In the third meeting of our 2022 depression module, Dr. Stephen Sisselman presents the case of a 20 year old patient with depression and persistent suicidal thoughts and cultural barriers to support. He discusses how he intervened when this patient presented with suicidality on the PHQ-9 and seeks feedback from the group on how to handle difficult cases where patients lack family support. Dr. Katie Angelova then gives a didactic presentation on pharmacological management of depression in the primary care setting. She provides an overview of common agents (SSRIs, SNRIs, buproprion, etc.), tips for speaking with patients about antidepressant therapy, and indications for when to switch agents.
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Case Presentation Case Discussion Didactic Presentation Didactic Q&A everybody involved. I did want to present this case. You can advance the slide. This is a 20 year old Korean young male who came to me for the first time for a physical exam. He he came an hour and a half late for his appointment. We talked about that briefly at the beginning. He didn't know why he came late and he briefly gave me a story about how two weeks ago he was fighting with his friends and was knocked unconscious. He had headaches and flashing lights. Uh He wasn't seen by anyone for these but all of those symptoms has gone away. So like any new patient I wanted to take a thorough history and this is someone who has really no past medical history. Wasn't taking any medications for any reason. You can advance to the next slide please. Uh He was born in the United States but both of his parents were born in Korea and we were going through medical history, social history. He told me that he sees a therapist and he's been diagnosed in the past with depression, anxiety and A. D. H. D. And from there we moved on to the P. H. Q. Nine which I think is an important intake form along with alcohol screening. And what I found immediately noteworthy is that his P. H. Q. Nine was positive for the highest score on every question. He scored a perfect 27 out of 27. And what struck me was even the question reports that he'd be better off dead. Uh He had a big big circle around it so immediately I knew that that was gonna be the focus of of our patient encounter. We were talking about the P. H. Q. Nine and why he answered that way. And he told me quite frankly and you could advance to the next slide. He felt symptoms that many depressed patients feel lack of energy, lack of motivation, feelings of hopelessness, helplessness and guilt. But I wanted to speak to him specifically about thoughts of suicide which he had uh intimated on the P. H. Q. Nine. He said that for the last eight years he has had eight years he has had a rope in his room and every day he thinks about using it to hurt himself. And I couldn't believe first of all how lucky that eight years goes by and he's never acted on these impulses. But certainly these are some pretty severe symptoms of depression with thoughts of active suicide. Not not necessarily a specific plan but certainly a way to do it with access to this. So we got to talking whose your therapist who's who's your psychologist that you see. And he disclosed that it's someone who's in my building and come back. So I immediately excused myself from the room because I didn't feel comfortable managing him by myself. I asked my medical assistance to watch him that he didn't leave. And to text me I grabbed my phone. I went downstairs to the psychologist office again. I got lucky he was just sitting in his office between patients. I explained the situation who I had, I had previously gotten the patient's permission to speak to the psychologist and I brought the psychologist back upstairs with me and he and I and the patients spoke in the exam room and the psychologist told me that he was aware of these feelings of suicide and that he didn't think that the patient was going to act upon them. But nevertheless, I was still struck with the severity of the symptoms. So the next thing I wanted to do was call the patient's parents and I had the patient's permission to do. So I called the patient's mother and the patient's mother spoke very, very poor english and she didn't really understand what I was saying. Uh And I was also struck with the fact that the patient's mother really had no idea what was going on and didn't understand the severity of the situation. I called the patient's father at work and I'm doing this in my office while the patient sitting in the exam room still. And the patient's father was just very blase about it, nonchalant, yes. You know, he has depression and didn't know anything about this rope. I knew his son had depression, but really didn't think it was such a big deal and I was floored floored by this. So I asked the dad's permission if I could put him on speaker in the room with the patient. So the three of us can talk about what's going on. And I was really expressed my concern about the severity of the patient's symptoms and the dad didn't really seem to think that this was a big deal. And I said okay. So we hung up. I spent more time with the patient. I thought it was a big deal and I certainly thought I needed you know, psychiatric help. But I wanted to get the patient started on medication. But the first thing I said to the patient was I want you to go home and I want you to get that rope and bring it to me. And he said okay. And he brought the rope to me and I have it here in this bag which you know, just as a reminder of how people struggle sometimes with their mental health. And it's it's it's it's a symbol of his of his struggle. And the fact that he brought it to me was great. I did start him on Lexapro. We could advance to the to the next slide here. I wanted to make sure that he was given uh suicide hotline information, Suffolk County crisis intervention hotline information. I gave him my cell phone number. I told him you can call me any time if you feel like you're in trouble or in crisis or struggling. I need you to reach out to me or one of these phone numbers or your psychologist and told him that I wanted. I gave him a list of 3 to 5 psychiatrists who are accepting patients in the area. It's an important community resource that we have to be able to give people mental health resources. And I sent the patient home. I wanted to see him back in a week. He came back in a week and he's made every follow up appointment with me and he has done incredibly well. He his symptoms are much less and every visit, he's more engaging and more willing to talk to me about how he feels. And I feel great uh with every patient visit because I know that we all can make a difference in in our patients with mental health who struggle. But I was really, really struck with this case and I think it gives, you know, yields itself to a lot of different discussion points. So that's my case and thank you for listening. Thank you so much. Dr Solomon. Did you want to just note for the group what your main hope is to to hear about today from the group? Sure. Of course. I I I know that there is, you know, cultural implications to treatment and the family dynamic and we all all of us who practice realize that social support system is so important for patients, whether it's heart disease, gastrointestinal disease or mental health. And I was struck by how little family support he seemed to have. His parents did not have very much interest in discussing their son's mental health or acknowledging the severity of the crisis that their son was going through at the time. So, you know, some insight and and learning on how to deal with with that complicated dynamic would be important as well as, you know, management of the acute crisis patient. Because when when you have someone with active suicidal ideation, you know, even though he had brought back to me the the the Method that that he was thinking of using and that it had been in his, you know, this is a 20 year old kid who's struggled for eight years and that's how long this rope has been in his room. It's it's amazing. That's you know, more than a third of his life, you know, with severe mental health. How do we deal with these things as as primary care physicians? You know, I hope I, you know, I got lucky the psychologist was in my building, I was able to access him quickly uh and get him involved. He quite frankly didn't seem nearly as concerned as I was. But uh you know, how do we handle these these difficult cases going forward? I think it is something that I'd like to to get out from the from the panel here. Yeah, great, thank you. I appreciate you clarifying that. Certainly complex case. I imagine you're waiting room is getting pretty full. Um yeah, but this, I tell people all the time. Some people, some people take five minutes, a sore throat and ear ache and some people need 30 minutes and you don't always know what it's going to be when they walk in the door. But I try to promise my patients when you need it, I'm there for you and I think Joe and I are