Posted: May 8th, 2022

The depressed man who thought he was out of options

Week three Dialogue
Case three: Quantity 1, Case #29
The depressed man who thought he was out of options.
The affected person is a 69 12 months previous male with unremitting persistent melancholy. He has suffered from depressive episodes for 40 years and has at all times had an excellent response to remedy till 5 years in the past when he relapsed on venlafaxine. Two years in the past he underwent 9 therapies of ECT with partial response. He has tried each identified antidepressant and augmentation obtainable prior to now few years.
The affected person ought to be requested about latest annoying life occasions, consumption of illicit medication, alcohol abuse, present medical situations and prescribed medicines (Preda, 2018). If the affected person was in my workplace, I might additionally wish to ask questions to realize an understanding of the severity of his melancholy. You will need to assess the general severity of melancholy signs as a result of symptom severity corelates with suicide danger (Preda, 2018). The PHQ-9 screening may very well be used and this screening asks about emotions of hopelessness, loss of pleasure in doing issues, and emotions of being higher off lifeless. A targeted severity Assessment for hopelessness, suicidal ideation, and psychotic signs is really useful; these signs independently enhance the chance for suicide (Preda, 2018). This affected person reviews feeling severely depressed and demoralized, in addition to, helplessness, hopelessness, and worthlessness. His melancholy is the worst it has ever been.
Members of the family are useful informants, can guarantee medicine compliance, and may encourage sufferers to alter behaviors that perpetuate melancholy (eg, inactivity) (Halverson, 2019). Some questions I might ask members of the family would come with whether or not or not the affected person is taking their medicine and I might ask the household to supply some perception as to how the affected person behaves at house. The spouse reviews that she feels he is letting go and giving up.
There aren’t any lab checks that can affirm depressive dysfunction; nonetheless, labs might be ordered to rule out sicknesses that will current as depressive dysfunction resembling endocrinological or neurological ailments. Labs checks might embrace TSH, B12, RPR, HIV check, electrolytes, BUN and creatinine, blood alcohol, and blood and urine toxicology screening. Neuroimaging might help make clear the character of the neurologic sickness that will produce psychiatric signs, however these research are expensive and could also be of questionable worth in sufferers with out discrete neurologic deficits (Halverson, 2019). CT scanning or MRI of the mind ought to be ordered for suspected natural mind syndrome. PET scans present a way for finding out receptor binding of sure ligands and the impact a compound might have on receptors (Halverson, 2019).
Differential prognosis would come with main depressive dysfunction, bipolar dysfunction, and/or poor or fast metabolism. From 25-50% of instances of Therapy Resistant Despair (TRD) are related to bipolar dysfunction; that is by far the most typical particular person trigger of TRD (Preda, 2018). The remaining 50-75% are related to noncompliance, poor or fast metabolism, or misdiagnosis (Preda, 2018). This affected person is exhibiting indicators and signs per main depressive dysfunction, resembling anhedonia, loss of vitality, emotions of worthlessness, depressed temper, which have been constant for greater than a two week interval. TRD is outlined as MDD that fails to answer at the very least two antidepressant trials which might be of ample dose and length; the 2 antidepressants might belong both to the identical class or to completely different courses (Preda, 2018). Differential diagnoses embrace main melancholy, bipolar dysfunction, and/or gradual or fast metabolism. Bipolar dysfunction is related to 25-50% of instances of Therapy Resistant Despair (TRD); that is by far the most typical particular person trigger of TRD (Preda, 2018). The remaining 50-75% are as a result of noncompliance, gradual or quick metabolism, or misdiagnosis (Preda, 2018). This affected person has been exhibiting indicators and signs per main depressive dysfunction, resembling anhedonia, loss of vitality, emotions of worthlessness, and depressed temper, for greater than two weeks. TRD is outlined as MDD that doesn’t reply to at the very least two ample dose and length antidepressant trials; the 2 antidepressants could also be from the identical or completely different courses (Preda, 2018).
SSRIs, which embrace fluoxetine, sertraline, paroxetine, citalopram, escitalopram, and fluvoxamine, have change into the first-line remedy for main melancholy (Brown, 2011). SSRIs work by selectively blocking the reuptake of serotonin to extend the quantity of serotonin obtainable in synapses within the mind (Brown, 2011). The STAR*D trial examined numerous methods for remedy resistant melancholy in sufferers who didn’t reply to an preliminary SSRI, together with switching to a different SSRI antidepressant, altering medicine class, and switching to CBT. Honest high quality research have indicated a pattern towards better effectiveness when switching to an SNRI resembling venlafaxine than with citalopram, fluoxetine, or paroxetine (Halverson, 2019).
For sufferers with main depressive dysfunction, I might begin the affected person on citalopram 20mg and enhance the dose to a most of 40mg. If the affected person failed to reply, I might change to venlafaxine 75mg every day prolonged launch pill and enhance dose if tolerated. I couldn’t discover any contraindications or dosing alterations wanted for Citalopram or venlafaxine associated to ethnicity.
Week 20 follow-up concluded with ordering venlafaxine ranges. This had been thought-about 20 weeks prior. I agree with ordering this lab and I might have opted to do that earlier than pursuing ECT. A lab is way much less invasive, inexpensive, and with out the unwanted side effects he is experiencing at this level.
The sufferers aphasia and temper are enhancing however his temper continues to be low. He hadn’t had labs accomplished. The venlafaxine stayed at 225mg and aripiprazole was elevated. Aripiprazole was elevated to 15mg. When used to reinforce remedy with an SSRI or SNRI for melancholy, the dose can be no better than 10mg. I disagree with this alteration.
By week 28 the affected person labs present low ranges of venlafaxine on a 225mg dose. The dose was elevated to 300mg. As much as 600mg/day has been given for heroic instances (Stahl, 2014). I agree with this alteration. His aripiprazole was discontinued. I agree with discontinuing for the reason that venlafaxine was not at a therapeutic degree.
The affected person was nonetheless not exhibiting enchancment by week 32. One other blood degree was drawn. At week 36, the extent was low on a 300mg dose. The dose was elevated to 375mg. The sufferers BP is nice and there haven’t been any unwanted side effects. He has proven some enchancment after the dose enhance. A rise to 450mg was made and ranges ordered. By week 40, the affected person was feeling hopeful and temper was enhancing. His lab values had been within the low therapeutic vary. At 450mg/day, the affected person was nonetheless throughout the dosage for a heroic case. He was tolerating nicely. The suggestion at this level was to boost dose by 75mg/day, redraw degree and lift once more to 600mg if nonetheless in therapeutic vary. I feel it is a good technique based mostly on the sufferers enchancment and his capability to tolerate the dose. Classes discovered embrace the significance of therapeutic drug degree monitoring when that is an choice. Doable causes for low ranges may very well be: pharmacokinetic failure, genetic variant inflicting pharmacokinetic failure, or noncompliance. Final however not least, by no means quit.

