Patient evaluation on intake

• 27-year-old man states he is in between graduate school assignments and “has some concerns”

• Has been depressed and anxious but is most concerned about his alcohol use

Patient evaluation on intake

• 32-year-old woman with a chief complaint of unremitting depression for several years, who was transferred from another provider who had just retired

Patient evaluation on intake

• 36-year-old man states he “cannot sleep”

• He is all “worked up” and his “head is all wrong at night”

Patient evaluation on intake

• 52-year-old man cannot sleep

• He has been “in a funk” for about a year after he had difficulty at his work site

Patient evaluation on intake

• 55-year-old woman with a chief complaint of unremitting depression for 30+ years

Patient evaluation on intake

• 42-year-old woman with a chief complaint of depression

Patient evaluation on intake

• 48-year-old woman states she has been “depressed and anxious since childhood”

• She is extremely worried she will become incapacitated and institutionalized

Patient evaluation on intake

• 70-year-old female with a chief complaint of “being sad”

• Feels she had been doing well until her hearing began to diminish in both ears

– Candidate for cochlear implants in the future, but this is a long way off

– Despite the promise of improved hearing, she often has crying spells for no clear reason

Patient evaluation on intake

• 30-year-old identical twins are referred separately for depression and anger problems

• Both state that external stressors, e.g., work, family, etc. have driven them to depression and “mood swings”

Patient evaluation on intake

• 57-year-old man with a chief complaint of “horrible depression”

• Feels he “made a bad decision” late in his career and is now unemployed after many successful years in equipment sales

• Fearful and nervous that, at his age, he is too young to retire and too old to find a new job and be successful again Psychiatric history

• He had been without major mental health issues until he left his gainful employment of 25 years as an equipment salesman

• – He left during poor corporate economic times assuming his company would fold

• – He left for a second company for a sales position in a different market, and performed poorly on commission and was let go

• – Psychiatric symptoms developed after this

• Has not been able to go back to work at all due to anxiety and fear about failing again

• He admits to full syndromal depressive symptoms

• – He has passive suicidal thoughts and ideational guilt that he is a bad spouse in that he has let his family down by being unsuccessful and unemployed

• – Additionally, he is amotivated, fatigued, and states he is hopeless and pessimistic about the future

• He now worries about everything, all the time, cannot focus, and is tense. He states he was never like this before

• Additionally, he can barely “look people in the eye” and talk to them

• – He is very concerned about doing and saying the right thing

• – After years of remembering many details in sales, he can barely keep any facts straight, and is convinced that he will fail

• – Panic attacks have occurred at recent job interviews, and since then is avoiding most situations where he has to speak to superiors

• He has relatively few friends as most were colleagues at his previous job

• While he is at home more, he is experiencing more conflict with his wife, although states she is supportive

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).

Patient evaluation on intake

• 26-year-old man with a chief complaint of being “depressed, more or less”

• Mainly experiences MDEs of varying lengths and severities, occurring since he was a teenager

• Asks for a consultation because he has legal issues concerning an altercation that occurred recently

Patient evaluation on intake

• 56-year-old woman with a chief complaint of “not doing well for many years”

• Has suffered anxiety and depression for over 30 years

Patient evaluation on intake

• 42-year-old woman with a chief complaint of depression and interpersonal stress

Patient evaluation on intake

• 42-year-old man with a chief complaint of depression and family stress

Patient evaluation on intake

• 23-year-old woman states that she feels “sad, down, and amotivated”

• Admits to all MDD symptoms except for suicidality for the last two to three months

• There was no psychosocial trigger and she reported that “life was going well”

Patient evaluation on intake

• 55-year-old man is admitted to the psychiatric hospital because of MDD

Patient evaluation on intake

• 26-year-old man met initially on an inpatient unit while paranoid

Patient evaluation on intake

• Nine-year-old presents with his parents who note that they are having a hard time managing him at home and at school

• He is “not like their other kids”