both both practice that way. Yeah, I appreciate it. Um I certainly have some thoughts um you know, and certainly chronic suicidal ideation, if that was the nature of what he was experiencing can be complex and trying for for the provider um to figure out when it when is it urgent when you need to intervene versus managing it and other other with other strategies. But I'd love to first start with the group to see if folks were gathered here have thoughts, questions, um suggestions for dr Solomon. I have a thought if that's okay. Sure. Of course any relation, it's not so much a thought as um you know, I think it really reiterates how important that P. H. Q. Nine is because for someone like this patient, he had no one to talk to and you can't go to your parents and you can't go to your friends and you know what will there really is still such a stigma put on mental health issues. So I think a lot of people, you know, we give it to everybody, I'm sure everybody does, but we give it to every patient that walks in the door at least once a year obviously and it's marked in the chart the last time we gave it. So I always look at it because I feel it's when someone fills out something the way that this patient did. It's such a cry for help. And I believe that because they're filling it out by themselves in the quiet and handing it over quietly to a doctor they're hoping somebody recognizes it and looks at it and brings it up so that you don't have to. It's the same way in my review of systems for physical. I'll always bring up erectile or sexual dysfunction. People don't want to mention it or bring it up. But if you open that door it's so much easier for them to walk through it. And you know this patient, even his own therapist wasn't really very taken by his thoughts and feelings and he was so fortunate to have somebody who intervened and didn't just throw him back to the therapist got everybody involved and took you know was able to start him on something. And sometimes even that P. H. Q. Nine. It gets mixed up in the papers and I didn't notice it and then I'll look back when I have more time and say oh my God I didn't address it and I'll call the patient back and say hey I'm so sorry I didn't address your depression screen with you But let's talk about it. So you know, it's not just a paper to be filled out to check a box that we did it and satisfying insurance company requirement. It's really a great tool and a cry for help for a lot of people. Yeah, incredibly well said um thank you for saying that. Um can I maybe go to Dr Cheung? You have the question here about, you know, you may have wanted to know a little bit more about the patient's likelihood of following through on his plan. You want to ask it because a lot of times people are checking those boxes a lot. Like they may not be all the way with the big circle, but they're checking them a lot. So you can't ask, you can't do this uh talk to their therapist, Talk to their parents every one of those patients. If you're just asking, well what's the chance you're using that road? And he says, oh that has been there all this time, I'm never gonna use it. I just want to tell you that it's there. So maybe that's what he's been telling the therapist and his parents all the time. Maybe he's threatening to kill himself every day. So for them this is like, you know, good morning and his good morning, I think I'll kill myself today. So maybe there's something going on like that where this is just part of his personality is still depressed. But that's why there was a disconnect between what they thought, what you thought, because this is your first experience with, right? That's a that's a very good point. And we we did spend some time talking about exactly that and, you know, any, anyone could wake up and have a bad morning and you never know what's gonna happen. So, I wanted to be very proactive and I wanted to make sure that he was safe and and was given Outlets if he didn't feel safe and he chose to call me or a therapist or crisis hotline or suicide prevention hotline. I mean, those are why those resources are there. So even even though, and I agree with you, perhaps, you know, eight years of having a rope in your bedroom and being a 20 year old adolescent, I think perhaps that proves that his actual intent may have been lower. But when you're when you're in the heat of that moment and I'm meeting him for the first time, I I needed to know if he left my office, that there wasn't gonna be a problem. So I needed to protect him. I needed to protect myself. I needed to make sure that there was a really solid plan in place for him. I think that's a very good point and I think dr cecil man, you did a wonderful job and I'm and I'm so glad that there are folks like you out there, you know, taking care of people with mental health problems and you know, I think sometimes in mental health we become a little bit desensitized as well to these issues and it's kind of like, okay, well this patient has been saying this for you know, 8, 10, 25 40 years, right? Um but I think there's also, you know, something to say about positive reinforcement which which guides all of our learning and all of our behavior, right? And it sounds like this patient um doesn't have a lot of that in his life, right? And sometimes behaviors um whether they're intentional or not will escalate in that search for positive reinforcement, right? So having a rope wasn't enough for my parents to pay attention to me. Maybe I should use it, right? And and you you have intervened and you have given him some sense that somebody out there cares about him and wants to know that he's safe and that may have saved his life, right? You know, I agree and thank you for that. Either it's an incredible cry for help when you circle all of those boxes on a P. H. Q. Nine or you are very very actively struggling and potentially actively suicidal. So, you know, cry for help or the other. I still think that, you know, you have a duty to try to protect this patient. I think it's absolutely important and you know, I want to echo what dr Angelo said about how lucky he was to have had you on the receiving end of that paper um on that incident. But I want to just note that, you know, the National Suicide Prevention Lifeline. They researchers at Columbia looked at some of their processes um you know, around the calls like what helps patients. They're very high rate of being able to deescalate people in a suicidal crisis. And you want to look at like what is effective about this. And one of the things that the lifeline tested was follow up, meaning the patient or the caller tells them I'm having thoughts of suicide, they get deescalated, they make a plan, they agreed to not go through with their plan that day or what have you. And then the lifeline will follow up with the patient in a couple of days. And some of the findings from this notes that um like 80 something percent of the people that were uh interviewed noted that that follow up call was the reason they were alive because to them it told them someone it matters to a person out there that I'm alive and they remembered me and they called me back and they checked in on me. So, so that's sort of like going above and beyond trying to connect the dots, reaching out to people trying to coordinate, telling him go call me any time those things matter in ways that we haven't even fully, I think started to capture and measure. But there is some data out there to support how how impactful that is. I just wanted to to share that um um dr camera, you had a question that speaks a bit more to dr layman's question about cultural dynamics. I wonder if you want to ask that Sarah Hi steve and I really wanted to get a sense of to what degree did you as a clinician feel pressured to manage culture or to understand culture in that situation with that patient knowing that you know this this person may have been born in the United States but had parents born somewhere else with other cultural values of what is socially acceptable to speak about and to what degree do you think the father's response was influenced by what he has been told is socially acceptable or not acceptable. Did you feel pressure to like have to manage that and then wondering now that this patient seems to have had a more robust plan that's being heard. Have you had an occasion to speak with that dad again or at least get a sense of what that support looks like for that young man at home. Yes and thank you for that question. It's I knew it was an issue that I had to deal with at the time. I couldn't really delve into it then, but I have subsequently the patient came back to me a week later and I wanted to speak to him specifically about the interaction with the parents and he told me very frankly that in his culture, korean culture, men talking about mental health is almost taboo. They don't discuss it at all. It's something that is a sign of weakness and the father didn't want to acknowledge that his son was was weak in his eyes, interestingly the