- •Question
- •Attending physician’s mental notes: interim follow-up visits through six months
- •Case outcome: interim follow-up visits through six months
- •Question
- •Attending physician’s mental notes: interim follow-up visit through six months (continued)
- •Case outcome: interim follow-up visits through nine months
- •Question
- •Attending physician’s mental notes: interim follow-up visits through nine months
- •Case outcome: interim follow-up visits through 15 months
- •Case debrief
- •Take-home points
- •Performance in practice: confessions of a psychopharmacologist
- •Tips and pearls
- •Neurocircuitry moment
- •Treatments for ocd
- •Posttest-self assessment question and answer
- •Patient evaluation on intake
- •Psychiatric history
- •Social and personal history
- •Patient evaluation on initial visit
- •Current medications
- •Question
- •Attending physician’s mental notes: initial evaluation
- •Question
- •Attending physician’s mental notes: initial evaluation (continued)
- •Further investigation
- •Case outcome: first interim follow-up visit four weeks later
- •Question
- •Attending physician’s mental notes: second interim follow-up visit at two months
- •Case outcome: second interim follow-up visit at two months
- •Question
- •Attending physician’s mental notes: second interim follow-up visit at two months (continued)
- •Case outcome: interim follow-up visits through four months
- •Question
- •Attending physician’s mental notes: interim follow-up visits through four months
- •Case outcome: interim follow-up visits through nine months
- •Attending physician’s mental notes: interim follow-up visits through 12 months
- •Case outcome: interim follow-up visits through 18 months
- •Case debrief
- •Take-home points
- •Performance in practice: confessions of a psychopharmacologist
- •Tips and pearls
- •Mechanism of action moment
- •Diagnosis
- •Etiology
- •Rls and comorbidity
- •Rls treatment
- •Posttest self-assessment question and answer
- •Patient evaluation on intake
- •Psychiatric history
- •Current medications
- •Question
- •Attending physician’s mental notes: initial evaluation
- •Question
- •Attending physician’s mental notes: initial evaluation (continued)
- •Further investigation
- •Case outcome: first interim follow-up visit four weeks later
- •Question
- •Attending physician’s mental notes: second interim follow-up visit at two months
- •Case outcome: second interim follow-up visit at two months
- •Question
- •Attending physician’s mental notes: second interim follow-up visit at two months (continued)
- •Case outcome: interim follow-up visits at three months
- •Question
- •Case outcome: interim follow-up visit at four months
- •Attending physician’s mental notes: interim follow-up visits through four months
- •Case outcome: interim follow-up visits through six months
- •Case debrief
- •Take-home points
- •Performance in practice: confessions of a psychopharmacologist
- •Tips and pearls
- •Pharmacokinetic moment
- •Patient evaluation on intake
- •Psychiatric history
- •Psychotherapy history
- •Patient evaluation on initial visit
- •Current medications
- •Question
- •Attending physician’s mental notes: initial evaluation
- •Question
- •Attending physician’s mental notes: initial evaluation (continued)
- •Further investigation
- •Case outcome: first interim follow-up visit four weeks later
- •Question
- •Attending physician’s mental notes: second interim follow-up visit at three months
- •Case outcome: second interim follow-up visit at three months
- •Question
- •Attending physician’s mental notes: second interim follow-up visit at three months (continued)
- •Case outcome: interim follow-up visits through 12 months
- •Question
- •Attending physician’s mental notes: interim follow-up visits through 24 months
- •Case debrief
- •Take-home points
- •Performance in practice: confessions of a psychopharmacologist
- •Tips and pearls
- •Patient evaluation on intake
- •Psychiatric history
- •Current medications
- •Question
- •Attending physician’s mental notes: initial evaluation
- •Question
- •Attending physician’s mental notes: initial evaluation (continued)
- •Further investigation
- •Case outcome: first interim follow-up visit three months later
- •Question
- •Case outcome: first interim follow-up visit three months later (continued)
- •Question
- •Attending physician’s mental notes: second interim follow-up visit at six months
- •Case outcome: second interim follow-up visit at six months
- •Question
- •Case outcome: interim follow-up visits through nine months
- •Question
- •Attending physician’s mental notes: interim follow-up visits through nine months
- •Case outcome: interim follow-up visits through 36 months
- •Question
