Order Now
Item account not registered or doesn't have a view.php file.

Task: Adult and Geriatric Antidepressant Therapy

Task: Adult and Geriatric Antidepressant Therapy

ORDER CUSTOM, PLAGIARISM-FREE PAPERS ONTask: Adult and Geriatric Antidepressant Therapy

Week 3: Adult and Geriatric Antidepressant Therapy

Discussion: The Impact of Ethnicity on Antidepressant Therapy

Major depressive disorder is one of the most prevalent disorders you will see in clinical practice. Treatment for this disorder, however, can vary greatly depending on client factors, such as ethnicity and culture. As a psychiatric mental health professional, you must understand the influence of these factors to select appropriate psychopharmacologic interventions. For this Discussion, consider how you might assess and treat the individuals in the case studies based on the provided client factors, including ethnicity and culture.

To prepare for this Discussion:

Note: By Day 1 of this week, your Instructor will have assigned you to one of the following case studies to review for this Discussion. To access the following case studies, click on the Case Studies tab on the Stahl Online website and select the appropriate volume and case number.

Case 1: Volume 1, Case #1: The man whose antidepressants stopped working

  • Review this week’s Learning Resources and reflect on the insights they provide.
  • Go to the Stahl Online website and examine the case study you were assigned.
  • Take the pretest for the case study.
  • Review the patient intake documentation, psychiatric history, patient file, medication history, etc. As you progress through each section, formulate a list of questions that you might ask the patient if he or she were in your office.
  • Based on the patient’s case history, consider other people in his or her life that you would need to speak to or get feedback from (i.e., family members, teachers, nursing home aides, etc.).
  • Consider whether any additional physical exams or diagnostic testing may be necessary for the patient.
  • Develop a differential diagnoses for the patient. Refer to the DSM-5 in this week’s Learning Resources for guidance.
  • Review the patient’s past and current medications. Refer to Stahl’s Prescriber’s Guide and consider medications you might select for this patient.
  • Review the post test for the case study.

Note: For this Discussion, you are required to complete your initial post before you will be able to view and respond to your colleagues’ postings. Begin by clicking on the “Post to Discussion Question” link and then select “Create Thread” to complete your initial post. Remember, once you click on Submit, you cannot delete or edit your own posts, and you cannot post anonymously. Please check your post carefully before clicking on Submit!

BY DAY 3

Post a response to the following:

  • Provide the case number in the subject line of the Discussion thread.
  • List three questions you might ask the patient if he or she were in your office. Provide a rationale for why you might ask these questions.
  • Identify people in the patient’s life you would need to speak to or get feedback from to further assess the patient’s situation. Include specific questions you might ask these people and why.
  • Explain what physical exams and diagnostic tests would be appropriate for the patient and how the results would be used.
  • List three differential diagnoses for the patient. Identify the one that you think is most likely and explain why.
  • List two pharmacologic agents and their dosing that would be appropriate for the patient’s antidepressant therapy based on pharmacokinetics and pharmacodynamics. From a mechanism of action perspective, provide a rationale for why you might choose one agent over the other.
  • For the drug therapy you select, identify any contraindications to use or alterations in dosing that may need to be considered based on the client’s ethnicity. Discuss why the contraindication/alteration you identify exists. That is, what would be problematic with the use of this drug in individuals of other ethnicities?
  • If your assigned case includes “check points” (i.e., follow-up data at week 4, 8, 12, etc.), indicate any therapeutic changes that you might make based on the data provided.
  • Explain “lessons learned” from this case study, including how you might apply this case to your own practice when providing care to patients with similar clinical presentations

Week 3: Adult and Geriatric Antidepressant Therapy

The National Institute of Mental Health estimates that approximately 15.7 million adults in the United States have depression (NIMH, 2014), making depression one of the most common disorders you will treat in practice. Although this disorder is so prevalent, antidepressant therapy must be as unique as each individual you treat. There are dozens of antidepressant medications on the market, and you must be able to identify which medication or combinations of medications will result in the best outcomes for your clients.

This week, as you study antidepressant therapies, you examine the assessment and treatment of clients with mood disorders. You also explore ethical and legal implications of these therapies.

