This new selection of clinical stories, covers treatments that work, or fail, and mistakes made along the journey. Designed with a distinctive user-friendly presentation and making use of icons, questions/answers and tips, they address complex issues in an understandable way and with direct relevance to the everyday experience of clinicians.
Print monograph released: April,
2016 Electronic books released: May, 2016
CME credit expires: September, 2018
This book is a series of case studies in psychiatric disorders, all adapted from real practice, that provide a glimpse into what cases look like after the first consultation and over time, living through the treatments that work, the treatments that do not work, the mistakes, and the lessons to be learned.
This activity has been developed for prescribers specializing in psychiatry. All other healthcare providers interested in psychopharmacology are welcome for advanced study, especially primary care physicians, nurse practitioners, psychologists, and pharmacists.
Mental disorders are highly prevalent and carry substantial burden that can be alleviated through treatment; unfortunately, many patients with mental disorders do not receive treatment or receive suboptimal treatment.There is a documented gap between evidence-based practice guidelines and actual care in clinical practice for patients with mental illnesses. This gap is due, at least in part, to lack of clinician confidence and knowledge in terms of appropriate usage of the diagnostic and treatment tools available to them.To help address clinician performance deficits with respect to diagnosis and treatment of mental disorders, this book provides education regarding: (1) diagnostic strategies that can aid in the identification and differential diagnosis of patients with psychiatric illness; (2) effective clinical strategies for monitoring and treating psychiatric patients; and (3) new scientific evidence that is most likely to affect clinical practice.
After completing this book, you should be better able to:
Diagnose patients presenting with psychiatric symptoms according to best practice standards
Implement evidence-based psychiatric treatment strategies designed to maximize adherence and patient outcomes
Integrate novel treatment approaches into clinical practice according to best practice guidelines
Assess treatment effectiveness and make adjustments as needed to improve patient outcomes
The Neuroscience Education Institute (NEI) is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.
The Neuroscience Education Institute designates this enduring material for a maximum of 55.0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
The American Society for the Advancement of Pharmacotherapy (ASAP), Division 55 of the American Psychological Association (APA), is approved by the American Psychological Association to sponsor continuing education for psychologists. The ASAP maintains responsibility for this program and its content. The American Society for the Advancement of Pharmacotherapy designates this program for 55.0 CE credits for psychologists. Nurses: for all of your continuing nursing education (CNE) requirements for recertification, the American Nurses Credentialing Center (ANCC) will accept AMA PRA Category 1 Credits™ from organizations accredited by the ACCME. The content of this activity pertains to pharmacology and is worth 55.0 continuing education hours of pharmacotherapeutics.
Physician assistants: the National Commission on Certification of Physician Assistants (NCCPA) accepts AMA PRA Category 1 Credits™ from organizations accredited by the American Medical Association (AMA) (providers accredited by the ACCME).
A certificate of participation for completing this activity is available.
Note: the content of this print monograph activity also exists as an electronic book under the same title. If you received CME credit for the electronic book version, you will not be able to receive credit again for completing this print monograph version.
This material has been peer-reviewed by an MD to ensure the scientific accuracy and medical relevance of information presented and its independence from commercial bias. NEI takes responsibility for the content, quality, and scientific integrity of this CME activity.
It is the policy of NEI to ensure balance, independence, objectivity, and scientific rigor in all its educational activities. Therefore, all individuals in a position to influence or control content are required to disclose any financial relationships. Although potential conflicts of interest are identified and resolved prior to the activity being presented, it remains for the participant to determine whether outside interests reflect a possible bias in either the exposition or the conclusions presented.
Disclosed financial relationships with conflicts of interest have been reviewed by the NEI CME Advisory Board Chair and resolved.
Thomas L. Schwartz, MD
Professor and Vice Chair, Department of Psychiatry, SUNY Upstate Medical University, Syracuse, NY
No financial relationships to disclose.