- •Case outcome: interim follow-up visits through 48 months
- •Case debrief
- •Take-home points
- •Performance in practice: confessions of a psychopharmacologist
- •Tips and pearls
- •Patient evaluation on intake
- •Psychiatric history
- •Patient evaluation on initial visit
- •Current medications
- •Question
- •Attending physician’s mental notes: initial evaluation
- •Question
- •Attending physician’s mental notes: initial evaluation (continued)
- •Further investigation
- •Case outcome: first interim follow-up visits four and eight weeks later
- •Question
- •Attending physician’s mental notes: second interim follow-up visit at three months
- •Case outcome: second interim follow-up visit at three months
- •Question
- •Attending physician’s mental notes: second interim follow-up visit at three months (continued)
- •Case outcome: interim follow-up visits through six months
- •Question
- •Attending physician’s mental notes: interim follow-up visits through six months
- •Case outcome: interim follow-up visits through nine months
- •Attending physician’s mental notes: interim follow-up visits through nine months
- •Question
- •Case outcome: interim follow-up visits through 15 months
- •Case debrief
- •Take-home points
- •Performance in practice: confessions of a psychopharmacologist
- •Tips and pearls
- •Neuropsychiatric moment
- •Causes, incidence, and risk factors
- •Symptoms
- •Signs and tests
- •Treatment
- •Prognosis
- •Pharmacodynamic moment
- •Patient evaluation on intake
- •Psychiatric history
- •Psychotherapy history
- •Patient evaluation on initial visit
- •Current medications
- •Question
- •Attending physician’s mental notes: initial evaluation
- •Question
- •Attending physician’s mental notes: initial evaluation (continued)
- •Further investigation
- •Case outcome: first interim follow-up visit four weeks later
- •Question
- •Attending physician’s mental notes: second interim follow-up visit at two months
- •Case outcome: second interim follow-up visit at two months
- •Question
- •Case outcome: interim follow-up visits through five years
- •Question
- •Attending physician’s mental notes: interim follow-up visits through five years
- •Case outcome: interim follow-up visits through six years
- •Question
- •Attending physician’s mental notes: interim visits through year six
- •Case outcome: interim follow-up visits through six years (continued)
- •Question
- •Attending physician’s mental notes: interim visits through year six (continued)
- •Case debrief
- •Take-home points
- •Performance in practice: confessions of a psychopharmacologist
- •Tips and pearls
- •Mechanism of action moment
- •Patient evaluation on intake
- •Psychiatric history
- •Psychotherapy history
- •Patient evaluation on initial visit
- •Current medications
- •Question
- •Attending physician’s mental notes: initial evaluation
- •Question
- •Attending physician’s mental notes: initial evaluation (continued)
- •Further investigation
- •Case outcome: first interim follow-up visits one to two weeks later
- •Question
- •Attending physician’s mental notes: second interim follow-up visit at three to four weeks
- •Case outcome: second interim follow-up visit at three to four weeks
- •Question
- •Case outcome: interim follow-up visits through four to six weeks later
- •Question
- •Attending physician’s mental notes: interim follow-up visits through six weeks
- •Case outcome interim follow-up visits through 10 weeks
- •Case debrief
- •Take-home points
- •Performance in practice: confessions of a psychopharmacologist
- •Tips and pearls
- •Chronic risks
- •Acute risks predictive of future suicide attempt include*
- •Summary
- •Posttest self-assessment question and answer
- •Patient evaluation on intake
- •Psychiatric history
- •Psychotherapy history
- •Patient evaluation on initial visit
- •Further investigation
- •Case outcome: first interim follow-up visits through six months
- •Question
- •Case outcome: second interim follow-up visits through 12 months
- •Question
- •Case outcome: second interim follow-up visits through 12 months (continued)
- •Question
- •Attending physician’s mental notes: interim visits through 18 months
- •Case outcome: interim follow-up visits through 18 months
- •Question
- •Case outcome: interim follow-up visits through 24 months
- •Question
- •Attending physician’s mental notes: interim follow-up visits through 24 months
- •Case outcome: interim follow-up visits through 24 months (continued)
- •Case debrief
- •Take-home points
- •Performance in practice: confessions of a psychopharmacologist
- •Tips and pearls
- •Gaba-a receptors and the positive allosteric modulation of the bZs
- •Gaba-a receptors: desensitization, tachyphylaxis, and tolerance
- •Why does this happen?