Learning Objectives

Students will:
  • Assess client factors and history to develop personalized plans of antidepressant therapy for adult and geriatric clients
  • Analyze factors that influence pharmacokinetic and pharmacodynamic processes in adult and geriatric clients requiring antidepressant therapy
  • Analyze the impact of ethnicity on antidepressant therapy
  • Evaluate efficacy of treatment plans
  • Apply knowledge of providing care to adult and geriatric clients presenting for antidepressant therapy

Photo Credit: Comstock Images/Getty Images

Learning Resources

Note: To access this week’s required library resources, please click on the link to the Course Readings List, found in the Course Materials section of your Syllabus.

REQUIRED READINGS

Note: All Stahl resources can be accessed through the Walden Library using this link. This link will take you to a log-in page for the Walden Library. Once you log into the library, the Stahl website will appear.

Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (4th ed.). New York, NY: Cambridge University Press.
Note: To access the following chapters, click on the Essential Psychopharmacology, 4th ed tab on the Stahl Online website and select the appropriate chapter. Be sure to read all sections on the left navigation bar for each chapter.

  • Chapter 7, “Antidepressants”

Stahl, S. M. (2014b). The prescriber’s guide (5th ed.). New York, NY: Cambridge University Press.
Note: To access the following medications, click on the The Prescriber’s Guide, 5th ed tab on the Stahl Online website and select the appropriate medication.
Review the following medications:

  • amitriptyline
  • bupropion
  • citalopram
  • clomipramine
  • desipramine
  • desvenlafaxine
  • doxepin
  • duloxetine
  • escitalopram
  • fluoxetine
  • fluvoxamine
  • imipramine
  • ketamine
  • mirtazapine
  • nortriptyline
  • paroxetine
  • selegiline
  • sertraline
  • trazodone
  • venlafaxine
  • vilazodone
  • vortioxetine

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
Note: Retrieved from Walden Library databases.

Howland, R. H. (2008a). Sequenced treatment alternatives to relieve depression (STAR*D). Part 1: Study design. Journal of Psychosocial Nursing and Mental Health Services, 46(9), 21–24. doi:10.3928/02793695-20080901-06
Note: Retrieved from Walden Library databases.

Howland, R. H. (2008a). Sequenced treatment alternatives to relieve depression (STAR*D). Part 2: Study outcomes. Journal of Psychosocial Nursing and Mental Health Services, 46(19), 21–24. doi:10.3928/02793695-20081001-05
Note: Retrieved from Walden Library databases.

Yasuda, S.U., Zhang, L. & Huang, S.-M. (2008). The role of ethnicity in variability in response to drugs: Focus on clinical pharmacology studies. Clinical Pharmacology & Therapeutics, 84(3), 417–423. Retrieved from https://web.archive.org/web/20170809004704/https:/…

SEE ATTACHED CASE STUDY 1

 

