2. Using readings and references, complete the worksheet, Case Study Questions (PDF).
3. Review the Instructions for Depression Case Study to view the grading criteria for this assignment.
4. Post your responses to questions 5-8 and 13 to this discussion board.
5. Submit your completed worksheet for grading to the Week 5 Assignment 2: Depression Case Study.
Critique the decision making of two of your peers in your response post.
1. Do you agree/disagree with their medication choice? Why?
2. Is there anything else you recommend including?
3. Compare peer’s decision making to yours—what are the advantages and disadvantages of each?
Your response should include evidence of review of the course material through proper citations using APA format.
e: Week 5 Discussion 1: Depression Case Study
by Lindsey Schoener – Wednesday, 2 October 2019, 1:59 PM
Medication Choice 1
5. List 1 medication that would be appropriate for this case. Include name, starting dose.
For the patient Allison, it would be appropriate to start her on sertraline (Zoloft) 50 mg orally daily. The dose may be gradually increased based on response and tolerability in increments of 25 to 50 mg intervals of no less than once weekly, to a maximum dosage of 200 mg per day (Up To Date, 2018). In patients sensitive to side effects, it is suggested to start at a lower dose of 12.5 to 25 mg daily and gradually titrate in increments of no more than 25 mg.
6. Describe your clinical decision making. What is your rationale for choosing this medication? Also, include the mechanism of action for this medication choice and the neurotransmitters and areas of the brain in which the medication is proposed to act on.
Medication therapy is often influenced by the patient’s history of a previous response or by evidence-based practice if no history is available. Sertraline is one of the most widely prescribed selective serotonin reuptake inhibitors (SSRI) and it is suggested that it provides the best efficacy and acceptability (Up To Date, 2018). SSRIs are the drug of choice for depression and quite suitable for the initial treatment because of their efficacy, tolerability, decreased side effects, and general safety in the event of an overdose. In a systematic review of 132 randomized controlled trials comparing antidepressants, sertraline and venlafaxine were found to be slightly more effective than tricyclics, SSRIs, SNRIs, and monoamine oxidase inhibitors on both dichotomous and continuous outcomes (Cipriani et al., 2010).
Sertraline selectively inhibits effects on presynaptic serotonin (5-HT) reuptake and only very weak effects on norepinephrine and dopamine neuronal uptake and possess no significant anticholinergic activity. Sertraline has two candidate mechanisms that distinguish it: dopamine transporter (DAT) inhibitor and sigma-1 receptor binding in addition to serotonin reuptake inhibition (Stahl, 2013). Sertraline has minimal inhibitory effects on the major cytochrome P450 (CYP450) enzymes, mildly inhibiting the CYP2D6 iso-form, and with little effect on CYP1A2, CYP3A3/4, CYP2C9 and CYP2C19. It is thought that the mechanism of action of this medication may improve energy, motivation, concentration, and low energy levels while eliminating many of the undesirable effects of adverse drug reactions (Stahl, 2013). The onset of action is within a week; however, full response may not be seen until eight to twelve weeks after initiation of treatment.
7. What laboratory testing/monitoring is needed for safely prescribing this medication?
While there is no specific laboratory testing indicated for sertraline there are some monitoring interventions needed. At every visit, the patient should be assessed for weight, height, body mass index; mental status for depression, suicidal ideation (especially at the beginning of therapy or when doses are adjusted), anxiety, social functioning, mania, panic attacks, or other unusual changes in behavior; and signs/symptoms of serotonin syndrome. For elderly patients, it is important to monitor sodium concentration closely when initiating or adjusting the dose in older adults with susceptibility of hyponatremia (Up To Date, 2018).
8. Are there any contraindications or safety issues associated with this medication?
According to the Beers Criteria, SSRIs are potentially inappropriate medications that should be used with caution in patients 65 years and older due to the potential to cause or exacerbate syndrome of inappropriate antidiuretic hormone secretion (SIADH) or hyponatremia (as cited in Up To Date, 2018). The greatest adverse reactions of SSRIs include gastrointestinal upset in the first few weeks of use, drowsiness, dizziness, fatigue, and may cause or exacerbate sexual dysfunction. SSRIs can increase the risk of suicidal thoughts and behavior in pediatric and young adults and patients should be closely monitored for worsening symptoms, suicidality, or unusual changes in behavior, particularly during the initial first few months of therapy or during dosage adjustments. QTc prolongation and torsades de pointes have been reported with sertraline use and should be carefully considered before prescribing. Because SSRIs affect platelet serotonin levels, abnormal bleeding can also occur (Up To Date, 2013).