father was also a patient so I felt comfortable talking to him before and I had known the father for a couple of years before I met his son and I've seen the father since all this happened in in january when this started and we spoke a little bit about it. I was gingerly you know treading around the issue, I didn't want to be accusatory or insulting of course, but I asked about you know have you spoken to your son about how he feels and just trying to be open ended about it and see what he was going to say and he he said that he did and just the fact that they had a conversation about it made me feel good because it seemed like previously they had no interaction about mental health whatsoever. So it made me feel better that at least there is a line of communication there which I think is so important for the patient and yeah I mean I was struck that I had to deal with what I perceived as a as a cultural barrier and I didn't think that was the right time to do it, but I had subsequently, and, you know, we talked about it. He comes now once a month and, you know, the lines of communication with him and his dad are definitely opened and I think a little bit with his mom as well, so you may find a golden thread to the dad and help that relationship even more. That's great. I think sometimes it's also important to, you know, there's the cultural issues, but then there's also parents, right, parents. Um, you know, we see this so often where, you know, we diagnose somebody with first break psychosis or severe depression or something that we know is going to be hard to handle, and and there's denial, there's denial on the family's part, and that's that's a very common coping mechanism to, right? So for, you know, parents will usually say, oh, it's nothing they're exaggerating or, oh no, it's probably drugs, like they can't be psychotic, they can't be, you know, this, they can't be that, and and that's a difficult thing to work through. Um and I think sometimes what helps is actually addressing the problem and treating the problem, and then the family kind of seeing that the problem can improve and that treatment exists and that it can help and then kind of slowly they begin to to process that and and become more supportive actually as as treatment goes on. So that's an interesting phenomenon as well. Um these are all really great points. I particularly appreciate the note about, you know parsing out cultural dynamics from parenting dynamics and the parent, the relationship between the patient and his parents. I would also just note that in a lot of asian cultures, certainly south asian culture, I can speak to pretty confidently, but also in other east asian cultures, you know, there's a lot of deference and respect to authority and physicians can certainly be placed in that category of people that there's a certain amount of deference to. And there's some, you know, kind of awareness of how you're presenting to them to that authority figure. And so it could also be that, you know, in that moment, the way the father reacted um was born out of sort of a cultural need to kind of keep things together and you know, not overreact and kind of present himself in a way that would be appropriate and sanctioned culturally and such and I don't know him, but I know those dynamics come into play. I mean, you know, my father for example, no matter what his physician asked him, he's always gonna say I'm fine. Um you know, because there's a there's a desire to present a certain way. Um so that might also be, I think a piece piece here, um dr Christopher dr brody wanted to see if, you know, either of you had any thoughts um as well before we go into some other comments that have come up. Yeah, I think you really did a job, especially in the context of a primary care setting. I think you know many people would have you know rushed to maybe call 911 or even rushed to do we need to get this person in the emergency room without even taking the time to really just address it. Person to person in the room. And it sounds like the intervention you made was so effective for this patient. And I think you know, having the benefit of the psychologist, you know in your building is amazing as well and coordinating care that way I think could be Yeah seriously that was really because without that honestly I mean emergency room or 911 or even I've had Suffolk county crisis team come to the office and speak to a patient. I've had that before. You know there's a bunch of different other avenues this could have gone but enough things kind of fell into place where I felt that he can go home and you know I also got lucky that he turned around and brought me the rope and came back and to me that was a great symbol of you know I wanna get better. And I think likely for this patient more therapeutic. So thank you I wanted to just just jump in and dr brody I think we've lost your audio. Hmm perhaps as dr brody's resetting doctor, are you still there? We lost you there for a bit. Oh okay well I can hear you now. You can hear me now. Okay so I was gonna say that I don't have the most ideal connection today that there's a literature goes back a long time that when you interview patients in their primary language um you can get a completely different assessment of their of their of their symptoms and psychotherapy uh is so dependent on language that a lot of times it really pays off to try and find a therapist who speaks the patients you know primary language. But in any case in terms of this it might be interesting uh to imagine um a family meeting with a translator. Uh so you can really uh you know really talk to the parents and have the translator really help them understand the kinds of things that you're concerned about your asking about and and whatnot. Thank you. Okay I just wanted to um sort of think about the father in a little bit of a different way and certainly the cultural issues may have definitely impacted how he responded. Dr cecil man when you called. But I'm also thinking of somebody who's been dealing with a depressed adolescent for how many ever years? eight years. You know however long with a wife whose english is not good. Who might have gotten these types of calls at work before who feels like okay here's his son going again talking about the rope, here's this physician, you know and yes, you know, deferential to you. But but thinking of the father possibly feeling helpless alone and so sort of reacting in the way he did, maybe angry at his son. You know, maybe just like wanting to throw up his hands and possibly then when you took such a sort of ownership of trying to help the sun that it also helped the father not feel so alone possibly. And then maybe it could open the communication with the sun so that maybe another benefit for this family of of your interest. And the only other thing I would say is it is too bad that the sun wasn't provided with medications earlier he responded so well to them and you know, for all those years that maybe if he had been medicated sooner he would have had a better happier maybe adolescence. That's a good point. Thank you judy. Um dr Cheung speaking of medications, you had a question about how you know, the conversation around medication went with the patient quite for for those kind of patients, they are young and the communication isn't so good I guess with his parents and you haven't met him before then all of a sudden you're calling his dad calling his mom punches therapist. I'm gonna put you on this medicine. So in my experience it's very difficult to convince him to take the medicine. So I'd like to hear your, your approach. He took that thing and then he got better. So what were the words you used to soothe that transition? Well, what I told him was that I wanted, I never intended to be the primary provider of pharmacologic therapy for, for this patient because I felt like it was, you know, out of my comfort level, something like this. And but but but I did want to get it started. So I chose Lexapro and started a low dose, told him five mg for the first week and 10 mg after that. And my intent was to have him transitioned to psychiatrist within four weeks. So I'd given him a 30 day supply and I was going to see him back in four weeks. I was gonna see him back in one week. So we would have ample opportunity to talk about side effects or adverse effects. I tried to answer. He didn't really have any questions about the medications that I remember. Um, but he, he was very willing to start taking it. There was, there was no reluctance to, to starting a medication. He didn't feel like it was unnecessary. I thought that he bought into to the process very quickly and he certainly responded obviously anything better in the first week. I wouldn't expect to be, you know, anything other than placebo effect. But over the course of that first 4 to 8 weeks, he definitely approved improved. You could see it in his face, you could see it in his affect. You could his engagement with me talking about what was going on, What was