attachment_1

Unformatted Attachment Preview

PATIENT FILE The Case: The man whose antidepressants stopped working The Question: Do depressive episodes become more difficult to treat and more recurrent over time? The Dilemma: When can you stop antidepressant treatment and what do you do if medications that worked in the past no longer work? Pretest Self Assessment Question (answer at the end of the case) When should antidepressant maintenance become indefinite? A. Following remission from one episode of major depression B. Following remission from two episodes of major depression C. If there is a particularly severe episode or one with suicidality, especially if a positive family history for depression D.
Following remission from three episodes of major depression E. On a case by case basis Patient Intake • 63-year-old man with the worst depression and anxiety he has ever felt Psychiatric History: First Episode • Age 42, became depressed and anxious after his episode of atrial fibrillation • Felt vulnerable and afraid of death • After his hospitalization for atrial fibrillation, which resolved with medications, he felt depression, anxiety, “butterflies in his stomach” and felt like his whole body was “plugged into an electrical circuit” • Began having suicidal thoughts Task: Adult and Geriatric Antidepressant Therapy
• This episode also coincided with the death of his mother • Treatment with alprazolam (Xanax) and clonazepam (Klonopin): no improvement • Sertraline (Zoloft) treatment 100 mg/day and he was much improved within 2–3 months, functioning normally at work but had sexual side effects • Felt totally normal after 6 months and discontinued sertraline Social and Personal History • Married 33 years, 3 children • Non smoker • No drug or alcohol abuse 1 Downloaded from http://stahlonline.cambridge.org by IP 100.111.251.218 on Tue Jun 11 21:11:24 UTC 2019 Stahl Online © 2019 Cambridge University Press. All rights reserved. Not for commercial use or unauthorized distribution. PATIENT FILE Medical History • • • • • Atrial fibrillation age 42, resolved with medication Hypercholesterolemia BP normal BMI normal Normal fasting glucose and triglycerides Family History • • • • Mother: depression and alcohol abuse Maternal uncle: alcohol abuse Son: depression Daughters: one with mild depression, one with postpartum depression Medications One Year Following the First Episode of Depression
• • • • Antiarrhythmic Statin for cholesterol Antihypertensive Aspirin Psychiatric History: Second Episode • Relapsed into his second episode of major depression at age 52, 10 years after his first episode and 9 ½ years after stopping sertraline • Symptoms same as last time • Fear, anxiety, depression, “plugged into a circuit” • Suicidal thoughts • Symptoms worse in the morning • Unable to function and wife had to drive him to work for 3 months • Depression could have been triggered in part by his taking partial early retirement just before this episode, and feeling vulnerable again and worried about whether this meant his life was over • For some reason, not given sertraline again at first, but paroxetine (Paxil) which showed no benefit • Switched to sertraline 150 mg/day with supplemental clonazepam (Klonopin) prn anxiety, and symptoms resolved within 2–3 months but with recurrent sexual dysfunction, same as the first time • Discontinued sertraline after 1 year Psychiatric History: Third Episode • Relapsed into a third episode of major depression at age 58, 6 years after his last episode, and 5 years after stopping sertraline the second time 2 Downloaded from http://stahlonline.cambridge.org by IP 100.111.251.218 on Tue Jun 11 21:11:24 UTC 2019 Stahl Online © 2019 Cambridge University Press. All rights reserved. Not for commercial use or unauthorized distribution. PATIENT FILE Task: Adult and Geriatric Antidepressant Therapy
• Symptoms exactly the same again, with fear, anxiety, suicidal thoughts, unable to function, symptoms worse in the morning • Was not started on sertraline again because of prior sexual dysfunction, but given bupropinon SR (Wellbutrin SR), but no improvement after 8 weeks • Added sertraline again, and helped after 8 weeks (completely normal) and stopped bupropion but continued sertraline for a year and then discontinued it Psychiatric History: Fourth Episode • Relapsed into a fourth episode of major depression at age 61, 3 years after his last episode and 2 years after discontinuing sertraline for the 3rd time • The patient had gone back to work, had been very successful again, and retired again • Brought up worries about his mortality again • However, doing volunteer work and this helps a bit • This time, given venlafaxine XR (Effexor XR) and this worked even faster than before and he did not have sexual dysfunction, but discontinued it after less than a year Based on just what you have been told so far about this patient’s history and recurrent episodes of depression, do you think it was a mistake to allow him to discontinue his antidepressant after – this last fourth episode? – after his third episode? – after his second episode? Psychiatric History: Fifth Episode • Patient has been suffering with fifth episode for 15 months • New psychosocial factors from marital difficulties seem to have triggered this episode • Same symptoms as before Task: Adult and Geriatric Antidepressant Therapy
