Page 546 - Basic _ Clinical Pharmacology ( PDFDrive )

30 Antidepressant Agents
C H A P T E R

Charles DeBattista, MD

C ASE STUD Y

A 47-year-old woman presents to her primary care physician house and has no motivation, interest, or energy to pursue
with a chief complaint of fatigue. She indicates that she was recreational activities that she once enjoyed such as hiking.
promoted to senior manager in her company approximately She describes herself as “chronically miserable and worried
11 months earlier. Although her promotion was welcome all the time.” Her medical history is notable for chronic neck
and came with a sizable raise in pay, it resulted in her having pain from a motor vehicle accident for which she is being
to move away from an office and group of colleagues she treated with tramadol and meperidine. In addition, she is
very much enjoyed. In addition, her level of responsibility on hydrochlorothiazide and propranolol for hypertension.
increased dramatically. The patient reports that for the last The patient has a history of one depressive episode after a
7 weeks, she has been waking up at 3 am every night and divorce that was treated successfully with fluoxetine. Medical
been unable to go back to sleep. She dreads the day and the workup including complete blood cell count, thyroid func-
stresses of the workplace. As a consequence, she is not eating tion tests, and a chemistry panel reveals no abnormalities.
as well as she might and has dropped 7% of her body weight She is started on fluoxetine for a presumed major depressive
in the last 3 months. She also reports being so stressed that episode and referred for cognitive behavioral psychotherapy.
she breaks down crying in the office occasionally and has What CYP450 and pharmacodynamic interactions might be
been calling in sick frequently. When she comes home, she associated with fluoxetine use in this patient? Which class
finds she is less motivated to attend to chores around the of antidepressants would be contraindicated in this patient?

The diagnosis of depression still rests primarily on the clinical antidepressants to treat a host of conditions and that patients have
interview. Major depressive disorder (MDD) is characterized by been increasingly receptive to their use.
depressed mood most of the time for at least 2 weeks or loss of The primary indication for antidepressant agents is the treat-
interest or pleasure in most activities, or both. In addition, depres- ment of MDD. Major depression, with a lifetime prevalence of
sion is characterized by disturbances in sleep and appetite as well around 17% in the USA and a point prevalence of 5%, is associ-
as deficits in cognition and energy. Thoughts of guilt, worthless- ated with substantial morbidity and mortality. MDD represents
ness, and suicide are common. Coronary artery disease, diabetes, one of the most common causes of disability in the developed
and stroke appear to be more common in depressed patients, and world. In addition, major depression is commonly associated with
depression may considerably worsen the prognosis for patients a variety of medical conditions—from chronic pain to coronary
with a variety of comorbid medical conditions. artery disease. When depression coexists with other medical con-
According to the Centers for Disease Control and Prevention, ditions, the patient’s disease burden increases, and the quality of
antidepressants are consistently among the three most commonly life—and often the prognosis for effective treatment—decreases
prescribed classes of medications in the USA. The wisdom of such significantly.
widespread use of antidepressants is debated. However, it is clear Some of the growth in antidepressant use may be related to the
that American physicians have been increasingly inclined to use broad application of these agents for conditions other than major

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