markedly improved. So it wasn't a hard sell to put him on medication. I knew I wanted him on medication and it wasn't a struggle. He was very accepting. It's great. It's perhaps speaks to the cry for help comment as well, that we had heard earlier that maybe he was letting you know because he wanted intervention um uh dr Jill system. And you had a thought and a question about um the potential for increased risk of suicidality. Um when you start a patient off on antidepressants. Yes. I um you know, there's always a black box warning that's in there and that's one of the reasons why we push to bring our patients back every three months, even though there's a lot of pushback from them because they think they're so stable. Now, I can't say that I've ever had someone score three on the suicidal question on the questionnaire. But my concern in that kind of situation is that, you know, do you start someone on that medication? I know you did and you had the therapist close at hand to do that and that was able to have a conversation. But if you aren't able to have that conversation with the therapist, Do you go ahead and start those medications with that risk. And let's pretend they have nobody else. It's so hard. Like I have patients right now trying to get them into a psychiatrist or even therapy is taking weeks to months because they call their insurance company? They don't they give them names and numbers, those people aren't taking new patients despite what the insurance company says. So how does one handle starting them on medications with those black box warnings with a suicidal potentially suicidal patient? That's a great question. Dr Angelo, I know you talk about that in your didactic coming up later. I will be mentioning that only briefly, but I think, you know, unfortunately the honest answer is we take a chance um and and I think that um you know, knowing that that is exactly what the psychiatrist would do once the patient does get there after however many months, right. Um You know, we're just doing it in a primary care setting. And I also, you know, I also acknowledge that the resources and the primary care setting are a lot more limited, right, in terms of check in and frequency of visits and um support from social work staff and therapists and things like that. Um But you know, again, explaining the possible risk to the patient, um documenting that that's been discussed and checking in frequently and just seeing how the patient's doing. Um I think is is the best we can do and again, there's a lot of theories about why that black box warning even exists in the first place, right? Is it that the medication directly causes suicidal ideation or is it that the patient is getting better to the point where they have enough energy and they have enough cognitive improvement that they're finally able to unfortunately plan and act. Are they already a depressed subset of people? So you're taking a class of people who are already potentially high risk and you know, seeing that there are more suicides. So I always wondered if that was a contributing factor to that black box formulation? Right. Right. Um You know, it's it's hard to say, you know, these things kind of, it reminds me of the black box warning on antipsychotics in the elderly. Right. I mean is it folks who are already at risk for mortality and morbidity or you know, are we just catching them in that in that phase of their life? But in any case, I think, you know, my recommendation would be to go ahead and start and not delay the process and and help these folks get treated and you know, hopefully they get picked up by a psychiatrist moving forward. Um yep. Can I just jump in for a minute? Can people hear me? Yeah. So um so I've had several patients who had that reaction to an ss ri and uh it is uh it is rare. Uh it is younger people, people under the age of 25 as as as a rule. Um and it is unmistakable and that's what I tell patients in that age group that you will know uh that this medication is doing something to, you will begin to feel markedly worse. You may even be flooded by suicidal thoughts which are uncomfortable. And when that happens, you obviously have to reach out, you stop the medicine and you have to reach out to me right away in a primary care setting. You know, I don't know if you have the ability to in the first few weeks to I don't know, message the patient or quick call, just how you doing. You know what not? But but being in that younger group, just being unequivocal about the fact that you will not. If this happens, it's not going to be subtle, you'll know it and that's a red flag and you've got to be in touch with us. So do you do you warn people each time you start them that because you say that you tell them that that could happen and that they'll know they'll be flooded. Do you when starting anyone on a medication like that? Do you uh warn them that that could happen? Or did they automatically come and tell you that when they feel something? Because what if they feel it and they decide to act on it because they can't help it? No, I mean obviously there's that risk. But but for a younger patient, I mean, and when I'm for example, I see a lot of college kids, I mean that's something that I talked to them about before, you know prescribe it, but if I'm starting a 35 year old, you know person, you know on you know on Paxil or something, I mean I really don't, you know, get into it because it just doesn't happen in that age group, it happens, it happens in young, young younger people. Thank you, I appreciate that. And I've also for patients who are willing to have their parents involved or close collateral support, I'll also talk it through with them, especially for my like 18 19 year old patients make them aware of the risk, let them know, you know, keep an eye and have the patient let them be comfortable talking with their parents and sometimes that can help just facilitate comfort across the board with the medication. Now everyone's aware that this is a risk and to let us know immediately if anything like that happens, thank you. Um Those are great points of input. I um you know, there were a few other questions we weren't able to get to and I want to be respectful of um time here, but I do want to share a couple of resources um you know, for others on the call, like dr Silverman who are Supporting patients with chronic thoughts of suicide. I mean I know for me personally, you know situations where it's much more clear cut, this is an acute episode. Um the 123 of it seems a lot clearer than when there is a lingering, it comes up every so often. Then you have to use your judgment right in those moments to be like is today the day when it is like when he's really thinking about it and there's kind of a detailed assessment and kind of knowing how to parse those moments out. Um some resources that help um you know safety planning um I think is um key, there's a free app called my Three um which the patient can download on their phone complete with you store um you know details like what gets the thought started, you know what helps you distract yourself from it. Who are some people that help you distract yourself? Who are some people in your personal and professional circles that you can contact. Um that might help him prompt him to have other numbers besides just you dr Solomon as well just to expand that network because there's only so much you can do as much as you're willing to go above and beyond. Um I also want to share the response of Suffolk County um is the hotline in Suffolk County. Um which they do some really good work. They also have their own mobile crisis teams um that you can call, where there are plainclothes clinicians that can go to patients home and assess them. Um And typically they'll respond within the same day. That's an alternative to 911. Or to send the patient to the E. D. I know dr chang you have a question about this in the chat. Um You know for those situations where you're not worried about imminent risk. Um But there's active enough ideation, there's a thought plan intent but the patients not thinking about killing themselves today. Um In those situations you might send them to the E. D. They might come right back. Um But having mobile crisis as an option to go visit the patient at least that day or the next day can be helpful and can serve as sort of an extender for you as a resource. Um And then I also just want to share um the cams method comprehensive assessment and management of suicidality um developed by David jobs at catholic University. Um You know first tested robust amount of data from in the veteran community um is a really effective evidence based strategy for managing chronic suicidal ideation. Um uses a lot of principles of dialectical behavior therapy. Um And and just as very effective in the short term model as well involves a lot of like you know coming up with concrete plans on how to deal with the moments when the suicidal thoughts happen because we know that the evidence on this is pretty copious