19 Mar Major Depressive Disorder
Major Depressive Disorder
Major Depressive Disorder (MDD) is a very severe, highly prevalent and very costly psychiatric disorder that is one of the leading causes of the global burden of diseases because of its substantial morbidity and mortality (Dreimuller et al., 2019). However, about two-thirds of patients do not benefit sufficiently from the first antidepressant and they require a switch to or an augmentation with a second substance (Dreimuller et al., 2019).
Questions for the Patient and Family
My case study involves a 69-year-old man with a 40-year history of depression. He is a married man with three children and eight grandchildren. He is a retired engineer. Questions that would be important to me would first deal with what if anything happened five years ago when the treatment stopped working. This could possibly something to work through in psychotherapy. I would also want to know if the patient is having any suicidal thoughts. If the patient is actively feeling suicidal, inpatient treatment may be necessary for this acute period. Assessing whether the patient is hearing voices and what are they saying? If the voices are command voices, is the patient a danger to himself or others. I would like to speak to the patient’s wife and ask how she would describe her relationship with her husband and what has changed. What type of activities do they do as a couple? Also speaking with one of his children, I would assess their relationship and how it has changed in the last five years. These questions would help to gather information related to the patient’s relationship and interaction with his family.
Diagnostic Tests
Structural and functional MRI studies have been performed, though their interpretation is limited by small sample size, differing protocols, and often divergent results (Leonpacher et al., 2015). Biomarker studies, mainly focused on peripheral proteins such as brain-derived neurotrophic factor, have identified potential differences across the diagnosis, but these findings remain preliminary (Leonpacher et al., 2015). Many psychometric measures to aid in the assessment of depression, such as the Minnesota Multiphasic Personality Inventory, the Beck Depression Inventory, the Zung Self-Rating Depression Scale and The Center for Epidemiological Studies Depression Scale (Hartzell, Mayer, and Gatchell, 2015). Genotyping can be done to explain variants in drug-metabolizing enzymes. Phenotyping can be done to detect high or low levels of medication.
Differential Diagnosis
Major depressive disorder (MDD) is defined as “feelings of sadness and/or a loss of interest in activities once enjoyed and it can lead to a variety of emotional and physical problems and can decrease a person’s ability to function at work and at home (McConnell, Carter and Patterson, 2019). This would be the diagnosis for the case study patient. He has dealt with depression for forty years and he has been treated with Electroconvulsive Therapy nine times with just a partial response. He has been treated with multiple medications and many augmentations of medications.
Dysthymia is a type of low-grade depression that lasts for at least two years, it is less severe than major depressive disorder, but the chronic symptoms have negative effects on work, relationships, family, and social interactions (Jidhun and Chitra, 2016).
Bipolar depression is more common and detrimental to the overall quality of life, with impairments in social and workplace functioning, leading to a detrimental socioeconomic effect (Capote, Rainka, Westphal, Beecher and Gengo, 2018).
Pharmacologic Agents
Venlafaxine has shown effective in treating the elderly with depression. This effectiveness might be attributed to the characteristic of venlafaxine, a dual-action drug inhibiting the reuptake of both, serotonin and epinephrine (Sigurdsson et al., 2015). The patient has responded to venlafaxine in the past, so I would keep him on what I know is helping to improve his symptoms even minimally. Venlafaxine is metabolized in the liver via hepatic cytochrome by P450 enzymes and venlafaxine serum concentration may increase or decrease if co-administered with CYP2D6 inhibitors or CYP2C19 modulators (Sigurdsson et al., 2015).
The 5-HT receptor has been shown to be involved in several functions modulated by the 5-HT system such as circadian rhythm and poor circadian synchrony has been linked to maladaptive changes in bipolar depression (Delcourte et al., 2017). Asenapine has a high affinity for serotonin and noradrenaline receptors and increases the release of serotonin, dopamine, norepinephrine, and acetylcholine in the prefrontal cortex and hippocampus (Delcourte et al., 2017). These drugs I selected to give should have no bearings based on ethnicity. Phenotyping is the issue with this patient, there is a defect in his absorption of the venlafaxine.
In continuing to follow this patient, I would continue to monitor blood levels of the venlafaxine every four weeks. I would limit the use of ECT related to his past history of aphasia and memory issues.
In applying this case to my practice, I realize every patient is not by the book and it takes trying different medication and augments to treat the patient effectively. This patient made me understand the need for many treatment modalities to reach the desired outcome.
References
Capote, H. A., Rainka, M., Westphal, E. S., Beecher, J., & Gengo, F. M. (2018). Ropinirole in Bipolar Disorder: Rate of Manic Switching and Change in Disease Severity. Perspectives In Psychiatric Care, 54(2), 100–106.
Delcourte, S., Abrial, E., Etiévant, A., Rovera, R., Arnt, J., Didriksen, M., & Haddjeri, N. (2017). Asenapine modulates mood-related behaviors and 5-HT1A/7 receptors-mediated neurotransmission. CNS Neuroscience & Therapeutics, 23(6), 518–525.
Dreimüller, N., Wagner, S., Engel, A., Braus, D. F., Roll, S. C., Elsner, S., Tadić, A., & Lieb, K. (2019). Predictors of the effectiveness of an early medication change strategy in patients with major depressive disorder. BMC Psychiatry, 19(1), 24.
Hartzell, Meredith M; Mayer, Tom G; Gatchel, Robert J; In: Spine Journal; Jun2015; v.15. n.6, 1510-1511.
Jidhun, P., & Chitra, P. (2016). A Case Report on Childhood Dysthymia-Low Mood Triggers The End. International Journal of Nursing Education, 8(2), 219–222.
Leonpacher, A. K., Liebers, D., Pirooznia, M., Jancic, D., MacKinnon, D. F., Mondimore, F. M., . . . Goes, F. S. (2015). Distinguishing bipolar from unipolar depression: The importance of clinical symptoms and illness features. Psychological Medicine, 45(11), 2437-2446.
McConnell, V. L., Carter, S. L., & Patterson, K. (2019). Major Depressive Disorder: Treatment-Resistant Depression and Augmentation of Other Medication Classes. MEDSURG Nursing, 28(4), 251–256.
Sigurdsson, H. P., Hefner, G., Ben-Omar, N., Köstlbacher, A., Wenzel-Seifert, K., Hiemke, C., & Haen, E. (2015). Steady-state serum concentrations of venlafaxine in patients with late-life depression. Impact of age, sex and BMI. Journal Of Neural Transmission (Vienna, Austria: 1996), 122(5), 721–729.
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