Posted: February 14th, 2023

Discussion: The Impact of Ethnicity on Antidepressant Therapy Essay

Discussion: The Impact of Ethnicity on Antidepressant Therapy
Major depressive disorder is one of the most prevalent disorders you will see in clinical practice. Treatment for this disorder, however, can vary greatly depending on client factors, such as ethnicity and culture. As a psychiatric mental health professional, you must understand the influence of these factors to select appropriate psychopharmacologic interventions. For this Discussion, consider how you might assess and treat the individuals in the case studies based on the provided client factors, including ethnicity and culture.

To prepare for this Discussion:

Note: By Day 1 of this week, your Instructor will have assigned you to one of the following case studies to review for this Discussion. To access the following case studies, click on the Case Studies tab on the Stahl Online website and select the appropriate volume and case number.

Case 1: Volume 1, Case #1: The man whose antidepressants stopped working

Case 2: Volume 1, Case #7: The case of physician do not heal thyself

Case 3: Volume 1, Case #29: The depressed man who thought he was out of options

Review this week’s Learning Resources and reflect on the insights they provide.
Go to the Stahl Online website and examine the case study you were assigned.
Take the pretest for the case study.
Review the patient intake documentation, psychiatric history, patient file, medication history, etc. As you progress through each section, formulate a list of questions that you might ask the patient if he or she were in your office.
Based on the patient’s case history, consider other people in his or her life that you would need to speak to or get feedback from (i.e., family members, teachers, nursing home aides, etc.).
Consider whether any additional physical exams or diagnostic testing may be necessary for the patient.
Develop a differential diagnoses for the patient. Refer to the DSM-5 in this week’s Learning Resources for guidance.
Review the patient’s past and current medications. Refer to Stahl’s Prescriber’s Guide and consider medications you might select for this patient.
Review the posttest for the case study.
Note: For this Discussion, you are required to complete your initial post before you will be able to view and respond to your colleagues’ postings. Begin by clicking on the “Post to Discussion Question” link and then select “Create Thread” to complete your initial post. Remember, once you click on Submit, you cannot delete or edit your own posts, and you cannot post anonymously. Please check your post carefully before clicking on Submit!

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Case 1: Volume 1, Case #1: The man whose antidepressants stopped working

This scenario is about a 63-year-old male who has been battling depression and anxiety for 15 years. This patient has been on and off multiple antidepressant medications, and he recently suffered his 5th episode of major depression (Stahl, 2013). His first episode occurred at the age of 42 after he was diagnosed and treated for atrial fibrillation. The patient reported he had successful treatment with Zoloft in the past, but he later discontinued the medication after several months. However, anytime he felt relief from his symptoms, he stops taking his medication. During his third episode of major depressive disorder, the patient stated he had sexual dysfunction after starting Zoloft. The patient was then treated with venlafaxine XR, and there were no side effects from this medication. But he is now exhibiting his 5th major depressive episode. A combination of drug therapy has been prescribed to treat this patient: Dextroamphetamine 20mg daily, Buspirone 30 mg daily, Sertraline 200mg daily, Lorazepam 2 mg morning and night, Clonazepam 2mg morning and night. But this patient is still not responding as expected, and he is now displaying psychomotor retardation.

List three questions you might ask the patient if he or she were in your office. Provide a rationale for why you might ask these questions.

The first question to be addressed will be focused on the subjective data by asking the patient to tell me about himself and what has been going on with him. This data will comprise of his history of mental health before his treatment, and what opinions, biases or beliefs does he hold that could influence his treatment. This information will help the nurse practitioner to understand the major underlying symptom common to a major depressive disorder such as feelings of sadness, increased fatigue, lack of interest in relationships, and previously pleasurable activities, poor concentration, and feelings of worthlessness.
What medications have you been taking, and have you been taking them regularly as prescribed?
This question is necessary because his case history indicates he is taking heart medications but does not give the names or doses. It is unethical, immoral, and illegal to prescribe medication without knowing all the medications the client is taking as well as the dosages. Taking under dose or persistently skipping doses or just being non-compliant can result in the persistence of symptoms. According to the scenario, the client’s atrial fibrillation is “controlled by medicine.” There are side effects and drug/drug interactions. The medications typically used to treat atrial fibrillation warfarin, and NSAIDS are known to have a potential interaction with drugs such as sertraline and venlafaxine, which are both been prescribed for this client. The “anti-hypertensive” causes the same problems.