and pretty vast that um you know when a person knows what to do when those thoughts come up. Um They tend to feel better equipped to navigating those moments when they do inevitably pop up again and typically it might pop up when he's not in your office. Um So having him have some tools in his tool belt can certainly help for those moments when you're not there. Um So I want to shift to our didactic dr Simon, thank you so much for presenting this case here. Clearly a generated tremendous amount of discussion, but also thank you for everything you're doing for this patient and all the other patients in your care. They're very lucky to have you. Well thank you and thank you for those resources which I think will benefit definitely Jill and myself as as well as all of us in primary care and we're just very grateful to have you guys to be able to bounce these things off of. Absolutely. Um So now shifting gears, I want to turn it over to Dr Katie Angela, who is a psychiatrist at our um Internal Medicine Associates Clinic. Sorry, I just I saw myself all over my screen for a second, I was like what's happening? Um So Katie, I'll print it over to you, thank you so much. Um and I think you know this is a nice segue into um you know, kind of what what we're gonna actually do if we do decide to start medication for depression. Um So I'm gonna talk a little bit about how to potentially choose a medication. Um This is a question that I get a lot uh in in the various consulting services that that I work in um sort of how do you know which one to choose? Um We can make an educated guess based on certain properties of certain um antidepressants. I'm also going to talk a little bit about uh side effect profiles um what to look for, what to warn our patients about and why what side effects we can actually potentially use to our advantage when we're choosing these medications and and then finally also kind of what to do if the medication is not working or if the side effect profile is um you know to intolerable uh and a patient needs to be uh switched off of that medication. I have no disclosures next slide. Thank you. So we'll jump right in. I'm just gonna talk about a couple of agents and a little bit more detail because those are the common more commonly used ones um that we typically start in primary care. Uh So the S. R. I. S. Um as we know are usually first line for depression, anxiety um Some other issues as well like pTSD sometimes we use it for um So starting out with flu oxytocin, which is the brand name PROzac um great medication because of this long half life. Um That's probably one of its most notable properties and um this is very good for folks who you know we know might not be able to keep up with every single dose every single day. Right? I mean this is including our 18 and 19 year olds like we were talking about right they go away for a weekend. They go out partying with their friends. Maybe they skip the morning dose. Maybe they forget the bottle at home. Right? Um So this education is very unlikely to cause any withdrawal symptoms if it is missed once or twice. Um It also is curiously used to for this reason to assist with this continuing other ss arise that might have more of a withdrawal syndrome and and will mention those briefly as well. Um It is pretty activating for most people. Some people will have that paradoxical reaction where it makes them a little more sleepy. But for most it is activating it gives you a little bit of that pep in your step a little more energy. Um So of course it's it's always prescribed to be taken in the morning unless the patient does sort of experience that paradoxical reaction. Um And it also has some evidence in treating eating disorders. So if a patient has struggled with that or continues to struggle with that this might be a good choice. Um Another commonly prescribed agent. Uh Lexapro like dr cecil man had selected um great choice and CeleXA which is um kind of the cousin of Lexapro. Um These are usually very well tolerated and very commonly used in primary care. Um Just of notes. CeleXA specifically carries a risk of Q. T. C. Prolongation if the dose is higher than 40 mg. So something to just keep in mind um If the patient has any kind of cardiac problems or are prone to arrhythmias or already have a prolonged Q. T. Next slide. Um paroxetine is another commonly used agent also known as Paxil. Um It's notoriously great for anxiety. So somebody who suffers with depression and anxiety or anxiety alone um It's also very sedating. So this one particularly is usually prescribed at night. Um So somebody who's very anxious the anxiety is keeping them up from sleep. This could potentially be a good choice. Um um However couple of very strong cons here um Weight gain being one of them so significantly more uh than than most of the other ss ri um As well as drug drug interactions. So Paxil happens to be a very strong two D six inhibitors. So it can potentially interact with other medications um that are that are cleared by that enzyme. And finally it also has a pretty significant withdrawal syndrome. Uh So this is one of the medications that um I would educate the patient you know don't skip because because you will you will feel um terrible. Uh And it will be very noticeable. And this is one of those medications where we could potentially use low dose um PROzac or FLUoxetine to help the patient taper off without experiencing so much of that withdrawal syndrome. Uh flu vaccine is listed here. It's not as commonly used these days. One of the main indications um is O. C. D. But a lot more cons than pros. Um It is to dating. There are a lot of drug drug interactions. It's a very dirty agent um and it is usually dosed twice a day so folks who have trouble with adherence. Um This is probably not a great choice. Next slide. Um So coming to the black box warning like we've already discussed at length. This was issued for S. R. I. Specifically in patients under the age of 24. Um And this was based on a meta analysis that showed increased risk of suicidal thoughts and behaviors uh and possibly also aggression and hostility in Children and adolescents who are treated with um S. S. R. I. S. Uh Sexual side effects are also quite common and this is one of those side effects that unfortunately um can come with long term use and stay. Um So usually I tell my patients, you know, a little nausea, a little vomiting, maybe diarrhea, constipation, all of that will go away in the first week or two of treatment. Um But the sexual side effects unfortunately don't most most of the time if they do occur. Um If they do occur we can usually start by trying to decrease the dose of the medication, especially if the patient's pretty stable and they've benefited significantly. Um There's also some studies that recommend adding appropriate which is Wellbutrin or abuse far. Um That has been shown to alleviate some of the sexual side effects. Um And you can also kind of treat the sexual side effects as they come. So for instance erectile dysfunction can be treated with Viagra or some other agents um on the market if the you know especially if the patients benefiting from the medication um and they want to stay on it. G. I. Side effects. We mentioned some already so nausea, diarrhea, vomiting. These are pretty common especially with social in and and loot box. But again these do usually go away with time next one. Um Way gain, way gain is pretty common with S. S. R. I. S. Um It's usually not terribly much but certain agents like paroxetine can be significant. Um So we have patients who are particularly um at risk for you know weight gain metabolic problems and and so on and so forth. We have to be a little bit more careful with the agents that we choose um activation like I mentioned with um PROzac uh sometimes can be perceived as this jittery feeling. Um or increased anxiety. Even so patients who are already very anxious um and have a lot of kind of somatic symptoms of anxiety. Uh They can really struggle when when we're first starting an ss ri. So for those folks I usually recommend maybe starting at half of the starting dose um for a couple of days or even up to a week making sure that they're tolerating it and then gradually tight trading up. Um S. S. R. I. S. Can inhibit platelet aggregation and binding. Um And this can lead to bruising and bleeding. Uh So patients who are high risk for gi bleeds for brain bleeds for whatever it is, we have to do a very careful risk benefit assessment before starting an ss Ri. Um Usually it could S. S. R. I. S. Could still be safely started. Um I do start them on patients in the hospital who you know have have had all sorts of medical problems. But I think especially active bleeds or recent bleeds in areas of the body that are not great to be bleeding in like the brain, right? We want to be very careful about um serotonin syndrome. This comes up a lot um especially in board questions. Right? Uh So serotonin syndrome is potentially fatal. Right? But luckily it's very very rare. Um And usually