- •Patient evaluation on intake
- •Psychiatric history
- •Attending physician’s mental notes: initial evaluation
- •Question
- •Attending physician’s mental notes: initial evaluation (continued)
- •Further investigation
- •Case outcome: first interim follow-up visits through three months
- •Question
- •Case outcome: interim follow-up visits through four months
- •Question
- •Case outcome: interim follow-up visits through six months
- •Question
- •Attending physician’s mental notes: visits through six months
- •Case outcome: interim follow-up visits through nine months
- •Question
- •Case outcome: interim follow-up visits through nine months (continued)
- •Case debrief
- •Take-home points
- •Performance in practice: confessions of a psychopharmacologist
- •Tips and pearls
- •Pretest self-assessment question (answer at the end of the case)
- •Patient evaluation on intake
- •Psychiatric history
- •Case outcome: via telephone
- •Further investigation
- •Case outcome: first interim follow-up six hours later
- •Question
- •Attending physician’s mental notes: six hours later
- •Question
- •Attending physician’s mental notes: interim follow-up information through 72 hours
- •Case outcome: interim follow-up information through 72 hours
- •Case outcome: interim follow-up visits through 80 hours
- •Attending physician’s mental notes: interim follow-up information through 72 hours (continued)
- •Question
- •Case outcome: interim follow-up information through 92 hours
- •Case debrief
- •Take-home points
- •Performance in practice: confessions of a psychopharmacologist
- •Tips and pearls
- •Delirium primer
- •Posttest self-assessment question and answer
- •Pretest self-assessment question (answer at the end of the case)
- •Patient evaluation on intake
- •Psychiatric history
- •Psychotherapy history
- •Patient evaluation on initial visit
- •Current psychiatric medications
- •Question
- •Attending physician’s mental notes: initial evaluation
- •Question
- •Attending physician’s mental notes: initial evaluation (continued)
- •Case outcome: initial visit
- •Further investigation
- •Question
- •Case outcome: first interim follow-up visit one week later
- •Case debrief
- •Take-home points
- •Performance in practice: confessions of a psychopharmacologist
- •Tips and pearls
- •Mechanism of action moment
- •Disulfiram (Antabuse)
- •Naltrexone (ReVia)
- •Acamprosate (Campral)
- •Posttest self-assessment question and answer
- •Patient evaluation on intake
- •Psychiatric history
- •Social and personal history
- •Medical history
- •Family history
- •Medication history
- •Psychotherapy history
- •Patient evaluation on initial visit
- •Current psychiatric medications
- •Question
- •Attending physician’s mental notes: initial evaluation
- •Question
- •Attending physician’s mental notes: initial evaluation (continued)
- •Case outcome: initial visit
- •Further investigation
- •Case outcome: first interim follow-up visit two months later
- •Question
- •Case outcome: interim follow-up visits three to six months later
- •Attending physician’s mental notes: follow-up visit, six months
- •Case outcome: interim follow-up visits eight to 12 months later
- •Case debrief
- •Take-home points
- •Performance in practice: confessions of a psychopharmacologist
- •Tips and pearls
- •Medication management of adhd in children versus adults
- •Posttest self-assessment question and answer
- •Patient evaluation on intake
- •Psychiatric history
- •Patient evaluation on initial visit
- •Question
- •Attending physician’s mental notes: initial evaluation
- •Case outcome: initial visit
- •Question
- •Attending physician’s mental notes: initial evaluation (continued)
- •Case outcome: interim visit at six weeks
- •Case debrief
- •Take-home points
- •Patient’s genetic summary
- •Case outcome: initial visit
- •Question
- •Attending physician’s mental notes: initial evaluation (continued)
- •Case outcome: interim visit at four weeks
- •Case debrief
- •Take-home points
- •A short tutorial on the scientific background of this case
- •Patient’s genetic summary
- •Case outcome: initial visit
- •Question
- •Attending physician’s mental notes: initial evaluation (continued)
- •Case outcome: interim visit through 16 weeks
- •Case debrief
- •Take-home points
- •Cme online posttest and certificate instructions
- •Index of drug names
- •Index of case studies
Question
What would you do next?