Finally, I will ask the patient if he will be willing to try a non-pharmacological method of treatment for depression together with antidepressant agents. The reason for this is because, studies have suggested that several non-pharmacological treatments for depression such as cognitive behavioral therapy, naturopathic interventions, psychotherapy, and exercise-based interventions may have beneficial effects in the treatment of depression and prevention of relapse (Farah, Alsawas, Mainou, Alahdab, Farah, Ahmed, & LeBlanc, 2016). This option will be beneficial for this patient considering the relapsing nature of his depression.
Appropriate People to Provide Feedback and Specific Questions

I would like to gather more information from close family members or friends. This information will give us an insight into other members of the family with a similar or different psychiatric condition. I will inquire about any recent changes in mood or behavior. This information will help me to put together the bits and pieces about my client’s medical history, and also to determine if the client is telling the truth. I will also ask his family members about his past and present behavioral history to gain more insight into his childhood and adult behavior.

Obtaining collateral information is very paramount to have a broader knowledge of the client’s condition. Petrik (2015) states that collateral information facilitates comprehensive mental health care and is consistent with recovery-oriented models care. Sometimes we face the dilemma of clients who do not consent to such an idea, ensuring the use of the legal and ethical guidelines will be helpful. Collateral information is vital when it comes to mental health care. Family( wife, son, and daughters), as well as outpatient providers, see the patient from another lens and can provide information that the inpatient team can utilize to provide the best quality of care and help the patient on the road to recovery. This information also gives us insight into other members of the family with similar or different psychiatric conditions.

Physical Exams and Diagnostic Tests

I will begin with a collection of vital signs, a physical assessment that includes head to toe assessments, neurological assessments, and blood work. Even though no physical findings are specific to resistant/recurrent major depression. However, medical Assessment is necessary to rule out organic conditions.

Laboratory testing: Complete blood count, to assess for other likely causes for depression, such as infection (Aguilar-Valles, Kim, Jung, Woodside, & Luheshi, 2014). I would also check the patient’s renal and liver function to assess the patient’s ability to eliminate medications (Anderson& Hakimian, 2014). Perform therapeutic lab level of drugs the client is currently taking to evaluate the pharmacokinetics of the drugs and to determine the therapeutic effect. According to Stahl (2013.),” Elderly patients, 65 years of age and older, may not respond as well or as quickly to antidepressants as other adults and may also experience more side effects than younger adults”.

A probable diagnostic test will be TSH, HgbA1c. An association between hypothyroidism and depression has been accepted and taught in medicine for a long time. The nature of this relationship and what determines it have not been proven. Thyroid hormone levels in the brain can influence serotonin and noradrenaline. It appears reasonable that thyroid hormones could be used to augment treatment for depression (Dayan & Panicker, 2013). A physical assessment to be done will be weight measurement. Weight gain associated with some antidepressant therapy may be a reason for noncompliance with the medication regimen.

CT scan or MRI of the brain: According to DSM-IV, hypothalamic-pituitary-adrenal axis hyperactivity had been the most extensively investigated abnormality associated with major depressive episodes. And it appears to be associated with melancholia, psychotic features, and risks for eventual suicide (Farah et.al,2016).

List three differential diagnoses for the patient. Identify the one that you think is most likely and explain why.

Major Depressive Disorder: Major depressive disorder (MDD), also known only as depression, is a mental disorder characterized by at least two weeks of low mood that is present across most situations. It is often accompanied by low self-esteem, loss of interest in normally enjoyable activities, low energy, and pain without a clear cause. People may also occasionally be delusional or experience hallucinations.

Bipolar Depressed: Patients with BD experience recurrent episodes of pathologic mood states, characterized by manic or depressive symptoms, which are interspersed by periods of relatively normal mood. The client in this case study has a 13 – year history of a recurrent episode of major depression. In BD 1 and 2, the duration of mood episodes are highly variable. Still, in general, a hypomanic episode may last days to weeks, a manic episode lasts weeks to months, and a depressive episode may last months to years(McCormick, Murray & McNew, 2015). The client has depressive symptoms for many years, and he meets the criteria to be diagnosed with bipolar type II.

Generalized anxiety disorder: This is characterized by excessive, exaggerated anxiety and worry about everyday life events with no apparent reasons for worry. People with symptoms of generalized anxiety disorder tend always to expect disaster and can’t stop worrying about health, money, family, work, or school.