uh there's very high dose ss ri and probably also several other 13 ergic medications on board. Um In in my experience it's serotonin syndrome just doesn't happened on 25 mg of Zoloft. Um But the things we usually see severe G. I upset autonomic instability, right? Blood pressure, heart rate going up and down hypothermia. Um Maya colonies uh is a big one um and then progressively can can lead to delirium coma and even death. So it is very serious but also very rare. Um Something to consider patients on multiple certain allergic agents next slide. Um So going now to the S. N. R. I. S. Um So this is a combination of serotonin and norepinephrine effect. Um Bella vaccine effects er um vest vaccine or prestige is kind of the newer agent which is a metabolite of effect sir. Uh So these are approved for major depressive disorder, anxiety. Um Also chronic pain. Uh Folks with neuropathic pain, folks who have migraines um as well as menopausal symptoms. Perimenopausal symptoms in in women um particularly hot flashes and things like that. These medications have been found helpful um Things to look out for uh the northern ergic inhibition um usually happens at much higher doses but that's also when we start seeing problems with increased blood pressure. Um There might also be increased anxiety. Um and and other side effects nausea, vomiting, insomnia sweating. These are all things that can happen. Um And unfortunately with effects are uh there is a pretty severe withdrawal syndrome as well if it's abruptly discontinued especially from a high dose and patients really describe this as unbearable sometimes. So I I really educate folks that if you're going to start an effects or you have to really be committed to take it every day. Um He says you can see listed there, dizziness, insomnia, nausea, diarrhea and these these brains apps um folks have described as literally kind of feeling like electricity is going through their brain. Um and it's it's very uncomfortable. Um deluxe 18 or Cymbalta is also an snR I um this was the first FDA drug approved for neuropathic pain associated with diabetes, just interesting fact. Um so a lot of folks with diabetes are are on Cymbalta for that neuropathic pain. Um it can also be used for fibromyalgia pain. Um so again, some of that chronic pain effect as well um problems with Cymbalta is that it can be particularly hip, a toxic um so anybody who has any sort of liver problems, liver transplant, um anything like that, I would I would avoid Cymbalta. Um It's also been shown in in some studies to increase hemoglobin a one c so if somebody's really struggling with their diabetes and they can't get it under control. This would also probably not be a good choice even though it could treat their neuropathic pain. Um and for Cymbalta, curiously, hypertension has not been shown to be dose dependent, whereas in effect, sir, it is next slide Wellbutrin is increasingly a commonly used drug. Um and I particularly consider it a favorite because one of the first things you hear when you start discussing medications with most patients is I don't want to be sleepy and I don't wanna gain weight like that. Those are the things I don't want. Um So Wellbutrin is fairly weight neutral. Um It is activating, it gives you a little bit of energy um And no sexual side effects. Uh So that's that's also a big one. Especially for folks who have struggled with that on S. S. R. I. S. And and have to switch to a different agent. Um It's used in a lot of different conditions as well which is another pro. So it is approved for major depression. Um It's also more frequently used bipolar depression because it's less likely to trigger mania according to some studies. Um It's also used for smoking cessation. It's approved for A. D. H. D. And adolescence. And also there have been some studies more recently. Like can it be beneficial for um co morbid cocaine use because it kind of targets that same dopamine re uptake. Um I think the jury is still out on that. But there have been a couple of positive studies. Um Some cons which I mean I don't think are that significant um seizure risk is always brought up. Um I always get this question, you know like will someone get a seizure on this medication Very very rare. Very rare and actually um significantly dose dependent. So usually below 600 mg. We don't worry and I normally don't prescribe more than 450. So um you know but with that said it is considered to be contraindicated in people with seizure disorders. And with eating disorders right? Because you have an eating disorder, you have electrolyte disturbances that can predispose you to seizures as well. Um Common side effects, headache, insomnia, right? Because it's activating dry mouth is something people complain pretty often about to. Which I will say water doesn't really help, it kind of goes right past your mouth. You need something that's gonna produce saliva. So lozenges gum, preferably sugar free um tends to be helpful. Next slide. Um Matassa Pine is a very nice medication um It has a pretty unique mechanism where it sort of blocks off all the serotonin receptors in the body except five HT one a which is the main site for the antidepressant effect. Um So it's a good antidepressant. Um And because it blocks off all those other serotonin sites it has very few of those other side effects that S. S. R. I. S. Have. So very few gi side effects no sexual side effects. Um So so it's helpful in that way. Um It is very sedating especially at lower doses because of that histamine affinity. Um And because of that it can also cause pretty significant weight gain. So this is one of those medications where I would say we can use the side effects to our advantage right? Somebody who's not sleeping and somebody who's losing weight. Um So these are usually elderly patients. Maybe some failure to thrive. Maybe people who have cancer or some other um progressive medical illness. This could be very helpful helping them sleep, helping them put a couple of pounds on. Um Okay and then of course you know as we go higher on the dose we lose some of that histamine affinity and we go more towards norepinephrine effect. So again the lower the dose the more sedating. So if we're gonna use Remeron for sleep and appetite stimulation usually 7.5 to 15 once we go to 30 45 it's more of an antidepressant and anti olympic. Next slide. Um I'm not gonna go terribly into T. C. A. S. And M. A. O. I. S. Because we really rarely use them anymore. Um T. C. A. S. Sometimes can be used for chronic pain. Um And like irritable bowel syndrome type of picture. Um Again they have a lot of side effects and a lot of medication interactions where for the most part these are like third or fourth line agents. Um M. A. O. I. S. I have not personally seen used in at least two years and you can see why. Right? Very low tolerable itty they can be toxic and you pretty much can't eat anything. You can't eat cheese, you can't eat pickled food, you can't drink wine. I mean that's that's awful. Really awful. Next slide. Um So how do we actually talk about you know starting these medications with our patients I think after chang brought up a good question that you know, a lot of the times patients are resistant and they're not terribly happy to you know, be going on a medication especially when we're gonna discuss all these different side effects, right weight gain sexual side effects and diarrhea. Who wants that? Um I usually try to set the expectations um from the beginning, you know, be transparent, be honest with the patient about what might happen um But at the same time kind of be be positive about it right like this this is going to benefit you. You may experience X. Y. Z. Um and if you do we'll address it, we'll address it and we'll we'll help you either tolerate the side effects or pick a different agent. Um You know no one's going to make you suffer for longer than you have to. Um Usually start you know at the starting dose dose or lower um Like if you know that somebody's gonna be particularly prone to some side effects. For instance, people who are very anxious uh might feel a little more activated jittery, you might want to start at half of that starting dose. Um And usually the guideline is to increase every two weeks but you know it's also understandable that sometimes you don't see the patient for 23 months. Um I always kind of educate the patients also from the very beginning that um it's going to be about 4-6 weeks before we really expect to see a benefit. Um and it's okay if you see a benefit right away, that's great placebo is fine too. We want that. So 4-6 weeks um you know, and I'll usually tell my patients, you know, these first 4 to 6 weeks is really to kind of make sure that you're tolerating the medication, you're not having any side effects, so it's not necessarily a waste of time. Um but you know, I also don't expect anything miraculous to happen. Um and in terms of an adequate trial, right, we want at least 4-8 weeks on an effective dose. Right? So that's the caveat um you