stressful life events, consumption of illicit drugs

Respond to at least two of your colleagues who were assigned to a
different case than you.  Explain how you might apply knowledge gained
from your colleagues’ case studies to you 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 #29 The depressed man who thought he was out of options.

The patient is a 69-year-old male with unremitting chronic
depression. He has suffered from depressive episodes for 40 years and
has always had a good response to treatment until 5 years ago when he
relapsed on venlafaxine. Two years ago, he underwent nine treatments of
ECT with partial response. He has tried every known antidepressant and
augmentation available in the past few years.

The patient should be asked about recent stressful life events,
consumption of illicit drugs, alcohol abuse, current medical conditions
and prescribed medications (Preda, 2018). If the patient was in my
office, I would also want to ask questions to gain an understanding of
the severity of his depression. It is important to assess the overall
severity of depression symptoms because symptom severity corelates with
suicide risk (Preda, 2018). The PHQ-9 screening could be used, and this
screening asks about feelings of hopelessness, loss of pleasure in doing
things, and feelings of being better off dead. A focused severity
assessment for hopelessness, suicidal ideation, and psychotic symptoms
is recommended; these symptoms independently increase the risk for
suicide (Preda, 2018). This patient reports feeling severely depressed
and demoralized, as well as, helplessness, hopelessness, and
worthlessness. His depression is the worst it has ever been.

            Family members are helpful informers, they can ensure
medication compliance, and can encourage patients to change behaviors
that continue depression (Halverson, 2019). Some questions I would ask
family members would include whether the patient is taking their
medication and I would ask the family to provide some insight as to how
the patient behaves at home. The wife reports that she feels he is
letting go and giving up.

There are no lab tests that will confirm depressive disorder,
however, labs can be ordered to rule out illnesses that may present as
depressive disorder such as endocrinological or neurological diseases.
Labs tests may include TSH, B12, RPR, HIV test, electrolytes, BUN and
creatinine, blood alcohol, and blood and urine toxicology screening.
Neuroimaging can help clarify the nature of the neurologic illness that
may produce psychiatric symptoms, but these studies are costly and may
be of questionable value in patients without discrete neurologic
deficits (Halverson, 2019). CT scanning or MRI of the brain should be
ordered for suspected organic brain syndrome. PET scans provide a means
for studying receptor binding of certain ligands and the effect a
compound may have on receptors (Halverson, 2019).

Differential diagnosis would include major depressive disorder,
bipolar disorder, and/or poor or rapid metabolism. From 25-50% of cases
of Treatment Resistant Depression (TRD) are associated with bipolar
disorder; this is by far the most common individual cause of TRD (Preda,
2018). The remaining 50-75% are associated with noncompliance, poor or
rapid metabolism, or misdiagnosis (Preda, 2018). This patient is
exhibiting signs and symptoms consistent with major depressive disorder,
such as anhedonia, loss of energy, feelings of worthlessness, depressed
mood, which have been consistent for more than a two week period. TRD
is defined as MDD that fails to respond to at least two antidepressant
trials that are of adequate dose and duration; the two antidepressants
may belong either to the same class or to different classes (Preda,
2018).

SSRIs, which include fluoxetine, sertraline, paroxetine, citalopram,
escitalopram, and fluvoxamine, have become the first-line treatment for
major depression (Brown, 2011). SSRIs work by selectively blocking the
reuptake of serotonin to increase the amount of serotonin available in
synapses in the brain (Brown, 2011). The STAR*D trial examined various
strategies for treatment resistant depression in patients who did not
respond to an initial SSRI, including switching to another SSRI
antidepressant, changing medication class, and switching to CBT. Fair
quality studies have indicated a trend toward greater effectiveness when
switching to an SNRI such as venlafaxine than with citalopram,
fluoxetine, or paroxetine (Halverson, 2019).

For patients with major depressive disorder, I would start the
patient on citalopram 20mg and increase the dose to a maximum of 40mg.
If the patient failed to respond, I would change to venlafaxine 75mg
daily extended release tablet and increase dose if tolerated. I could
not find any contraindications or dosing alterations needed for
Citalopram or venlafaxine related to ethnicity.

Week 20 follow-up concluded with ordering venlafaxine levels. This
had been considered 20 weeks prior. I agree with ordering this lab and I
would have opted to do this before pursuing ECT. A lab is much less
invasive, less expensive, and without the side effects he is
experiencing at this point.

The patient’s aphasia and mood are improving but his mood is still
low. He hadn’t had labs completed. The venlafaxine stayed at 225mg and
aripiprazole was increased. Aripiprazole was increased to 15mg. When
used to augment treatment with an SSRI or SNRI for depression, the dose
would be no greater than 10mg. I disagree with this change.

By week 28 the patient labs show low levels of venlafaxine on a 225mg
dose. The dose was increased to 300mg. Up to 600mg/day has been given
for heroic cases (Stahl, 2014). I agree with this change. His
aripiprazole was discontinued. I agree with discontinuing since the
venlafaxine was not at a therapeutic level.

The patient was still not showing improvement by week 32. Another
blood level was drawn. At week 36, the level was low on a 300mg dose.
The dose was increased to 375mg. The patients BP is good and there have
not been any side effects. He has shown some improvement after the dose
increase. An increase to 450mg was made and levels ordered. By week 40,
the patient was feeling hopeful and mood was improving. His lab values
were in the low therapeutic range. At 450mg/day, the patient was still
within the dosage for a heroic case. He was tolerating well. The
suggestion at this point was to raise dose by 75mg/day, redraw level and
raise again to 600mg if still in therapeutic range. I think this is a
good strategy based on the patient’s improvement and his ability to
tolerate the dose. Lessons learned include the importance of therapeutic
drug level monitoring when this is an option. Possible reasons for low
levels could be: pharmacokinetic failure, genetic variant causing
pharmacokinetic failure, or noncompliance. Finally, never give up.

                                                                 References

Bienenfeld, David. (2018). Screening tests for depression. Medscape.
Retrieved from https://emedicine.medscape.com/article/1859039-overview

Brown, Charles. (2011). Pharmacotherapy of major depressive disorder.
US Pharmacist, 36(11), HS3-HS8. Retrieved from
https://www.uspharmacist.com/article/pharmacotherapy-of-major-depressive-disorder

Halverson, Jerry. (2019). Depression. Medscape. Retrieved from https://emedicine.medscape.com/article/286759-overview

Howland, R. H. (2008a). Sequenced treatment alternatives to relieve
depression (STAR*D). Part 2: Study outcomes. Journal of Psychosocial
Nursing and Mental Health Services, 46(19), 21–24.
doi:10.3928/02793695-20081001-05. Retrieved from Walden Library
databases.

Howland, R. H. (2008a). Sequenced treatment alternatives to relieve
depression (STAR*D). Part 1: Study design. Journal of Psychosocial
Nursing and Mental Health Services, 46(9), 21–24.
doi:10.3928/02793695-20080901-06. Retrieved from Walden Library
databases.

Preda, Adrian. (2018). Major depressive disorder: Disabling and
dangerous. Medscape. Retrieved from
https://reference.medscape.com/slideshow/major-depressive-disorder

Pigott H. E. (2015). The STAR*D Trial: It Is Time to Reexamine the
Clinical Beliefs That Guide the Treatment of Major Depression. Canadian
journal of psychiatry. Revue canadienne de psychiatrie, 60(1), 9-13.

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

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