AFP Clinical Answers

Depression, Cervical Myelopathy, Diagnostic Imaging, Eating Disorders, Vitamin K Antagonists


Am Fam Physician. 2021 Oct ;104(4):354.

What is an effective approach to treatment-resistant depression in adults?

Atypical antipsychotics can be an effective augmentation therapy for adults with treatment-resistant depression. According to a Cochrane review, adding quetiapine (Seroquel) to anti-depressant therapy reduces symptoms below the remission threshold (number needed to treat = 9), and the number of people who stop using the medicine increases only at the highest dosage. Augmentation with cariprazine (Vraylar) or ziprasidone (Geodon) improves the clinical response; however, the benefit is offset by increased treatment dropouts.

How should patients with degenerative cervical myelopathy be evaluated and treated?

Magnetic resonance imaging with and without contrast is the modality of choice for patients with suspected degenerative cervical myelopathy. Surgical management is indicated for patients with moderate to severe myelopathic signs and symptoms; however, even with surgery, many patients have residual deficits.

What are examples of clinical scenarios where diagnostic imaging is not indicated?

Do not perform imaging in patients with primary headache disorders without new or progressive features who have normal neurologic examination findings. Do not perform plain chest radiography for preoperative evaluations or baseline testing during hospitalizations for patients who are asymptomatic. Do not perform imaging in patients with acute (less than six weeks) low back pain and no red flag findings on history or physical examination.

What is the first-line treatment approach for patients with an eating disorder?

Family-based therapy should be a first-line approach for youths with anorexia nervosa and bulimia nervosa, and medications should not be used as monotherapy. If medications are used for adjunctive therapy, lisdexamfetamine (Vyvanse) can be effective in reducing binge-eating



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