know, the starting dose is usually not the most effective dose. Um And then right discussing common side effects, we've already talked about um interest encouraging the patient to be to be patient, right um explaining which side effects are expected to go away which ones may not be. Um And just you know, being up front about what may happen and you know may not, it may not happen, but I've noticed that people really prefer to know what may happen than to not know. Um and again, daily, daily adherence is very important. Um even for the medications that are long acting that you know, don't cause the withdrawal syndrome um you really want the medication to be in your system every day because that is that is how it's going to do its job. Um and and be effective in those 4-6 weeks next week. So, when to switch, um That's that's a good question too. Right? Um You know, it's not working. Somebody's really struggling with the medication. When do we switch? How do we switch? Right. So I think intolerable side effects. And for every patient that might be different. What's tolerable? What's intolerable, right? Because that's very subjective, but if somebody comes to you and they say, you know what, like, I I feel so sick that I cannot tolerate another hour of this, let alone another week. Um I think it's it's reasonable to to stop, Right? Um if there's any kind of medical contra indication, right? And and it's important to keep track of any new medical issues that might come up um that weren't present when the medication was first started. Right. For instance, somebody is diagnosed with a seizure disorder and they're on, you know, 450 mg of Wellbutrin. It might be time to reconsider that um if somebody falls and develops a subdural and they're on high dose of Paxil, it might be time to reconsider that um if there's no improvement, right? If you're, you know, you've reached a good dose, you've reached a good duration. Um The patients adherent, there's no like co morbid condition that might be muddying the picture. Um It's it's just not working right. We're not getting to where we want to get. So it's reasonable to switch. Um You might also want to consider at that point reassessing the diagnosis, right? So for instance, folks with bipolar depression um often don't respond to traditional antidepressant medication. So somebody who's tried to three different things and they're kind of like no improvement at all, you might want to um reconsider what what they're actually struggling with and then um you know, the antidepressant always has to be tapered off gradually unless the patients on that initial starting dose then it could just be stopped. Um And you know, there there are guidelines for for tapers and cross hydration that I that I could, you know, share share with you. Um It's probably a little bit beyond the scope of this, this talk. Uh next line. Yeah. So, so this is just this is the famous um star D study that basically looked at the efficacy of antidepressants. Um And that first line there on the learning points um nearly one third of depressed patients will remit with optimized use of an initial ss ri treatment. I know they wrote nearly, but to me it's always only one third of depressed patients will remit. Right. So I think that it's reasonable to expect that we might have to try a few agents, we might have to augment we might have to start and switch. Um And there is nothing wrong with that. That's just the science behind these. Okay, I think there's one more slide. Yes. And this is basically just a little illustration of the metabolism of these medications and the range of doses uh just helpful to look at. Especially if you're looking at drug interaction potential drug interactions with other medications. Okay great. Thank you so much Dr Angelo to um and um I just wanted to let everyone know that you will have access to Doctor Angelou's slides as well as a recording from this meeting um later on our website. So that if you wanted to look through some of those visuals that dr Angelo had um and read through them more in detail, you certainly can do that. Um I'm wondering Sidney if we can put it into the gallery view because i it should be. Now, do you not see that? It's still in speaker view on my end. I don't know if other people are seeing it in gallery view. I see it in gallery. You can if you go to the view in your upper on my end. Okay. Got it. Perfect. Thank you. Um I wanted to open it up for questions for dr Angelo. We did have one in the chat which we can start with perhaps um Doctor Go. You had a question about PROzac's activating effect. I wanted to know if you wanted to raise the question yourself, dr she responded in the chat that I've already got answered. Oh God answered. Okay. Okay. Um Other questions for dr Angela. Hi. Yeah. Hi. So I just wanted to thank you for that really nice comprehensive thing. I wanted to just make a couple of um sort of observation. Uh And this is directed at um my primary care colleagues because this is well known to to psychiatry. Um there's no differential efficacy amongst any of the antidepressants from the earliest antidepressants that, you know, came on the market in the late 1950s to something that was introduced a year two ago. There's no evidence of any differential efficacy. They're all equally effective for for depression. So what you're picking for your patients is the side effects. You're not really picking efficacy. There's also well documented studies that if a patient has a mild to moderate depression, the outcomes are equivalent with psychotherapy versus medication. So we end up giving and this is both in primary care and psychiatry. We end up prescribing medications in many, many cases because the patient is either unable to find a therapist or unable to afford a therapist or the patient doesn't want to invest in the time for psychotherapy. And I think it's important to explain to the patient that if they were to um engage in a course of psychotherapy, they will do as well as with the medication, which by the way is no is not a reason to withhold medication, but they should just understand that, you know, we're providing the treatment that they can get that's accessible, but it it's not necessarily, you know, um uh superior to to psychotherapy. If you then think about patients like this 20 year old Korean who does not have a mild depression or a moderate moderate severity depression as a severe depression. Those are patients who absolutely should have medication. But there are also patients that I believe really need to be managed by a psychiatrist and and the and and access to psychiatrists for reasons that were discussed briefly earlier, like the lack of psychiatrists who participate in commercial insurance plans really limits access. But, you know, in in some cases I've I've encouraged patients to um I've seen patients rather who have been encouraged to see a psychiatrist who's not in their network, they have to pay cash for the consultation. But getting started, you know, getting the right diagnosis against them, the right medication can sometimes and allow the primary care doctor to continue the pharma co therapy. But anyway, it's just some just some observations on the whole sort of from a global or global perspective. I really appreciate you noting all those pieces, especially kind of the reinforcing the idea of psychotherapy and medications and where the two are needed separately versus together. Um So, I really appreciate you noting that. Um I also just wanted to know, you know, insurance companies by federal law are required to reimburse out of network visits for psychotherapy or management by a psychiatrist. Um it's not a not a thing, they advertise as much as perhaps they should but you know in my experience I've found patients get 50-80% of their session fees reimbursed. Um and the submission process for invoices is fairly simple. Um So if that's something the patient can manage if their deductible is low enough, you know sometimes that those are the logistical concerns that it ends up bumping against. But if it's something they can manage I often find it helpful to tell people you know if you want to see this person and they're not in your network, talk to your insurance company about whether their visits would be reimbursed. Um And more often than not the insurance company, their answer is yes. Even though they sometimes give more pushback than they perhaps should. Um So it's just something as a as a analog to what dr brody just said dr gro you had another question. Would you like to ask it about overlapping depression and anxiety? Hi. Can you hear me? Yes we can. Hello everybody. Thank you for this wonderful presentation. Um So I'm a family medicine physician here at town. Um I do get a lot of patients with over, not like over line but they have both. Depression and anxiety. Um You know with all all the obstacles we mentioned before. I was just wondering um you know with the physicians here and also the experts to see if there's any preferred agents um