Stephen M. Stahl, MD, PhD
Adjunct Professor, Department of Psychiatry, University of California, San Diego School of Medicine, San Diego, CA
Honorary Visiting Senior Fellow, University of Cambridge, Cambridge, UK Director of Pharmacotherapy, California Department of State Hospitals, Sacramento, CA
Grant/research: Alkermes, Clintara, Forest, Forum, Genomind, JayMac, Jazz, Lilly, Merck, Novartis, Otsuka America, Pamlab, Pfizer, Servier, Shire, Sprout, Sunovion, Sunovion UK, Takeda, Teva, Tonix
Consultant/advisor: Acadia, BioMarin, Forum/EnVivo, Jazz, Orexigen, Otsuka America, Pamlab, Servier, Shire, Sprout, Taisho, Takeda, Trius Speakers
Bureau: Forum, Servier, Sunovion UK, Takeda
Board Members: BioMarin, Forum/EnVivo, Genomind, Lundbeck, Otsuka America, RCT Logic, Shire
Meghan Grady (posttest questions author)
Director, Content Development, Neuroscience Education Institute, Carlsbad, CA
No financial relationships to disclose.
The peer reviewer has no financial relationships to disclose.
This educational activity may include discussion of unlabeled and/or investigational uses of agents that are currently not labeled for such use by the Food and Drug Administration (FDA). Please consult the product prescribing information for full disclosure of labeled uses.
Participants have an implied responsibility to use the newly acquired information from this activity to enhance patient outcomes and their own professional development. The information presented in this educational activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this educational activity should not be used by clinicians without evaluation of their patients’ conditions and possible contraindications or dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities. Primary references and full prescribing information should be consulted.
A variety of resources addressing cultural and linguistic competency can be found at this link: nei.global/CMEregs
Provided by the Neuroscience Education Institute.
Additionally provided by the American Society for the Advancement of Pharmacotherapy.
This activity is supported solely by the provider, Neuroscience Education Institute.
Following on from the success of the launch volume of Case Studies in 2011, we are very pleased to present a second collection of new clinical cases. Stahl’s Essential Psychopharmacology started in 1996 as a textbook (currently in its fourth edition) on how psychotropic drugs work. It expanded to a companion Prescriber’s Guide in 2005 (currently in its fifth edition) on how to prescribe psychotropic drugs. In 2008, a website was added (stahlonline.org) with both of these books available online in combination with several more, including an Illustrated series of books covering specialty topics in psychopharmacology. The Case Studies shows how to apply the concepts presented in these previous books to real patients in a clinical practice setting.
Why a case book? For practitioners, it is necessary to know the science and application of psychopharmacology – namely, both the mechanism of action of psychotropic drugs and the evidence-based data on how to prescribe them – but this is not sufficient to become a master clinician. Many patients are beyond the data and are excluded from randomized controlled trials. Thus, a true clinical expert also needs to develop the art of psychopharmacology: namely, how to listen, educate, destigmatize, mix psychotherapy with medications, and use intuition to select and combine medications. The art of psychopharmacology is especially important when confronting the frequent situations where there is no evidence on which to base a clinical decision.
What do you do when there is no evidence? The short answer is to combine the science with the art of psychopharmacology. The best way to learn this is probably by seeing individual patients. Here we hope you will join us and peer over our shoulders to observe 30 complex cases from our own clinical practice.
Each case is anonymized in identifying details, but incorporates real case outcomes that are not fictionalized. Sometimes more than one case is combined into a single case. Hopefully, you will recognize many of these patients as similar to those you have seen in your own practice (although they will not be exactly the same patient, as the identifying historical details are changed here to comply with disclosure standards, and many patients can look very much like many other patients you know, which is why you may find this teaching approach effective for your clinical practice).
We have presented cases from our clinical practice for many years online (e.g., in the master psychopharmacology program of the Neuroscience Education Institute (NEI) at neiglobal.com) and in live courses (especially at the annual NEI Psychopharmacology Congress). Over the years, we have been fortunate to have many young psychiatrists from our universities, and indeed from all over the xi world, sit in on our practices to observe these cases, and now we attempt to bring this information to you in the form of a second case book.
The cases are presented in a novel written format in order to follow consultations over time, with different categories of information designated by different background colors and explanatory icons. For those of you familiar with The Prescriber’s Guide, this layout will be recognizable. Included in the case book, however, are many unique sections as well; for example, presenting what was on the author’s mind at various points during the management of the case, and also questions along the way for you to ask yourself in order to develop an action plan.
There is a pretest, asked again at the end as a posttest, for those who wish to gain CME credits (go to neiglobal.com to answer these questions and obtain credits).