Finally, serotonin syndrome can occur which is a potentially life-threatening condition when used in combination with other serotonergic agents or agents that impair metabolism of serotonin. The patient should be closely monitored for signs of the condition such as mental status changes (e.g., agitation, hallucinations, delirium, coma); autonomic instability (e.g., tachycardia, labile blood pressure, diaphoresis); neuromuscular changes (e.g., tremor, rigidity, myoclonus); GI symptoms (e.g., nausea, vomiting, diarrhea); and/or seizures (Up To Date, 2018). For patients experiencing acute suicidal ideation or symptoms of serotonin syndrome, they should seek immediate emergency treatment. As with all SSRIs, this medication should not be discontinued abruptly or without the consent of the prescriber as it can lead to worsening of psychological symptoms and distressing physical withdrawal type symptoms.
Non pharmacologic Interventions
13. What non-pharmacologic interventions do you recommend? Do you recommend including but not limited to psychotherapy, complementary and holistic therapies?
Some milder forms of depression can be managed with psychotherapy alone and any patient with the diagnosis of depression should always be recommended to start therapy. However, for patients with moderate to more severe forms, psychotherapy should be used in conjunction with psychopharmacology. One particular research study examined a self-report questionnaire about current clinical status and non-pharmacological treatment for depression answered by 236 outpatients being treated for depression. When asked about the goal of treatment for depression, 75.5% of patients answered that they are seeking improvements in physical and affective symptoms, and 24.5% desired reformulation of personality or resolution of inner conflicts (Cheol Park et al., 2014). The study concluded that medications alone are not offering the improvement patients are seeking and deduced that psychotherapy in conjunction with medication management together are helping the patients reached desired effects of treating depression.
Therefore, patients should be encouraged to always participate in self-care activities. These methods can include obtaining at least seven to eight hours of sleep each night; exercising on a daily basis for at least 20 to 30 minutes to increase energy and boost mood; eat a healthy and balanced diet; and participate in activities that enhance interpersonal relationships to build self-esteem. Other common self-care methods for depression include computer-based treatment, dietary supplements (St. John’s wort, S-adenosylmethionine, selenium, vitamin B, C, D, folic acid, Ginkgo biloba, glutamine, tyrosine, natural progesterone, oriental medicine, caffeine, alcohol, omega-3 fatty acids, and others), acupuncture therapy, light therapy, massage therapy, exercise therapy, relaxation therapy, music therapy, hypnotherapy, yoga, meditation, and aromatherapy (Cheol Park et al., 2014).
Additional forms of therapy include cognitive-behavioral therapy (CBT) and interpersonal psychotherapy (IPT). Both CBT and IPT follow structured procedures with limited numbers of therapy sessions. CBT helps patients reconstruct the association between negative emotions and thoughts, while IPT helps the patient to distinguish an association between negative emotions and corresponding life-events, which are generally interpersonal. Thus, a number of studies have concluded that CBT and IPT are considered to be more efficacious than placebo for adult patients with mild or moderate depression and to be as efficacious as antidepressant treatment alone (Cheol Park et al., 2014).
In the event of multiple treatment failure, some more intensive forms of therapy can include electroconvulsive therapy (ECT) which is thought to involve changes in major neurotransmission response through electrical current; and while it is the most effective treatment for severe depression, it holds many severe adverse effects including seizures, memory loss, and confusion with deficits being irreversible. There is also transcranial magnetic stimulation (TMS) which appears to be quite effective in nonpsychotic depression which is similar in treatment to ECT, but less invasive, and uses electromagnetic pulses to the prefrontal cortex, with no associated cognitive side effects (Papadakis & McPhee, 2017). Many forms of psychotherapy have proven to help patients master interpersonal conflicts, develop new coping strategies, and improve self-esteem. Using the Patient Health Questionnaire (PHQ) has also proven an effective screening tool for providers that serves as an indicator of depression severity or response to treatment for patients with a depressive disorder and can be used as a continuous measure of severity and should be utilized at all visits to assess the patient’s improvement or lack thereof, and continued approach to treatment (The Department of Veterans Affairs and the Department of Defense, 2016).