Behavioral Science
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174 Deja Review: <strong>Behavioral</strong> <strong>Science</strong><br />
CLINICAL VIGNETTES<br />
An unresponsive young woman is brought to the ER by her college roommate.<br />
Her roommate states that she had confided in her that she was being treated for<br />
depression for quite some time with little success. She found an empty pill bottle<br />
by the patient as well, but didn’t bring it in. On examination the patient has<br />
widely dilated pupils, a dry mouth, and tachycardia.<br />
What was likely in that bottle of pills taken by the patient?<br />
She likely is suffering from tricyclic antidepressant overdose. Note the anticholinergic<br />
symptoms and the limited success of treatment (perhaps necessitating a few different<br />
medication trials).<br />
What diagnostic test would you order? What result do you expect on that test?<br />
You should order an ECG, on which you would likely see a prolonged PR interval,<br />
a widened QRS, and a long QT interval.<br />
What is the appropriate management of the patient?<br />
Of course you would start with ABCs, but intravenous bicarbonate is a specific<br />
treatment for TCA overdose.<br />
A 62-year-old patient with schizophrenia comes in to inquire about new treatment<br />
options. He has been on haloperidol which has controlled his symptoms well. His<br />
past medical history includes pre-diabetes, obesity (though he’s trying to lose<br />
weight), hypertension, and a family history of coronary artery disease. He says that<br />
he has heard that some of the new atypical antipsychotics are more effective than<br />
his old agent.<br />
What should you advise him?<br />
Atypical medications are no more effective than typical agents, with the notable<br />
exception of clozapine. The main advantage of atypical agents is a more favorable<br />
side-effect profile with less EPS and tardive dyskinesia than typical agents.<br />
What side-effects might you worry about in this patient?<br />
Prominent metabolic effects and weight gain are side effects of atypical agents,<br />
which would be especially detrimental to this patient.<br />
If he was treatment resistant, would this change your thinking?<br />
Patients who have failed multiple other antipsychotic medications may benefit<br />
from clozapine—though the risk of agranulocytosis and subsequent FDAmandated<br />
laboratory monitoring limit its widespread use.
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