Additionally, these cases incorporate ideas from the recent changes in maintenance of certification standards by the American Board of Psychiatry and Neurology for those of you interested in recertification in psychiatry. Thus, there is a section on Performance in Practice (called here “Confessions of a psychopharmacologist”). This is a short section at the end of every case, looking back and seeing what could have been done better in retrospect. Another section of most cases is a short psychopharmacology lesson or tutorial, called the “Two-minute tutorial,” with background information, tables, and figures from literature relevant to the case in hand. Shorter cases of only a few pages do not contain the tutes, but get directly to the point, and are called “Lightning rounds.” Drugs are listed by their generic and brand names for ease of learning. Indexes are included at the back of the book for your convenience. Lists of icons and abbreviations are provided in the front of the book. Finally, this second collection updates the reader on the newest psychotropic drugs and their uses, and adopts the language of DSM-V.
The case-based approach is how this book attempts to complement “evidence-based prescribing” from other books in the Essential Psychopharmacology series, plus the literature, with “prescribing-based evidence” derived from empiric experience. It is certainly important to know the data from randomized controlled trials, but after knowing all this information, case-based clinical experience supplements that data. The old saying that applies here is that wisdom is what you learn after you know it all; and so, too, for studying cases after seeing the data.
A note of caution: we are not so naïve as to think that there are not potential pitfalls to the centuries-old tradition of case-based teaching. Thus, we think it is a good idea to point some of them out here in order to try to avoid these traps. Do not ignore the “law of small numbers” by basing broad predictions on narrow samples or even a single case.
Do not ignore the fact that if something is easy to recall, particularly when associated with a significant emotional event, we tend to think it happens more often than it does.
Do not forget the recency effect, namely, the tendency to think that something that has just been observed happens more often than it does.
According to editorialists, 1 when moving away from evidence-based medicine to case-based medicine, it is also important to avoid:
– Eloquence or elegance-based medicine
– Vehemence-based medicine
– Providence-based medicine
– Diffidence-based medicine
– Nervousness-based medicine
– Confidence-based medicine
We have been counseled by colleagues and trainees that perhaps the most important pitfall for us to try to avoid in this book is “eminence-based medicine,” and to remember specifically that:
– Radiance of gray hair is not proportional to an understanding of the facts
– Eloquence, smoothness of the tongue, and sartorial elegance cannot change reality
– Qualifications and past accomplishments do not signify a privileged access to the truth
– Experts almost always have conflicts of interest
– Clinical acumen is not measured in frequent flier miles
Thus, it is with all humility as practicing psychiatrists that we invite you to walk a mile in our shoes; experience the fascination, the disappointments, the thrills, and the learnings that result from observing cases in the real world.
Dr. Schwartz would like to sincerely thank Stephen Stahl, Rich Davis, Steve Smith, Lou Achille, Richard Marley, and the Neu roscience Education Institute team for training, teaching, mentoring, and emphasizing that learning can be difficult and fun simultaneously.
Stephen M. Stahl, MD, PhD
Thomas L. Schwartz, MD
1 Isaccs D and Fitzgerald D. Seven alternatives to evidence based medicine.
British Medical Journal 1999; 319:7225.
