Week 3: Adult and Geriatric Antidepressant Therapy
The National Institute of Mental Health estimates that approximately 15.7 million adults in the United States have depression (NIMH, 2014), making depression one of the most common disorders you will treat in practice. Although this disorder is so prevalent, antidepressant therapy must be as unique as each individual you treat. There are dozens of antidepressant medications on the market, and you must be able to identify which medication or combinations of medications will result in the best outcomes for your clients.
This week, as you study antidepressant therapies, you examine the assessment and treatment of clients with mood disorders. You also explore ethical and legal implications of these therapies.
Learning Objectives
Students will:
Assess client factors and history to develop personalized plans of antidepressant therapy for adult and geriatric clients
Analyze factors that influence pharmacokinetic and pharmacodynamic processes in adult and geriatric clients requiring antidepressant therapy
Analyze the impact of ethnicity on antidepressant therapy
Evaluate efficacy of treatment plans
Apply knowledge of providing care to adult and geriatric clients presenting for antidepressant therapy
Learning Resources
Note: To access this week’s required library resources, please click on the link to the Course Readings List, found in the Course Materials section of your Syllabus.
Required Readings
Note: All Stahl resources can be accessed through this link provided.
Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (4th ed.). New York, NY: Cambridge University Press.
Note: To access the following chapters, click on the Essential Psychopharmacology, 4th ed tab on the Stahl Online website and select the appropriate chapter. Be sure to read all sections on the left navigation bar for each chapter.
Chapter 6, “Mood Disorders”
Stahl, S. M. (2014b). The prescriber’s guide (5th ed.). New York, NY: Cambridge University Press.
Note: To access the following medications, click on the The Prescriber’s Guide, 5th ed tab on the Stahl Online website and select the appropriate medication.
Review the following medications:
amitriptyline
bupropion
citalopram
clomipramine
desipramine
desvenlafaxine
doxepin
duloxetine
escitalopram
fluoxetine
fluvoxamine
imipramine
ketamine
mirtazapine
nortriptyline
paroxetine
selegiline
sertraline
trazodone
venlafaxine
vilazodone
vortioxetine
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
Howland, R. H. (2008). 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:02793695-20081001-0510.3928/02793695-20080901-06
Howland, R. H. (2008). Sequenced Treatment Alternatives to Relieve Depression (STAR*D). Part 2: Study outcomes. Journal of Psychosocial Nursing and Mental Health Services, 46(10), 21-24. doi:02793695-20081001-0510.3928/02793695-20080901-06
Yasuda, S.U., Zhang, L. & Huang, S.-M. (2008). The role of ethnicity in variability in response to drugs: Focus on clinical pharmacology studies. Clinical Pharmacology & Therapeutics, 84(3), 417–423. Retrieved from https://web.archive.org/web/20170809004704/https://www.fda.gov/downloads/Drugs/ScienceResearch/…/UCM085502.pdf
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.
Volume 1 Case #29- The depressed man who thought he was out of options (Sophia Zwirner Initial Post)
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NURS 6630: Psychopharmacologic Approaches to Treatment of Psychopathology
Week 3 Discussion Initial Post
The Depressed Man Who Thought He Was Out of Options
Depression is the most commonly diagnosed mood disorder today, affecting millions of people (Stahl, 2013). Major depression involves at least one major depressive episode, with many affected individuals experiencing recurrent episodes over time (Stahl, 2013). Those who suffer from depression may have feelings of helplessness, hopelessness, fatigue, lack of enjoyment in activities, anger, and many more that can be debilitating. Depression can be unipolar, meaning that the individual only experiences depressive episodes, or bipolar, meaning that they also experience the “up” manic pole of the cycle (Stahl, 2013). The purpose of this discussion is to examine the case study of a depressed man who believed he was out of treatment options, provide differential diagnoses for his condition, and propose potential drug therapies for him. Ethnicity will be taken into consideration for the drug therapy mentioned.
Background of the Case Study
The patient in this case study is a 69-year-old man with a chief complaint of unremitting, chronic depression. He had been experiencing recurrent episodes of depression for forty years with good response to treatment until five years previous, when he entered one long episode. At the time of his relapse, he was successfully taking venlafaxine 225mg, and had undergone nine ECT treatments since then with limited therapeutic response. Since his relapse, this man tried multiple different antidepressant therapies, as well as augmentation combinations without success. He was a retired engineer, married with three children and eight grandchildren, and did not smoke or use alcohol or drugs. His medical history was insignificant in regard to his depression, but several first-degree relatives had a history. He began to give up and was worrying his family. Upon intake, he was severely depressed, feeling helpless, hopeless, and worthless with difficulty concentrating. He rated his depression severity nine out of ten. He believed there was no hope for improvement.