• The referring psychiatrist has given venlafaxine 75–150 mg, which worked for his last (fourth) episode, but no response this time to 8 weeks of treatment at this dose, plus another 8 weeks at 375 mg/day (4 months total treatment) • This is very atypical for him, where antidepressants worked quickly and robustly in the past • Has severe psychomotor retardation and strong thoughts but no active plans for suicide • For months 5 through 11, venlafaxine was augmented with – Dextroamphetamine (Dexedrine) 20 mg/day 3 Downloaded from http://stahlonline.cambridge.org by IP 100.111.251.218 on Tue Jun 11 21:11:24 UTC 2019 Stahl Online © 2019 Cambridge University Press. All rights reserved. Not for commercial use or unauthorized distribution. PATIENT FILE • • • • • – Buspirone (Buspar) 30 mg/day – Clonazepam 2 mg in the morning and 2 mg at night – Lorazepam (Ativan) 2 mg in the morning and 2 mg at night This treatment regimen associated with only a partial response, and continuing depression, anxiety, guilt, hopelessness and suicidal ideation Switched the venlafaxine back to sertraline 200 mg/day which had worked in the past, along with continuing the same augmentation medications above, but no response for months 12 through 15 of treatment of this fifth episode He seems to have developed treatment resistant depression Would this have happened in any event, or could this have been prevented by earlier maintenance treatment? He now presents to you 15 months into his fifth episode of major depression, not responding to standard treatments Attending Physician’s Mental Notes: Initial Psychiatric Evaluation Task: Adult and Geriatric Antidepressant Therapy
• Patient has been suffering through fifth episode of depression for 15 months • Here is a case that indeed is linked to psychosocial stressors, but seems to have new episodes of depression coming closer and closer together following discontinuation of his antidepressant • First recurrence 9½ years after stopping sertraline the first time • Second recurrence 5 years after stopping sertraline the second time • Third recurrence 2 years after stopping sertraline the third time • He is now here only a year after stopping his venlafaxine following his fourth episode of depression • Treatment guidelines are consistent with discontinuing antidepressants 9 to 12 months after remission from a first episode of depression, with long term maintenance after the second episode reserved perhaps for very severe cases. Clearly the third episode of major depression should be treated indefinitely with antidepressant maintenance, and no doubt, after a fourth episode, indefinite antidepressant maintenance is indicated • One wonders if the fourth episode and the current fifth episode could have been prevented if he had been treated in maintenance after his third episode • Now, attending physician is a bit worried that the medications will not work as well this time Task: Adult and Geriatric Antidepressant Therapy
• Perhaps changes have occurred in the brain, with shrinkage of the hippocampus and/or prefrontal cortex due to 4 previous and now a fifth episode of depression, and that might make the current fifth episode very difficult to treat 4 Downloaded from http://stahlonline.cambridge.org by IP 100.111.251.218 on Tue Jun 11 21:11:24 UTC 2019 Stahl Online © 2019 Cambridge University Press. All rights reserved. Not for commercial use or unauthorized distribution. PATIENT FILE • Is this the natural history of treatment resistant depression in the making? How would you treat him? – – – – – – – – – Task: Adult and Geriatric Antidepressant Therapy
Increase the dose of dextroamphetamine Increase the dose of buspirone Augment with bupropion Augment with L-methylfolate (Deplin), or thyroid or SAMe Augment with an atypical antipsychotic, especially aripiprazole or quetiapine Refer for TMS Refer for ECT Augment with mirtazapine (Remeron) Switch to an MAOI Attending Physician’s Mental Notes: Initial Psychiatric Evaluation, Continued • Has not responded to bupropion in the past, and not clear his buspirone or amphetamine is helpful, and he does not need two different benzodiazepines • Maybe too treatment resistant for a natural product • He has anxiety and is quite depressed, so suggest an anxiolytic/ sedating/sleep inducing antidepressant like mirtazapine, while discontinuing his dextroamphetamine, buspirone, and consolidating his two benzodiazepines into one