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Pre- and posttest self-assessment question; question |
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Patient evaluation on intake; Patient evaluation on initial visit |
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Psychiatric History |
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Social and personal history |
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Medical History |
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Family History |
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Medication History |
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Current Medication |
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Psychotherapy history; psychotherapy moment |
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Mechanism of action moment |
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Attending Physician’s Mental Notes |
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Further Investigation |
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Case outcome; use of outcome measures |
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Case Debrief |
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Take-home points |
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Performance in practice: confessions of a psychopharmacologist |
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Tips and Pearls |
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Two-minute tutorial |
5-HT | serotonin |
5-HT1A, -2A, -2C, -7, etc. | serotonin (receptors) |
AA | Alcoholics Anonymous |
AAPA | American Academy of Physician Assistants |
AAWG | antipsychotic-associated weight gain |
ACC | anterior cingulate cortex |
ADHD | attention deficit hyperactivity disorder |
AIMS | Abnormal Involuntary Movement Scale |
AMA | American Medical Association |
AN | anorexia nervosa |
ANCC | American Nurses Credentialing Center |
APA | American Psychological/ Psychiatric Association |
ASAP | American Society for the Advancement of Pharmacotherapy |
ASD | autism spectrum disorder |
AUD | alcohol use disorder |
BMI | body mass index |
BN | bulimia nervosa |
BPDO | borderline personality disorder |
BZ | benzodiazepine |
BZRA | benzodiazepine receptor agonist |
CACNA1C | calcium channel, voltage- dependent, L-type, alpha 1c subunit |
CAD | coronary artery disease |
CAM | complementary alternative medicine |
CBT | cognitive behavioral therapy |
CIDP | chronic inflammatory demyelinating polyneuropathy |
CIT | combination-initiation- treatment |
CME | continuing medical education |
CNE | continuing nursing education |
CNS | central nervous system |
COMT | catechol-O- methyltransferase |
COPD | chronic obstructive pulmonary disease |
CPAP | central positive airway pressure |
CRSD | circadian rhythm sleep disorder |
CSF | cerebrospinal fluid |
CT | computerized tomography |
D2 | dopamine-2 receptor |
D3 | dopamine-3 receptor |
DA | dopamine |
DAT | dopamine transporter |
DBS | deep brain stimulation |
DBT | dialectical behavior therapy |
DDP | dynamic deconstructive psychotherapy |
DED | depression–executive dysfunction syndrome |
DID | dissociative identity disorder |
DLPFC | dorsolateral prefrontal cortex |
DM2 | diabetes type II |
DR | dorsal raphe |
DRD2 | D2 receptor gene |
DRI | dopamine reuptake inhibitor |
ECT | electroconvulsive therapy |
EEG | electroencephalogram |
EKG | electrocardiogram |
EMR | electronic medical record |
EpCS | epidural prefrontal cortical stimulation |
EPS | extrapyramidal syndrome |
ERP | exposure and response prevention therapy |
FDA | Food and Drug Administration |
FM | fibromyalgia |
fMRI | functional magnetic resonance imaging |
GABA | gamma-aminobutyric acid |
GAD | generalized anxiety disorder |
GERD | gastroesophogeal reflux disease |
GI | gastrointestinal |
GIT | gastrointestinal tract |
HA | histamine |
H1 | histamine-1 receptor |
HTN | hypertension |
IBS | irritable bowel syndrome |
IDS | Inventory of Depressive Symptomatology |
IOR | ideas of reference |
IPT | interpersonal psychotherapy |
LAT | lateral hypothalamus |
LC | locus coeruleus |
MAOI | monoamine oxidase inhibitor |
MDD | major depressive disorder |
MDE | major depressive episode |
MDQ | Mood Disorder Questionnaire |
M-PPPT | Manualized psychopharm-acopsychotherapy |
MRI | magnetic resonance imaging |
MST | magnetic seizure therapy |
MT1 | melatonin-1 receptor |
MT2 | melatonin-2 receptor |
MT3 | melatonin-3 receptor |
MTHFR | methylene tetrahydrafolate reductase |
NA | Narcotics Anonymous |
NAC | N-acetyl cysteine |
NaSSA | noradrenergic and specific serotonergic antidepressant |
NCCPA | National Commission on Certification of Physician Assistants |
NDRI | norepinephrine–dopamine reuptake inhibitor |
NE | norepinephrine |
NEI | Neuroscience Education Institute |
NET | norepinephrine transporter |
NMS | neuroleptic malignant syndrome |
NRI | norepinephrine reuptake inhibitor |
OCD | obsessive compulsive disorder |
ODD | oppositional defiant disorder |
