1. Azimatul Karimah
(uci.nugroho@gmail.com)
Clinical Experience Using
Quetiapine
RTD Astra Zeneca, 22-8-2014

2. Case 1
• Male, 56 y.o, religious leader in Sampang, was consulted by
his son, patient was absent
• Main complain : unmotivated
• Very low motivation, less socialized, less talk, less ADL since
over 1 year ago, intake <<, decreased body weight > 20 kg,
interrupted sleep
• Feeling : hopelessness, helplessness
• Cognitive : can’t do anything without other helps
• Premorbid : dependent personality
• Family burn out (physically, emotionally, financially)

3. Past Illness History
• Stressor : failed to be legislative candidate (3 years ago),
bancrupt
• 2 years ago, somatic complaints
– Neck calcification
– Dyspeptic Syndromes
– Diabetes Mellitus
– Mild fracture of plantar area
• Hospitalized and evaluated routinely. Prof and doctor said,
all had been good.
• Non adherence towards physiotherapy

4. 1st
meeting
S : patient was absent. Son showed video of his daily activities.
O : GA : px sat on wheelchair. Helped to brush his teeth.
Moved slowly and minimally
M/A: Depressed
Thought process : less talk, non verbal communication
(+), couldn’t be evaluated
Volition : minimal
A : Severe depression episode without psychotic feature
P : - Sertraline 50mg -0-0
- Clobazam 2 x 10mg
- Quetiapine 0-0-12,5mg
- Family psychoaeducation and supportive psychotherapy

5. 2nd
meeting (1 month)
S : px had willingness to come to clinic. Sat on wheelchair.
Calm. Smile once. More verbal communication, slow and
whispering. Sleep was improved. Intake was improved.
Cooperation was improved, Dependent (+), low motivation
(+), ADL (+) minimally
O : M/A: Depressed mood <, anxiety (+)
Thought process : verbal communication (+), ideas of
pessimistic, preocuppation of somatic complaints
Volition : <
A : Severe depression episode without psychotic feature
P : - Sertraline 50mg -0-0
- Clobazam 2 x 10mg
- Quetiapine 0-0-12,5mg

6. Discussion 1
Case 1
• Increasing literature supporting the efficacy of add-on
quetiapine in the treatment of major depressive disorder.
(Daly&Trivedi,2007. A review of quetiapine in combination with antidepressant therapy in patients with
depression. Neuropsychiatr Dis Treat. Dec 2007; 3(6): 855–867)
• Quetiapine is the first drug in Europe for bipolar depression
(Prieto et.al, 2010. Neurobiological bases of quetiapine antidepresant effect in the bipolar disorder. Actas
Esp Psiquiatr 2010;38(1):22-32)

7. Discussion 2
Case 1
Act on the three neurotransmitter
1. Dopaminergic pathway,
  prefrontal dopamine release by antagonism of 5-HT2A, partial
agonist of 5-HT1A and antagonism of α2 adrenoceptors.
2.  serotoninergic transmission
the density of 5-HT1A in the prefrontal cortex and by
antagonism of 5-HT2A receptors and a2 adrenoceptors.
3. Norquetiapine, a 5-HT2C antagonist and is a potent inhibitor
of norepinephrine transporter (NET).

8. Discussion 3
Case 3
• NET inhibition  an increase of noerpinephrine in the
synapse + the increase of prefrontal dopamine and serotonin
• Quetiapine’s action on glutamatergic and GABAergic
receptors  a potential neuroprotective effect that have
already been observed in animal models.
(Prieto et.al, 2010. Neurobiological bases of quetiapine antidepresant effect in the bipolar
disorder. Actas Esp Psiquiatr 2010;38(1):22-32)

9. Case 2
• Mrs. C, 33 y.o, Indonesian, married with expatriate, English
teacher, moved to Surabaya 3 years ago.
• Main complain : emotional unstable (mentioned by husband)
• Since 1st
year of marriage, particularly on premenstrual
period, anemic, psychosocial stressor (+)
• Husband suffered from PTSD (DD: Panic ds), had seen
psychiatrist in UK since > 20 years ago. Tx : Escitalopram
10mg-0-0, Alprazolam 0,25 mg prn, Quetiapine 0-0-12,5mg

10. Case 2
• One day, she couldn’t sleep, felt agitated, angry, frustated,
problem with immigration officers.
• Took husband’s quetiapine 12,5mg and was continued for 3
days.
• Dx : Borderline Personality Traits + Adjustment ds
• She got better and stopped using quetiapine. Sometimes
when she felt emotionally unstable, she took quetiapine prn.

11. Discussion Case 2
10-15% had personality ds, 2 % of borderline personality ds
Four clinical dimensions of Borderline Personality ds
• impulsive-aggressive,
• Affective instability,
• cognitive-perceptive
• anxiety-inhibition.
(Dias-Marza et,al, 2008. Psychopharmacological treatment in borderline personality disorder. Actas Esp
Psiquiatr 2008;36(1):39-49)

12. Clinical Dimension of BPD

13. Clinical Dimension of BPD (2)

14. Pharmaco
therapy

15. Pharmaco
therapy

16. Pharmaco
therapy

17. Pharmacotherapy