Case 27: The Case of Depressed Man Who Thought He Was Out of Options
The case presented in the above case study only happens in a few instances in a population. It is the case of a 69-year-old man who complains of chronic unremitting depression. Further, the patient’s MAIOs and ECT therapies have stopped working on him and thus, a different psychopharmacological therapy should be explored. In the course of the present analysis, several aspects of the diagnosis and treatment options for the patient will be explored to gain a comprehensive understanding of how to manage such cases in future by the present nurse.
During the patient interview process, the following three questions will be asked to the 69-year-old man:
Did you experience loss of interest or depressed mood for either a 2-week period or even longer over the last six months?
Have you had trouble falling asleep or staying asleep, or have you been sleeping too much over the last couple of months?
Have you had a feeling that you energy levels are too low or have you been feeling tired lately?
Those questions will be presented to the patient and are part of the Patient Health Questionnaire-9. According to studies, the questions from the PHQ-9 forms are imperative in cases where depression is suspected. Consequently, such questions will be utilized in making an objective decision concerning the degree of severity from the presented depression case. The same case applies in the present one.
People in the Patient’s Life
The patient appears as a consummate family man. His family including wife, children and grandchildren do not appear to have issues with him. Indeed, they are compassionate and worry for him hence the decision to seek solutions for his condition. Thus, the people in his family that will be questioned include his wife and one of his children. To the wife, the following questions will be presented: Has he shown abnormalities in his sleeping pattern of late? On the hand, the child will thus be asked: Has he lost interest in any of the things that he erstwhile enjoyed to do with you?
A history of the depressive symptoms obtained from the wife and his child will play avital role in the diagnosis of the condition. In most cases, major depressive disorder patients do not have insight regarding the happenings of their behavior and how they impact their immediate family relationships. Therefore, asking the above questions will help offer insight into the patient’s condition and how it has impacted the functioning of his family.
Physical Examination and Diagnostic Tests
During the diagnosis of patients with major depressive disorder, physical examinations with bias towards neurological diseases are important. The purpose of this examination involves the detection of concurrent medical disorders that may equally be affecting the patient. Specifically, the physicals of the present patient need to focus on stroke given his reaction to the ECT therapy.
Other equally important diagnostic tests need to be conducted on a patient suffering from depression. The persistence of the present depression could be indicative of another medical condition. Thus, diagnostic tests such as complete blood count, thyroid function studies, electrocardiogram, and brain scanning are important. These studies may be important in confirming whether the patient’s depression is induced by a medical condition or toxins within his system.
Differential Diagnoses for the Patient
The patient’s symptoms are unique and majorly present in patients with his type of condition. However, the possibility of other types of mental health conditions cannot be discounted. Some of the symptoms shown by the patient are also found in bipolar disorder, dementia, and mood disorder due to another medical condition (In Rhoads & In Penick, 2018). However, the more likely diagnosis would be major depressive symptom with dementia as the patient presented with memory problems, speech problems alongside worsening depression in week 20 of interim follow-up.
The patient shows resistance to most of the antidepressants that have been given to him. In order to effectively manage the patient’s conditions, the following two agents will be considered: Venlafaxine and Mitazarpine. In normal depressive cases, the dosage of Venlafaxine is supposed to be 37.5 mg orally daily, then increased to 75 mg orally daily, up to a maximum response of 250 mg daily depending on the response from the patient (In Acton, 2012). On the other hand, mirtazapine will be given in doses of 15 mg Q h.a, with a maximum dose of up to 45 mg/day permitted (Stahl, 2014). These two agents are preferred because of their plasma levels, with only 30% of Venlafaxine binding to plasma while mirtazapine also has a lower plasma binding rate.
Venlafaxine works by increasing inhibiting the reabsorption of dopamine, norepinephrine, and serotonin. However, mirtazapine has serotonergic and noradrenergic effects in addition to inhibiting 5HT-3 post-synaptic serotonin receptors, making it to have strong antihistamine properties (Stahl, 2013). As a result of this, Venlafaxine is the preferred psychopharmacologic therapy for the patient.
In the present situation, genetics obviously play an important role. The patient appears to be a poor metabolizer of all the SSRIs that he has so far been prescribed. That even MAOs and all the aggressive treatment regimens that he was given failed to work is raises the suspicion of genetic influence further. Thus, the patient may have a variant of the CYP2D6 enzyme or may lack the enzyme altogether (Sangkhul et al., 2014). As a consequence, the concentration of the drug in blood remains high, which makes it contraindicated with monoamine oxidase inhibitor. The contraindication may predispose the patient to the fatal serotonin syndrome.
Potential Therapeutic Changes
The standard procedure of treating mental health illnesses such as major depressive disorder demand that a practice nurse should change a pharmacological agent if it proves ineffective after eight weeks. However, the present patient has shown that he is not responsive to all other antidepressants. Thus, the nurse will need to consider an orthodox way of managing the symptoms using venlafaxine. When the patient was given Venlafaxine at 225 mg, he still demonstrated depressive symptoms. Given that other antipsychotics have proven unsuccessful initially, the nurse was left with no choice but to adopt heroic dosing of the drug. As a result, the drug’s dosage would be increased to 300 or 375 mg while at the same time monitoring the mood and BP levels of the patient. The dosage of venlafaxine would be increased up to its therapeutic level in this patient in all the subsequent assessments as each assessment proved that the drug was not working. In other words, the dosage should be increased to between 400-600 and the maximum safe dose determined.
Lessons Learned from the Case Study
In the present case study, the 69-year-old present with major depressive disorder symptoms. However, some of the most efficacious therapies including ECT and MAOIs failed to initiate a remission of the symptoms. Consequently, the present nurse practitioner has learned the following lessons:
There are instances wherein standard doses of antidepressants may not work due to either pharmacokinetic failure or genetic variant causing pharmacokinetic failure.
That even in cases whereby aggressive therapy is used, it does not need to be applied recklessly as the patient’s wellbeing may be jeopardized
The effectiveness of a drug therapy is contingent upon its level in the brain and not its level in the blood
Therapeutic drug monitoring ought to be given first consideration during treatment of a patient as opposed to more exotic options.
Therefore, the present nurse will use the above lessons to formulate therapy fir future patients presenting with similar conditions. Specifically, I will be using blood levels of certain antidepressants and/or their active metabolites to formulate a therapy.
In Acton, Q. A. (2012). Depression: New insights for the healthcare professional : 2011 edition. Atanta, Georgia: Scholarly Editions.
In Rhoads, J., & In Penick, J. C. (2018). Formulating a differential diagnosis for the advanced practice provider. New York, NY : Springer Publishing Company.
Sangkuhl, K., Stingl, J. C., Turpeinen, M., Altman, R. B., & Klein, T. E. (2014). PharmGKB summary: venlafaxine pathway. Pharmacogenetics and Genomics, 24(1), 62–72. http://doi.org/10.1097/FPC.0000000000000003
Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (4th ed.). New York, NY: Cambridge University Press.
Stahl, S. M. (2014). The prescriber’s guide (5th ed.). New York, NY: Cambridge University Press.