Questions for the Patient
If I was the provider treating this patient, I would have several questions for him. First, I would ask him if he was taking his medications as prescribed. Noncompliance is a major issue among those who are mentally ill. I have cared for many individuals in the acute psychiatric hospital for this very reason. When I ask them about their medications, many tell me that they were taking them as prescribed but stopped once they began to feel better. As a result, many patients experience a significant worsening of symptoms and require immediate intervention. This patient was prescribed phenelzine (an MAOI) and nortriptyline (a TCA), which requires tapering to discontinue since withdrawal symptoms are common (Stahl, 2014b). If he was not taking this drug as prescribed, he was risking depressive relapse as well as potential dizziness, nausea, stomach cramps, sweating, dysesthesias, and more (Stahl, 2014b). Additionally, the effects of phenelzine wear off within a few weeks once discontinued (Stahl, 2014b).
Another question I would ask this patient is if he had ever attempted psychotherapy in the past. While medications can be effective, they have not worked well for this man over the past few years. Psychotherapy may be a more effective treatment option for this man as an augmentation to his medications. A therapist can help him understand if there are any conditions in his life or events that can be contributing factors for his depression and help him talk through any thoughts he may have. This therapist can also help the patient learn coping skills that may allow him to get through the more difficult days of his depressive episodes. The patient file does not mention any history of psychotherapy, so it is unclear if he had attempted it. The combination of medication and psychotherapy may prove to be more effective treatment for this patient than medication alone. A third question I would ask this man is if he has ever undergone therapeutic drug monitoring. It is possible that he was taking medications that should work for him, but his blood levels are not within the therapeutic range. Therapeutic drug monitoring would provide more insight about whether he was taking a sufficient amount of each drug to be effective for his symptoms (Stahl, 2013).
Patient’s Loved Ones
While some patients are honest about their situation and will answer all questions fully, this is not always the case. It is a good idea to speak to the patient’s family members if possible to try to glean additional information about the situation. The first question I would ask this man’s loved ones is if he was taking his prescribed medication at the correct dose and frequency. I had also asked the patient this same question, but his wife or child may have different insights. I would ask his wife how he sleeps at night. Sleep can greatly affect the way a person feels, both physically and emotionally. If this patient was not sleeping well or enough hours, it could potentially worsen his depression. If sleep is an issue there are many ways that it may be improved, like exercising before bed, drinking hot tea, medical sleep aids, and more. A third question I would ask of loved ones would be if they had noticed any behavioral or cognitive changes in him. If so, the patient may be unaware of these changes, and could indicate a separate issue.
Physical Exams and Diagnostic Testing
According to the patient file, he has already had a neurological Assessment, medical, endocrine, and cancer workups, an MRI, and an EEG, all of which were negative (Stahl, 2013). Genotyping may be indicated in this patient due to his age and the severity of his disorder (Stahl, 2013). This test looks for genetic variants of multiple neurotransmitters and drug metabolizing enzymes in the brain that can alter the concentration of drugs in the body (Stahl, 2013). If these tests are positive, it is possible that he may require a higher dose of certain drugs to reach therapeutic levels in the brain (Stahl, 2013). These variants may also determine whether a drug will be effective at all (Stahl, 2013). Phenotyping is another diagnostic test that can show if the patient is a poor metabolizer or if any pharmacokinetic variants are present (Stahl, 2013).
Differential Diagnoses
While this patient certainly has a depressive disorder, there are several within the DSM-5 that could potentially pertain to his case. One differential diagnosis for this patient is major depressive disorder. Major depressive disorder involves depressive episodes lasting two weeks or longer, where the patient experiences changes in affect, cognition, and other day-to-day functions (American Psychiatric Association, 2013). Major symptoms of this disorder include depressed mood most of the time, diminished interest or pleasure in activities, insomnia or hypersomnia, fatigue, feelings of worthlessness or hopelessness, difficulty concentrating, and thoughts of death or suicidal thoughts (American Psychiatric Association, 2013). Individuals with immediate family members that have the disorder are far more likely to develop symptoms, especially for recurrent forms of the disorder (American Psychiatric Association, 2013).
Another possible diagnosis for this patient is persistent depressive disorder, or dysthymia. Dysthymia is characterized by a depressed mood most of the time for two years or longer (American Psychiatric Association, 2013). In addition, the affected person will experience at least two of the following symptoms: poor appetite or overeating, insomnia or hypersomnia, fatigue, low self-esteem, difficulty concentrating, and feelings of hopelessness (American Psychiatric Association, 2013). These symptoms cause significant distress in the patient’s life, any may decrease functional ability (American Psychiatric Association, 2013).