List two pharmacologic agents and their dosing that would be appropriate for the patient’s antidepressant therapy based on pharmacokinetics and pharmacodynamics

Possible alternative medications would include escitalopram (Lexapro) and citalopram (Celexa). According to Stahl (2014b), escitalopram is used for both major depressive disorder and generalized anxiety disorder. Pharmacokinetic considerations include half-life of 27-32 hours with steady-state plasma concentrations. Also, this has no significant actions on CYP450 enzymes, which are good due to the patient being on cholesterol medication. It is also safe for those with cardiac impairment. Dosage should begin at 10mg with an increase to 20mg and up to 40mg in some patients

My second drug of choice will be Lamotrigine is a first-line medication use for the treatment of bipolar depression. The starting dose is 25mg PO daily, increase to 50mg daily in 3 weeks, 100mg daily at week 5, then 200mg daily PO at week 6 (Stahl, 2013). Lamotrigine, in contrast to the other mood stabilizers, is more effective for preventing the recurrence of depressive than manic episodes of BD. Lamotrigine is generally well tolerated, does not appear to cause gastrointestinal discomfort, and unlike lithium, usually does not require monitoring of serum level for renal insufficiency (Goldsmith et al., 2003; Stahl, 2013). There are no warnings given regarding the use of Lamotrigine and race or ethnicity. It is recommended to monitor the client from the development of Steven-Johnson rash (Stahl, 2013). Children age 12 or younger are at the highest risk for this rash; it should be discontinued at the sight of a rash. It should be used sparsely in renal patients because it is excreted by the kidney(Stahl, 2013).

As providers, continuous monitoring and medication adjustment of our clients is essential to their overall wellbeing. Depression is very complex and needs to be thought about in an integrated way. The PMHNP must bear in mind that a careful analysis of the patients will need to be done before prescribing any form of therapy, and this must be done with a holistic approach. (Nemade, 2017). Major depression can be recurrent and featured by a short duration of wellness between subsequent breakdowns that can result in treatment resistance. Some strategies to use to modify drug therapy in a depressed patient includes but not limited to dosage optimization. Augmentation (with an adjunctive medication) is also appropriate. Switching to a different drug within the same or different classes could be helpful too. The last strategy is to combine medications.

References

Aguilar-Valles, A., Kim, J., Jung, S., Woodside, B., & Luheshi, G. N. (2014). Role of braintransmigrating neutrophils in depression-like behavior during systemicinfection. Molecular Psychiatry, 19(5), 599-606. doi:10.1038/mp.2013.137

Anderson, G., & Hakimian, S. (2014). Pharmacokinetic of Antiepileptic Drugs in Patients with Hepatic or Renal Impairment. Clinical Pharmacokinetics, 53(1), 29-49. doi:10.1007/s40262-013-0107-0

Dayan, C. & Panicker, V. (2013). Hypothyroidism and depression. European Thyroid Journal; Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4017747/

Farah, W. H., Alsawas, M., Mainou, M., Alahdab, F., Farah, M. H., Ahmed, A. T., & … LeBlanc, A. (2016). Non-pharmacological treatment of depression: a systematic review and evidence map. Evidence-Based Medicine, 21(6), 214-221. Doi:10.1136/ebmed-2016-110522.

Goldsmith, D., Wagstaff, A., Ibbotson, T., & Perry, C. (2003). Lamotrigine: a review of its use in bipolar disorder. Drugs, 63(19), 2029-2050.

McCormick, R., Murray, B., & McNew, B. (2015)Diagnosis and treatment of patients with bipolar disorder: A review for advanced practice nurses

Nemade, R. (2017). Depression: Depression & Related Conditions. Retrieved from https://library.wheelerclinic.org/poc/view_doc.php?type=doc&id=12998&cn=5

Petrik, M.L., Billera, M., Kaplan, Y, Matarazzo, B & Wortzel.H Balancing patient care and confidentiality: considerations in obtaining collateral information Journal of Psychiatry Practice 21(3) 220- 224 10.1097/PRA.0000000000000072

Stahl, S. M.(2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (4th ed.).New York, NY: Cambridge University press.

Stahl, S. M. (2014b). The prescriber’s guide (5th Ed.). New York, NY: Cambridge University

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