Description
Respond to your colleagues post. Explain how you might apply knowledge gained from your colleagues’ case studies to your own practice in clinical settings.
If your colleagues’ posts influenced your understanding of these concepts, be sure to share how and why. Include additional insights you gained.
If you think your colleagues might have misunderstood these concepts, offer your alternative perspective and be sure to provide an explanation for them. Include resources to support your perspective.
Case 3: Volume 1, Case #29: The depressed man who thought he was out of options
When presented with this case, it is important to look at the history and physical of this patient. How old is the patient, health history, medications taken to treat the depression, what symptoms persist and are there any situational triggers. It is important to look at Pharmacologic agents the patient takes for other pathology as these agents can produce changes in mood. These substances include the following: antihypertensive medications (especially reserpine and methyldopa), smoking-cessation aids (eg, varenicline), steroids, sex hormones and medications that affect sex hormones (eg, estrogen, progesterone, testosterone, gonadotropin-releasing hormone [GnRH] antagonists), H2 blockers (eg, ranitidine, cimetidine), sedatives, muscle relaxants, appetite suppressants, chemotherapy agents (eg, vincristine, procarbazine, L-asparaginase, interferon, vinblastine). (Halverson 2019) Lifestyle choices such as smoking can play a role in the in the metabolism of different medication which can lead to remission of depression. It has been suggested that patients with a later-life onset of the first major depressive episode may have a different etiology of the depression may be due to vascular brain pathology. Differences in etiology may result in differences in treatment response, which would have a clinical impact. (Kozel 2008) Feedback and data gathered from family is essential to assess triggers, antecedents, and manifestations of the depression. Considering the patient and families belief system is important in factoring how outcomes could be impacted. Studies show that racial and ethnic minorities prefer counseling for depression treatment before medications or other invasive interventions. Beliefs about the effects of antidepressants, prayer and counseling influence preferences for depression treatment. (Givens 2007)
Methods of diagnosing depression are done based on reported or observed symptoms such as poor mood, fatigue and change in appetite, which are vague and could be attributed to other pathology as well. The first blood test to diagnose major depression in adults has been developed by Northwestern Medicine scientists. The test identifies depression by measuring the levels of nine RNA blood markers. (Redei 2014).
The pathophysiology of depression indicates that this disorder affects the metabolism, the immune system and the nervous system, as well as the hypothalamus and the pituitary and the adrenal glands. Major depressive disorder does not cause focal neurologic signs. Such findings should prompt an evaluation for other organic syndromes.
Differential diagnosis for depression could be:
Central nervous system diseases such as Parkinson disease, dementia, multiple sclerosis, neoplastic lesions
Endocrine disorders such as hypothyroidism
Drug-related conditions such as side effects of some CNS depressants
Evaluating the patient without all the history makes it difficult to establish therapeutic pharmacologic agents. In treating a patient with resistant depression, several options must be considered and tailored for each patient. Specifically, current options consist of Switching therapies, Augmentation, Combination, and Optimization. Although the focus is on psychopharmacological treatment strategies, other strategies pertaining to psychotherapies, electroconvulsive therapy (ECT), transcranial magnetic stimulation (TMS), deep-brain stimulation (DBS), vagal nerve stimulation, light based-therapies, exercise, acupuncture, and yoga are all important considerations. For this patient, a combination of transdermal Emsam(selegiline) 6mg/24 hr and an atypical antipsychotic Seroquel (quetiapine) 100 mg at bedtime. Emsam can be extremely activating causing insomnia. With the addition of Seroquel, the insomnia she be managed.
References:
Stahl, S. M. (2008). Essential Psychopharmacology Online. Retrieved August 26, 2019 from; http://stahlonline.cambridge.org.ezp.waldenulibrary.org/essential_4th_chapter.jsf?page=chapter1_2.htm&name=Chapter%201&title=Signal%20transduction%20cascades
Howland, R. H., M.D. (2008). Sequenced treatment alternatives to relieve depression (STAR*D) part 1: Study design. Journal of Psychosocial Nursing & Mental Health Services, 46(9), 21-4. Retrieved from https://ezp.waldenulibrary.org/login?qurl=https%3A%2F%2Fsearch.proquest.com%2Fdocview%2F225535518%3Faccountid%3D14872
Kozel, F. A., Trivedi, M. H., Wisniewski, S. R., Miyahara, S., Husain, M. M., Fava, M., … Rush, A. J. (2008). Treatment outcomes for older depressed patients with earlier versus late onset of first depressive episode: A Sequenced Treatment Alternatives to Relieve Depression (STARD) report. The American Journal of Geriatric Psychiatry, 16(1), 58–64. https://doi-org.ezp.waldenulibrary.org/10.1097/JGP.0b013e31815a43d7
Robert H., H. (2008). Sequenced Treatment Alternatives to Relieve Depression (STAR*D) Part 2: Study Outcomes. Journal of Psychosocial Nursing and Mental Health Services, (10), 21. Retrieved from https://search-ebscohost-com.ezp.waldenulibrary.org/login.aspx?direct=true&db=conedsqd10&AN=edsovi.00005278.200810000.00006&site=eds-live&scope=site
Zolezzi M. (2016). Medication management during electroconvulsant therapy. Neuropsychiatric disease and treatment, 12, 931–939. doi:10.2147/NDT.S100908. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4844444/
Givens JL., Houston TK., Van Voorhees BW., Ford DE, Cooper LA. May-June 2007. PubMed: Ethnicity and preferences for depression treatment. Volume 29(3):182-91. Retrieved from: https://www.ncbi.nlm.nih.gov/m/pubmed/17484934
E E Redei, B M Andrus, M J Kwasny, J Seok, X Cai, J Ho, D C Mohr. 2014. Translational Psychiatry; Blood transcriptomic biomarkers in adult primary care patients with major depressive disorder undergoing cognitive behavioral therapy. 4 (9): e442 DOI: 10.1038/tp.2014.66. Retrieved from: https://www.sciencedaily.com/releases/2014/09/140917121229.htm
Jerry L Halverson, David Bienenfeld. Mar 28, 2019. Medscape: Depression Differential Diagnoses. Retrieved from: https://emedicine.medscape.com/article/286759-differential
Ionescu, D. F., Rosenbaum, J. F., & Alpert, J. E. (2015). Pharmacological approaches to the challenge of treatment-resistant depression. Dialogues in clinical neuroscience, 17(2), 111–126. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4518696/
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