ANTIDEPRESSANT DRUGS

Brief History. J.G., a 71-year-old retired pharmacist, was admitted to the hospital with a chief complaint of an inability to move his right arm and leg. He was also unable to speak at the time of admission. The clinical impression was right hemiplegia caused by left-middle cerebral artery thrombosis. The patient also had a history of hypertension and had been taking cardiac beta blockers for several years. J.G.’s medical condition stabilized, and the third day after admission he was seen for the fi rst time by a physical therapist. Speech therapy and occupational therapy were also soon initiated. The patient’s condition improved rapidly, and motor function began to return in the right side. Balance and gross motor skills increased until he could transfer from his wheelchair to his bed with minimal assistance, and gait training activities were initiated. J.G. was able to comprehend verbal commands, but his speech remained markedly slurred and diffi cult to understand. During his hospitalization, J.G. showed signs of severe depression. Symptoms increased until cooperation with the rehabilitation and nursing staff was compromised. Imipramine (Tofranil) was prescribed at a dosage of 150 mg/day.

Problem/Infl uence of Medication. Imipramine is a tricyclic antidepressant, and these drugs are known to produce orthostatic hypotension during the initial stages of drug therapy. Because the patient is expressively aphasic, he will have trouble telling the therapist that he feels dizzy or faint. Also, the cardiac beta blockers will blunt any compensatory increase in cardiac output if blood pressure drops during postural changes.

1. How can the therapist reduce the risk of orthostatic hypotension during rehabilitation sessions?

2. Will clinicians notice an immediate improvement in J.G.’s mood after starting this antidepressant drug?