OFC | orbitofrontal cortex |
OROS | osmotically controlled- release oral delivery system |
OSA | obstructive sleep apnea |
PAM | positive allosteric modulators |
PCP | primary care physician |
PD | panic disorder |
PDP | psychodynamic psychotherapy |
PDSQ | Psychiatric Diagnostic Screening Questionnaire |
PET | positron emission tomography |
PHQ-9 | Patient Health Questionnaire |
PMDD | premenstrual dysphoric disorder |
PME | premenstrual exacerbation |
PMS | premenstrual syndrome |
PPPT | psychopharmaco-psychotherapyy |
PTSD | post-traumatic stress disorder |
QIDS | quick inventory of depressive symptomatology |
RAS | reticular activating syndrome |
RLS | restless legs syndrome |
SAD | social anxiety disorder |
SAMe | S-adenosyl methionine |
SARI | serotonin antagonist reuptake inhibitor |
SCN | suprachiasmatic nucleus |
SDA | serotonin–dopamamine antagonist |
SERT | serotonin transporter |
SGRI | selective GABA reuptake inhibitor |
SJS | Stevens–Johnson syndrome |
SNRI | serotonin–norepinephrine reuptake inhibitor |
SODAS | spheroidal oral drug absorption system |
SPARI | serotonin partial agonist reuptake inhibitor |
SPMI | severe and persistent mental illness |
SRI | serotonin reuptake inhibitor |
SSRI | selective serotonin reuptake inhibitor |
SUD | substance use disorder |
TBI | traumatic brain injury |
TCA | tricyclic antidepressant |
TD | tardive dyskinesia |
TEN | toxic epidermal necrolysis |
TMJ | temperomandibular joint |
TMN | tuberomammillary nucleus |
TMS | transcranial magnetic stimulation |
TRA | treatment-resistant anxiety |
TRD | treatment-resistant depression |
URI | upper respiratory tract infection |
VLPO | ventrolateral preoptic area |
VMPFC | ventromedial prefrontal cortex |
VNS | vagus nerve stimulation |
VTA | ventral tegmental area |
Case 1 |
Case 16 |
---|---|
The Case: Achieving remission with medication management augmented with pet therapy The Question: Do avoidant symptoms respond to medication management? The Dilemma: Psychotherapy may not alleviate personality traits |
The Case: The woman who liked late-night TV The Question: What to do when comorbid depression and sleep disorders are resistant to treatment The Dilemma: Continuous positive airway pressure (CPAP) may not be a reasonable option for treating apnea; polypharmacy is needed but complicated by adverse effects |
Case 2 |
Case 17 |
The Case: The luteal, jaw-moving woman with paranoid paneling The Question: Can premenstrual hormone fluctuations affect established psychiatric symptoms? The Psychopharmacological dilemma: Finding an effective regimen for recurrent, treatment-resistant depression while juggling complex clinical variants and side effects |
The Case: The patient who interacted with everything The Question: What to do when treating depression is thwarted by pharmacokinetic problems and side effects The Dilemma: CYP450 enzyme genetic alterations may cause subtherapeutic, side effect-prone treatment |
Case 3 |
Case 18 |
The Case: The other lady with a moving jaw The Question: How to determine the cause of movement disorder side effects? The Psychopharmacological dilemma: Finding an effective regimen for depression while managing movement disorder side effects |
The Case: The angry twins The Question: Is pharmacologic treatment of personality traits effective? The Dilemma: There are no approved medications for personality disordered patients |
Case 4 |
Case 19 |
The Case: The lady with major depressive disorder who bought an RV The Question: What is a therapeutic dose and duration for vagus nerve stimulation therapy in depression? The Psychopharmacological dilemma: Finding an effective treatment for chronic treatment-resistant or refractory depression while managing a severely ill patient |
The Case: Anxiety, depression, or pre-bipolaring? The Question: When to decide if someone is truly becoming bipolar disordered The Dilemma: Antidepressant activation can be a side effect or a sentinel event |
Case 5 |
Case 20 |
The Case: The primary care physician who went the prescribing distance but came up short The Question: Do atypical antipsychotics treat generalized anxiety? The Psychopharmacological dilemma: Finding an effective treatment for chronic treatment-resistant generalized anxiety in an elderly patient |
The Case: The patient who was not lyming The Question: Can Lyme disease cause depression? The Dilemma: Managing depression and possible neuropsychiatric illness |
Case 6 |
Case 21 |
The Case: Interruptions, ammonia, and dyskinesias, oh my! The Question: Can stimulants complicate bipolar presentations? The Psychopharmacological dilemma: Finding an effective treatment for mania and mixed features without exacerbating symptoms and side effects |
The Case: Hindsight is always 20/20, or attention deficit hyperactivity disorder The Question: What to do when a primary anxiety disorder is fully treated and inattention remains The Dilemma: Residual inattention may be difficult to treat |
Case 7 |
Case 22 |
