Table 6 Examples of eConsult clinical questions

Depression

35 year old woman with dysthymia. Has been seeing a psychologist for over a year. Symptoms of low mood, decreased motivation and anhedonia. Not suicidal. No alcohol or drug use. No significant anxiety symptoms. Was started on Prozac and dose increased up to 40 mg without effect. She was then switched to Effexor with dose titrated up to 225 mg with little response. Do you have any suggestions?

ADHD

21 year old university student with diagnosis of ADD. Treated with Concerta 54 mg in the morning and Ritalin 30 mg at lunch/early afternoon as he has an evening class. He has asked to increase the dose of Concerta but I am uncomfortable with that as the dose is already high. Otherwise healthy. Takes no other medications. What would you advise?

Anxiety/Insomnia

My question is about insomnia. 42 year old woman is severely anxious and reports episodes of panic attacks. She is currently on sertraline 50 mg which is being titrated up but still has primary and secondary insomnia. She has responded to zopiclone 3.25 mg prn for small periods of time but I do not want to continue this due to the risk of tolerance/dependence. She is unable to tolerate trazodone. Is it reasonable to use zopiclone long term? Otherwise would nortriptyline be safe to use with sertraline? If so at what dose? Do you have other suggestions?