References
Bienenfeld, David. (2018). Screening checks for melancholy. Medscape. Retrieved from https://emedicine.medscape.com/article/1859039-overview
Brown, Charles. (2011). Pharmacotherapy of main depressive dysfunction. US Pharmacist, 36(11), HS3-HS8. Retrieved from https://www.uspharmacist.com/article/pharmacotherapy-of-major-depressive-disorder
Halverson, Jerry. (2019). Despair. Medscape. Retrieved from https://emedicine.medscape.com/article/286759-overview

Howland, R. H. (2008a). Sequenced remedy options to alleviate melancholy (STAR*D). Half 2: Examine outcomes. Journal of Psychosocial Nursing and Psychological Well being Companies, 46(19), 21–24. doi:10.3928/02793695-20081001-05. Retrieved from Walden Library databases.
Howland, R. H. (2008a). Sequenced remedy options to alleviate melancholy (STAR*D). Half 1: Examine design. Journal of Psychosocial Nursing and Psychological Well being Companies, 46(9), 21–24. doi:10.3928/02793695-20080901-06. Retrieved from Walden Library databases.
Preda, Adrian. (2018). Main depressive dysfunction: Disabling and harmful. Medscape. Retrieved from https://reference.medscape.com/slideshow/major-depressive-disorder-6009734#four
Pigott H. E. (2015). The STAR*D Trial: It Is Time to Reexamine the Medical Beliefs That Information the Therapy of Main Despair. Canadian journal of psychiatry. Revue canadienne de psychiatrie, 60(1), 9-13.
Stahl, S. M. (2013). Stahl’s important psychopharmacology: Neuroscientific foundation and sensible purposes (4th ed.). New York, NY: Cambridge College Press.
Stahl, S. M. (2014b). The prescriber’s information (fifth ed.). New York, NY: Cambridge College Press.

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