Adult and Geriatric Antidepressant Therapy

Adult and Geriatric 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 Adult and Geriatric Antidepressant Therapy.

To prepare for this Discussion:

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

(The Case: The depressed man who thought he was out of options

The Question: Are some episodes of depression untreatable?

The Dilemma: What do you do when even ECT and MAOIs do not work)

SELECT CASE #3- VOLUME 1- CASE #29 ON STAHL’S ONLINE WEBSITE ABOVE

• 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 (CASE #3) AS ATTACHED SEPARATELY. .
• Take the pretest for the case study.

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• 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 diagnosis 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.

QUESTION

Post a response to the following:

• Provide the case number in the subject line of the Discussion thread.
• 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.
• Identify people in the patient’s life you would need to speak to or get feedback from to further assess the patient’s situation. Include specific questions you might ask these people and why.
• Explain what physical exams and diagnostic tests would be appropriate for the patient and how the results would be used.
• List three differential diagnoses for the patient. Identify the one that you think is most likely and explain why.
• List two pharmacologic agents and their dosing that would be appropriate for the patient’s antidepressant therapy based on pharmacokinetics and pharmacodynamics. From a mechanism of action perspective, provide a rationale for why you might choose one agent over the other.
• For the drug therapy you select, identify any contraindications to use or alterations in dosing that may need to be considered based on the client’s ethnicity. Discuss why the contraindication/alteration you identify exists. That is, what would be problematic with the use of this drug in individuals of other ethnicities?
• If your assigned case includes “check points” (i.e., follow-up data at week 4, 8, 12, etc.), indicate any therapeutic changes that you might make based on the data provided.
• Explain “lessons learned” from this case study, including how you might apply this case to your own practice when providing care to patients with similar clinical presentations

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

Treating adults and geriatric patients with a major depressive disorder can be very challenging due to variations in patient factors such as culture and ethnicity. Therefore, for the mental health professionals to select the most appropriate interventions for such patients, they must have a comprehensive understanding of the influence of specific client factors on drug response (Stahl, 2013). The given case study describes the treatment process for a 69-year-old man who presents with depressive symptoms. If the patient was in my office, I would ask him three pertinent questions as part of history taking. First, I would ask him to explain the specific signs and symptoms that he has been having and for what period of time. Second, I would want to know whether any of his family members have suffered depression before. Third, I would ask about the types of drugs he is using at the moment. The rationale for why I might ask these questions is that knowledge of the patient’s symptoms, family medical history, and of the drugs he is using is very crucial for the selection of the most appropriate intervention for him (Stahl, 2013) Adult and Geriatric Antidepressant Therapy.

The patient’s wife, one of his children, and the clinician who has been providing care to him act as very good sources of information to allow a further assessment of his situation. The patient’s wife and child would be asked if they have noticed any changes in his behavior in the recent past. The clinician would be asked whether the patient has been responding positively to drugs. The physical exams that would be appropriate for the child include obtaining his weight, blood pressure, body mass index, body temperature, and pulse rate. The most appropriate diagnostic test is performing a magnetic resonance imaging (MRI) to assess brain function. The results of these tests will be used to determine the severity of the patient’s condition (Stahl, 2013).

Based on the client’s symptoms, the three differential diagnoses for him include major depressive disorder, bipolar disorder, and adjustment disorder with depressed mood. I think the most likely diagnosis for him is a major depressive disorder. The reason is that the patient is severely demoralized, depressed, worthless, helpless, hopeless, and has difficulty in concentrating (American Psychiatric Association, 2013). Based on pharmacokinetics and pharmacodynamics, the two pharmacologic agents for the patient’s antidepressant therapy are desvenlafaxine and venlafaxine at a dosage of up to 200 mg for the former and a dosing higher than 375 mg for the latter (Stahl, 2014b). From the pharmacokinetic perspective, I would choose venlafaxine over desvenlafaxine because the former drug would be metabolized faster than the latter thereby making it more effective in relieving symptoms (Stahl, 2014b; Howland, 2008a).

Based on the client’s ethnicity, the healthcare professional should not use tricyclic antidepressant (TCA) and monoamine oxidase inhibitors (MAOI) which are effective in treating patients from other cultures. Rather, the clinician must be careful to use high doses of venlafaxine if positive results are to be realized. The reason is that the patient in the given case study is resistant to TCA and MAOI. The use of high doses of venlafaxine in individuals of other ethnicities may complicate symptoms instead (Yasuda et al., 2008; Stahl, 2014b).

Based on the data provided, I would augment MAOI with a stimulant at week 20 and obtain blood level of venlafaxine while at the same time avoiding the administration of Aripiprazole at week 24. In the cases study, the named proposals have been ignored by the clinician, a factor that has delayed the patient’s recovery process (Stahl, 2013). The two lessons that have been learned from the case study are that ethnicity and culture have a great influence on some episodes of depression, and high doses of venlafaxine should be used when an electroconvulsive therapy (ECT) and MAOI have proven to be ineffective. Therefore, when providing care to patients with similar symptoms in future, I will consider a therapeutic drug monitoring earlier in the treatment. Besides, I will consider genetic testing, particularly in children and geriatric patients who might seem to be resistant to commonly used drugs Adult and Geriatric Antidepressant Therapy.

References

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 Press.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

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

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 Adult and Geriatric Antidepressant Therapy.