• Could have added an atypical antipsychotic, but because of his cardiovascular status, patient wished to try mirtazapine first • Patient willing to do all of this but discontinue his amphetamine, although he does agree to reduce the dose • Mirtazapine 15 mg/day added and given at night • Lorazepam discontinued and clonazepam increased to 2.5 mg in the morning and 1 mg at night • Buspirone discontinued • Dextroamphetamine decreased to 10 mg/day in the morning Attending Physician’s Mental Notes: First Interim Followup, Month 18 (3 months after initial psychiatric evaluation) • Referring psychiatrist maintained the above medication treatment, and patient finally started feeling better at month 18, which the patient attributed to sertraline • Far from well yet • Feels worst in the morning, his usual pattern (disorganized, lacking energy, anxious) 5 Downloaded from http://stahlonline.cambridge.org by IP 100.111.251.218 on Tue Jun 11 21:11:24 UTC 2019 Stahl Online © 2019 Cambridge University Press. All rights reserved. Not for commercial use or unauthorized distribution. PATIENT FILE • Suggested his mirtazpine dose be increased and to add quetiapine (Seroquel) • Maintained sertraline 200 mg/day • Increased mirtazapine to 30 mg/day at night • Maintained dextroamphetamine 10 mg in the morning • Maintained clonazapem 2.5 mg in the morning and 1 mg at night • Added quetiapine, tapered up to 300 mg/day Attending Physician’s Mental Notes: 2nd Interim Followup, Month 22 • Referring psychiatrist maintained the above medication treatment, but no improvement • Still very depressed in the morning • Recommended starting MAOI • Washed out of sertraline, mirtazapine, dextroamphetamine • Continued clonazapam, quetiapine • MAOI started in 7 days (equals 7 half lives of sertraline, mirtazapine; only 5 half life washout of these is required before starting an MAOI) • Transdermal selegilene 6 mg/24 hours prescribed Attending Physician’s Mental Notes: 3rd Interim Followup, Month 24 • Referring psychiatrist made the changes suggested above, but discontinued quetiapine because of excessive daytime sedation and some initial worsening of psychomotor retardation Task: Adult and Geriatric Antidepressant Therapy
• No side effects attributable to transdermal selegilene • 4–5 weeks after starting MAOI, began to feel better • Now he looks, if anything, a bit hypomanic, but upon close examination, patient is somewhat exhuberant about getting well, having waited 2 years to respond from this fifth episode • Let’s hope he does not stop his antidepressant this time Case Debrief • The patient has a 13 year history of recurrent unipolar major depressive episodes • His first 4 episodes were readily treated to full remission and he discontinued treatment each time several months to a year after remitting • His subsequent episodes came in an ever escalating pattern, with less and less time between them • By the time of his fifth episode, he had become treatment resistant, and took two years to get better • He responded to a single action agent several times (SSRI), then a dual action agent the fourth time (SNRI) and finally, after failing SSRI and SNRI 6 Downloaded from http://stahlonline.cambridge.org by IP 100.111.251.218 on Tue Jun 11 21:11:24 UTC 2019 Stahl Online © 2019 Cambridge University Press. All rights reserved. Not for commercial use or unauthorized distribution. PATIENT FILE treatment plus multiple augmentation strategies the fifth time, required an MAOI Take-Home Points • Major depression can be recurrent, and recurrences can possibly indicate disease progression potentially manifested as shorter and shorter periods of wellness between subsequent episodes, with eventually poor interepisode recovery, and ultimately, treatment resistance • This may be linked to changes in brain structure and neurotrophic factors • Patients with 3 or more episodes of depression should be treated indefinitely with antidepressant maintenance • Antidepressant-induced sexual dysfunction can be a powerful reason to discontinue antidepressants, despite the risks of recurrence and treatment resistance Performance in Practice: Confessions of a Psychopharmacologist • What could have been done better here?
– There is no question the patient should have been treated with maintenance antidepressants after his third episode of depression, possibly preventing his fourth and fifth episodes, and possibly preventing the development of treatment resistance Task: Adult and Geriatric Antidepressant Therapy
– The patient was very religious and did not believe in psychotherapy, but perhaps more efforts should have been made to get him into psychotherapy to deal with his issues about his own mortality and his reactions to psychosocial stressors • Possible action item for improvement in practice – Make a concerted effort to see that patients with recurrent episodes of major depression and who need maintenance treatment are not lost to followup Tips and Pearls • MAO inhibitors have fallen out of favor in the United States and are not used at all in many countries • These agents remain powerful alternatives for cases like this one, with treatment resistance • Some myths about dangers, side effects, diet and drug interactions regarding MAOIs can be dispelled with re-study of the facts about these agents, such as those shown below 7 Downloaded from http://stahlonline.cambridge.org by IP 100.111.251.218 on Tue Jun 11 21:11:24 UTC 2019 Stahl Online © 2019 Cambridge University Press. All rights reserved. Not for commercial use or unauthorized distribution. PATIENT FILE Two-Minute Tute: A brief lesson and psychopharmacology tutorial (tute) with relevant background material for this case – How MAOIs work – Tips on how to use MAOIs – Brain changes in recurrent depression