The Case: The lady and the man who sat on couches The Question: Are the symptoms of apathy of an elderly man and woman due to depression, dementia, or side effects of medication? The Dilemma: How to tell depression from vascular dementia (and everything in between as well) |
The Case: This one’s too hot, this one’s too cold…this one is just right The Question: What to do when patients cannot tolerate low-dose atypical antipsychotics The Dilemma: Activation or sedation, not sure what you are going to get when taking the atypical antipsychotics |
Case 8 |
Case 23 |
The Case: The lady who had her diagnosis altered The Question: When are symptoms psychotic or dissociative? The Psychopharmacological dilemma: Finding an effective treatment for dissociative, depressed, psychotic patients while not ruining the outcomes of their previous bariatric weight-loss surgeries |
The Case: Schizophrenia patient needs sleep The Question: What if patients are not responsive to benzodiazepine sedative–hypnotic agents? The Dilemma: Non-benzodiazepine hypnotics may or may not work if patients have been taking benzodiazepines routinely |
Case 9 |
Case 24 |
The Case: The man who picked things up The Question: How many antipsychotics can a patient take? The Psychopharmacological dilemma: Finding an effective antipsychotic monotherapy and treating side effects simultaneously |
The Case: The man with greasy hands needs fine tuning The Question: What to do with a bizarre side effect The Dilemma: Fine tuning polypharmacy treatment |
Case 10 |
Case 25 |
The Case: It worked this time, but with a hitch The Question: Can clozapine (Clozaril) work for patients without side effects? The Dilemma: Using this medication in treatment-resistant schizophrenia frequently requires measures to make the drug better tolerated. Sialorrhea is often a stumbling block |
The Case: The combative business woman The Question: What to do when a patient becomes abruptly psychotic The Dilemma: The age-old functional versus organic differential diagnosis argument |
Case 11 |
Case 26 |
The Case: The figment of a man who looked upon the lady The Question: Are atypical antipsychotics anti-manic, antidepressant, anxiolytic, and hypnotic as well? The Psychopharmacological dilemma: How to improve insomnia that is caused by depression, anxiety, mood swings, and hallucinations |
The Case: The man with a little bit of everything The Question: What to do when a patient does not meet full diagnostic criteria for anything The Dilemma: Categorical versus symptomatic treatment |
Case 12 |
Case 27 |
The Case: The man who could not sell anymore The Question: What to do when comorbid depression and social anxiety are resistant to treatment The Dilemma: Rational subsequent polypharmacy trials may fail to achieve remission |
The Case: Oops…he fell off the curve The Question: What to do when patients lose too much weight The Dilemma: In the era of weight-gain side-effect notoriety, the stimulants may cause equally problematic loss in weight and stature |
Case 13 |
Case 28 |
The Case: The woman who thought she was ill, then was ill The Question: What to do when medication is not absorbed, nor effective The Dilemma: Treating anxiety and agitation in the severely medically ill |
The Case: 54-year-old with recurrent depression and “psychiatric” parkinsonism The Question (Pharmacogenetics, Part 1): How might psychopharmacology be delivered in the future? The Dilemma: Can genotyping help predict successful treatment selection |
Case 14 |
Case 29 |
The Case: Generically speaking, generics are adequate The Question: What to do when using a generic is detrimental to a patient The Dilemma: Navigating clinical care when generic medications are not always equal |
The Case: 55-year-old with depression not responsive to serotonergic treatment The Question (Pharmacogenetics, Part 2): How might psychopharmacology be delivered in the future? The Dilemma: Can genotyping help predict successful treatment selection |
Case 15 |
Case 30 |
The Case: The woman who would not leave her car The Question: What to do when obsessive compulsive disorder with poor insight is resistant to treatment The Dilemma: Rational subsequent polypharmacy trials may help, but fail to achieve remission |
The Case: 23-year-old with first depression…that’s it! The Question: How might psychopharmacology be delivered in the future: neuropharmacogenetic imaging? The Dilemma: Can genotyping and functional neuroimaging help predict successful treatment selection |
The estimated time for completion of this activity is 55.0 hours. There is a fee for the optional posttest, waived for NEI members.
Read the book in sequence, evaluating the content presented
Complete the posttest and activity evaluation, available only online at www.neiglobal.com/CME (under “Book”)
Print your certificate (if a score of 70% or more is achieved)
Questions? Call 888-535-5600, or email CustomerService@NEIglobal.com
Note: page numbers in italics refer to figures and tables
Note: page numbers in italics refer to figures and tables