A third possible diagnosis for this patient is substance or medication-induced depressive disorder. This disorder is characterized by a persistent mood disturbance that includes diminished pleasure in activities (American Psychiatric Association, 2013). The patient would be on a medication that can trigger depressive symptoms or can occur after a patient is taken off of a medication (American Psychiatric Association, 2013). Based on this patient’s quality and duration of symptoms, the most likely disorder he suffers from is persistent depressive disorder, or dysthymia.
Pharmacological Agents and Contraindications
After reviewing the patient’s case, I agree that drug therapy with venlafaxine is appropriate. Venlafaxine is a serotonin and norepinephrine reuptake inhibitor, or SNRI, that works by boosting serotonin and norepinephrine levels in the brain (Stahl, 2014b). Dopamine is also increased because it is inactivated by norepinephrine reuptake and venlafaxine minimally blocks dopamine reuptake as well (Stahl, 2014b). Until his relapse five years previous, he was responding well to 225mg of venlafaxine, but he did not have any therapeutic drug monitoring to ensure that he was receiving enough of the medication to maintain that response. During follow-up check-ins, therapeutic drug monitoring was completed, and the dose was raised incrementally until he finally responded well, and symptoms abated. I would do the same and prescribe the final dose of 450mg since the patient saw relief of symptoms and tolerated treatment well on this dose. Throughout treatment, this man was subjected to additional ECT treatments that resulted in severe neurological side effects, and aripipazole and mirtazapine were added to augment therapy. If I were his provider, I would have probably obtained the drug monitoring before adding multiple medications to his regimen. Polypharmacy is not ideal, and I would have tried to keep him on as few medications effectively as was possible.
Another medication I would consider trying with this patient is lurasidone, or Latuda. This is a relatively new antipsychotic medication that is sometimes prescribed for treatment-resistant depression, and it is one of the few medications he has not tried yet (Stahl, 2014b). Latuda has several mechanisms of action, namely that it blocks serotonin 2A receptors, which enhances dopamine release, improving affective symptoms (Stahl, 2014b). The initial dose for Latuda should be 20mg per day with food and can be titrated up to 120mg per day if needed (Stahl, 2014b).
The patient’s ethnicity is not specified in the case study, but after researching venlafaxine, I found that the drug is generally more effective in females and Caucasian patients (Gibiino, Marsano, & Serretti, 2014). Additionally, venlafaxine is more effective for patients experiencing a short-term depressive episode (Gibiino, Marsano, & Serretti, 2014). Caucasians can be poor metabolizers of medications, which may be a factor in this patient’s case if he is a Caucasian (Yasuda, Zhang, & Huang, 2008).
Case Study “Check Points”
Over the course of nearly one year, the patient had regular interim follow-up appointments. Unfortunately, he did not receive therapeutic drug monitoring until nearly six months after treatment initiation and was found to have low drug levels. He was also subjected to multiple ECT sessions, which resulted in severe neurological side effects like memory and speech problems, as well as worsening depression. As his provider, I would not have prescribed additional ECT after he experienced these side effects and would have obtained neurological testing to rule out stroke. The provider in this case believed that he had suffered a stroke and changed medications in that belief without testing the theory. I would have also done therapeutic drug monitoring as early as possible. If this had been done early on, the patient may have seen symptom relief much earlier than he did and suffered less severe effects.
Lessons Learned
This case has given me a great deal to consider for my future patients. It was very interesting for me to learn about all of the possible treatments for major depression and all of the possible combinations of medications available. This was a difficult patient case, and I can understand how the patient was beginning to give up after nothing was working for him. In the end, he reached remission once more and felt better. This case study showed me that there really is a treatment for everyone and there is always hope, so it is very important to never give up on someone because it seems hopeless. There is always a way to help our patients and give them a better outcome.
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders
(5th ed.). Washington, DC: Author.
Gibiino, S., Marsano, A., & Serretti, A. (2014). Specificity profile of venlafaxine and sertraline
in major depression: metaregression of double-blind, randomized clinical
trials. International Journal of Neuropsychopharmacology, 17(1), 1–8. doi:
https://doi.org/10.1017/S1461145713000746
Stahl, S. M. (2013). Stahl’s essential pharmacology: 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
Press.
Yasuda, S. U., Zhang, L., & Huang, S.-M. (2008). The role of ethnicity in variability in response
to drugs: Focus on clinical pharmacology studies. Clinical Pharmacology &
Therapeutics, 84(3), 417-423. Retrieved from
https://web.archive.org/web/20170809004704/https://www.fda.gov/downloads/Drugs/Sci
enceResearch/…/UCM085502.pdf