– See also Case 10, Two Minute Tute, p 113 Table 1: Currently approved MAO inhibitors Name (trade name) Inhibition of MAO- A Inhibition of MAO-B Amphetamine properties phenelzine (Nardil) + + tranylcypromine (Parnate) + + isocarboxazid (Marplan) + + amphetamines (at high doses) + + + brain + + + gut +/- + + selegiline low dose oral (Deprenyl, Eldepryl) – + + rasaligine (Agilect/Azilect) – + – moclobemide (Aurorix, Manerix) + – – + selegiline transdermal system (Emsam) Table 2: MAO inhibitors with amphetamine actions or amphetamines with MAO inhibitions Drug Comment amphetamine MAOI at high doses tranylcypromine (Parnate) also called phenylcyclopropylamine, structurally related to amphetamine Selegiline metabolized to L-methamphetamine metabolized to L-amphetamine less amphetamine formed transdermally Table 3: MAO enzymes Substrates MAO-A MAO-B 5-HT Phenylethylamine NE DA DA Tyramine Tyramine Tissue distribution Brain, gut, liver, placenta, skin Brain, platelets, lymphocytes Table 4: Suggested tyramine dietary modifications for MAO inhibitors* Food to avoid Dried, aged, smoked, fermented, spoiled, or improperly stored meat, poultry, and fish Broad bean pods Aged cheeses cheese, yogurt Tap and nonpasteurized beers Food allowed Fresh or processed meat, poultry, and fish All other vegetables Processed and cottage cheese, ricotta Canned or bottled beers and alcohol (have little tyramine) Brewer’s and baker’s yeast Marmite, sauerkraut Soy products/tofu *No dietary modifications needed for low doses of transdermal selegiline or for low oral doses of selective MAO-B inhibitors. 8 Downloaded from http://stahlonline.cambridge.org by IP 100.111.251.218 on Tue Jun 11 21:11:24 UTC 2019 Stahl Online © 2019 Cambridge University Press. All rights reserved. Not for commercial use or unauthorized distribution. Task: Adult and Geriatric Antidepressant Therapy
ATIENT FILE MAO-A destroying NE A inactive substance NE NE transporter (NET) A MAO-A destroying NE no vasoconstriction no ↑ BP alpha 1 receptors Figure 1: Normal NE Destruction Tyramine, as in cheese, increases the release of NE (1) and the excess is destroyed by MAO-A (2) in NE neurons 22 A 1 1 22 1 NE transporter (NET) A no vasoconstriction no BP alpha 1 receptors = 40mg high tyramine meal 12–69 Figure 2: Tyramine increases norepinephine release Here, the tyramine increases the release of NE(1) and the irreversible MAO-A enzyme to stop destroying NE(2). This increase in NE(3) can lead to dangerous elevations of blood pressure. 2 MAO-A inhibitor stops the enzyme from destroying NE A 2 2 2 A NE transporter (NET) 3 alpha 1 receptors vasoconstriction and hypertension Figure 3: Inhibition of MAO-A and tyramine 9 Downloaded from http://stahlonline.cambridge.org by IP 100.111.251.218 on Tue Jun 11 21:11:24 UTC 2019 Stahl Online © 20 19 Cambridge University Press. All rights reserved. Not for commercial use or unauthorized distribution. Task: Adult and Geriatric Antidepressant Therapy
PATIENT FILE Table 5: Potentially dangerous hypertensive combos: agents when combined with MAOIs that can cause hypertension (theoretically via adrenergic stimulation) Decongestants phenylephrine (alpha 1 selective agonist) ephedrine* (ma huang, ephedra) (alpha and beta agonist; central NE and DA releaser) pseudoephedrine* (active stereoisomer of ephedrine – same mechanism as ephedrine) phenylpropanolamine* (alpha 1 agonist; less effective central NE/DA releaser than ephedrine) Stimulants amphetamines methylphenidate Antidepressants with NRI (norepinephrine reuptake inhibition) TCAs NRIs SNRIs NDRIs Appetite suppressants with NRI sibutramine* phentermine *withdrawn from markets in the United States and some other countries Table 6: Potentially lethal combos: agents when combined with MAOIs that can cause hyperthermia/serotonin syndrome (theoretically via SERT inhibition) Antidepressants SSRIs SNRIs TCAs (especially clomipramine) Other TCA structures cyclobenzaprine carbamazepine Appetite suppressants with SERT inhibition sibutramine* Opioids dextromethorphan meperidine tramadol methadone propoxyphene *withdrawn from markets in the United States and some other countries 10 Downloaded from http://stahlonline.cambridge.org by IP 100.111.251.218 on Tue Jun 11 21:11:24 UTC 2019 Stahl Online © 2019 Cambridge University Press. All rights reserved. Not for commercial use or unauthorized distribution. PATIENT FILE Table 7: Tyramine content of cheese … Task: Adult and Geriatric Antidepressant Therapy