You know in regards to pharmacist therapy if they have both or if there's a preference if the patients got more depressed and anxious or more anxious than depressed. Yeah so so most most of the antidepressants are are also an analytics. So it's it's kind of nice that they kill two birds with one stone. Um S. S. R. I certainly snr eyes especially at higher doses. Um even something like Martha's pian um you know higher doses can certainly address both. Um I think it's it's sort of easier almost to say which agents we want to potentially avoid. And I think one of the um one of the big ones is is well mutual. I think people do often um complain that that sort of activated jittery feeling um is is not tolerable, especially if their anxiety is already very high. Um Although that can unfortunately also happen with a lot of the ss ri is that initial activation? Um but eventually as the medication is high traded it will address anxiety as well. Thank you doctor Good. Does that answer your question? Yes definitely. And also any um like gender preferences like male versus female patients. That's a really good question in terms in terms of selecting the agent you mean? Yes. Uh you know it's interesting I and again this is not to be kind of gender biased or anything but it is usually um patients who identify as female who are first and foremost to say um I don't want to gain any weight. Uh I think that comes up more often with women. Um And so perhaps kind of leaning towards a more weight neutral agent than something like Paxil. Um I think the other interesting thing right, is is the difference between sexual side effects in in men and women um You know, explaining to um both kind of what that might look like for them. Um And often um you know, I have not often, but I have heard men say that they actually um prefer uh and the the sexual side effect which um basically delays orgasm. I've heard that um whereas for a woman that might be more problematic, I've heard that too. Um So, you know, I think to each their own and everybody has their own kind of unique um body and unique way in which they experienced side effects. But I think it's just always important to establish with the patient first and foremost, like what's most important to them, like which side effect could they absolutely not live with? Right? Like, some people might say it's gaining £5 some people might say it's gaining £30. Some people might say, you know, delayed orgasm or shortened orgasm or whatever, right? So I think it's just important to know like what that person's value is before discussing choices. You may also want to consider pregnancy. You female patients, are they intending to become pregnant in their future? Are they pregnant or are they breastfeeding that might dictate? You know safety profile in which medication you might choose? The other. The other thing about picking medication which is important is a family history medication response. Uh psychiatric medication very often runs in families. So if they have uh parent or sibling that's on an antidepressant i if possible, that's the one I'll choose for them. That's really interesting. Um I want to just note on this point that dr Christopher has actually helped us um design a med management guide for S. Srs and Srs which lists um some some characteristics patient characteristics as well as some other side effect elements that you can kind of use to compare. And we're in the process kind of curating this and hope to release it to folks um You know in short order um dr Baskin you had a question about switching agents versus adding another agent. I wonder if you could ask that. Hi, good evening. Thanks. Thanks for your help tonight and other nights. You know in internal medicine when we're managing chronic issues. Asthma, diabetes, hypertension. We often add agents and not switch. I know that when I do eat prescribing for S. S. R. I. S. And Wellbutrin is often a reminder of interactions between the two though many patients are on both. So my question is when we when we get someone on a therapeutic agent of usually the S. S. Sorry that will start that I usually use for depression and they're not responding. What decisions do you make about either adding a second agent. Um And what would you prefer versus stopping initial agent or tight trading it off and restarting another one. And how much time do we lose waiting for that second agent to kick in? So how do you make that decision? That's that's a really good question I think. You know personally I I would hope to see at least a partial response with the first agent right often. What happens is that you know a lot of symptoms are addressed with the agent that the patient is on at an adequate dose for an adequate period of time. But there are like there are a few things that that have not been addressed for instance um patients still feels fatigued or has trouble focusing. Maybe that's why well nutrient is added or like they feel like their mood has really improve but they're still not sleeping well. Right? So maybe a little bit um tiny dose of Remeron or or something like that. I think that if somebody has been on a trial with no uh no response whatsoever. Um That's that's when I would usually consider switching. So so just to just to just to add to that. So dr Angelo to put up the star d. Trial. Um And that's one of the best guides we have in terms of the exact question that dr Baskin is asking. So uh so in in broad brush uh after a patient has been on an ss ri for three weeks. If there's absolutely no improvement, uh you increase the dose or you switch. Uh If there's uh preferably increase the dose uh If after a total of six weeks on the drug that means another three weeks after that there's no improvement whatever. Then at that point you definitely switch. Or you augment an augmentation could be another medication but it could also be ogg with psychotherapy. So the what the star D. Trial basically showed is if you go through those sort of sequential steps over the course of many many many months roughly two out of three patients will get some significant amount of relief. There's about a third that just really don't get much relief at all unfortunately. Um And there's a very small percentage of people who get complete relief and and remain remain in remain in remission. But the sort of the take home I think in this I think is useful in primary care is don't stand still, Don't stand still. So if the if if the patient isn't responding isn't responding. Do something else. Don't don't wait three months for the medication to kick in. Thank you. Just one other Corollary question because of the comment that relapses are much harder to treat. So You have the patient who feels great 69-12 months and says hey DACA I want to go off the medication I feel great. Um What do you discussing with the patient at that point? Anybody. Yeah I mean it depends on their history if they if they if they if they have a history of recurrent major depressive disorder and it's really that's really the diagnosis. I mean their lifetime history is you know two or more very discreet episodes of D. S. M. Depression with meeting all the criteria. Um They need to remain on the medication for years. And if they've had you know You know say three episodes there's data that suggests it's a lifelong medication um if somebody it's their initial episode uh and they've been really rock solid stable asymptomatic for a year. I mean you could it's probably reasonable to taper them. Consider tapering them off at this point. But there's no evidence none that long term treatment with the S. S. R. I. S. Is detrimental. In fact if anything it's probably neuro protective because we know that S. S. R. I. S. Do good things for the brain. Like the increased levels would be DNF they increase hippocampal neurogenesis. So it's I mean it's it's managing side effects. Um And um you know these are not these are your active drugs but they're not neurotoxic toxic drugs. Thank you. Well we have several other questions in the chat that we actually weren't able to get to. I want to be respectful of everyone's time. I know at the end of the workday for everybody. Um This was such a great discussion. I'm so grateful to dr cecil menand dr Angelo via for presenting um you know a case and your didactic here today and for all of the participants, for your attendance, your questions, your suggestions. Um Dr brody always great to have you jump in and provide some insights as well. Um You know folks just look out for um the link to the post meeting survey, like I said at the beginning, we do analyses on these surveys. We do hope to share some of those findings um because we do see the impact of mind matters being positive so far. Um to please if you could take a couple of minutes to complete that, I would really appreciate it. And we will see you all back here in august um with another case and dr Angelo to um we'll be back to talk about sleep difficulties um and how to manage those. Thank you so very much and have a wonderful evening