Increase the bupropion-XL (Wellbutrin-XL) to the approved maximum 450 mg/d
Increase the citalopram (Celexa) further above the geriatric approved maximum dose
Increase zaleplon (Sonata) toward the approved maximum of 20 mg/d (10 mg/d in the elderly)
As she is a partial responder, make no changes until her cochlear implants are in place and her sleep study is performed
Attending physician’s mental notes: interim follow-up visits through four months
Fairly good resolution of dysphoria is reported but insomnia and fatigue are still a major problem
It will still be a while for her to obtain a sleep study and she likely has OSA clinically, thus markedly increasing a sedative at night is worrisome
RLS is now more concerning to the patient, and she admits she likes to stay up watching late-night TV
– The initial insomnia may be more of a circadian rhythm sleep disorder (CRSD) in that she is choosing to stay up late and then has to get up early when her home health aide arrives
– She is inappropriately awake in the early morning hours and inappropriately tired during the daytime. A circadian delayed phase shift has occurred
Perhaps a “win–win” situation exists where her RLS and initial insomnia could be treated with one medication
– This was attempted with tiagabine (Gabitril)
This helped the RLS
Did not improve her sleep onset
Left her more fatigued in the morning
Could consider using another off-label antiepileptic medication, given her partial RLS response to tiagabine and hope for less daytime fatigue
A literature search suggests that gabapentin (Neurontin) does have a limited evidence base showing effectiveness in RLS
– Otherwise, an option would be to choose a formal RLS-approved dopaminergic medication such as pramipexole (Mirapex) or ropinirole (Requip)
– These D2 receptor agonists have some data suggesting they may provide antidepressant response but fatigue is a key side effect
– It might help fatigue at night, but the daytime fatigue may be a problem
Case outcome: interim follow-up visits through nine months
Gabapentin (Neurontin) is titrated to 300 mg twice a day as patient also has RLS symptoms intermittently through the day as well
Zaleplon (Sonata) 5 mg at bedtime is still allowed, but only as needed for severe insomnia
SSRI (citalopram [Celexa]) and NDRI (bupropion-XL [Wellbutrin-XL]) are continued at the same doses, 30 mg/d and 300 mg/d, respectively
There is remission of MDD symptoms
RLS resolves and she sleeps better with minimal morning fatigue
However, she still seems to go to bed after midnight due to watching TV
– Patient and family educated about sleep hygiene and behavioral management of sleep initiation
– It is not possible to ask the home health aide to arrive later due to her schedule, so the patient cannot sleep late to allow for an adequate number of hours of sleep
Her sleep study shows moderate OSA
– She is fitted for a CPAP mask, which causes discomfort and claustrophobia and she declines to wear it
Medications with known sedation side effects are moved to afternoon or dinner-time to avoid iatrogenic sedation in the morning
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