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: The man whose antidepressants stopped working<\/strong><\/p>\n Major depressive disorder is one of the most prevalent disorders we will see in our clinical practice. \u00a0Treatment options for MDD can vary greatly contingent on the appropriate psychopharmacologic interventions being adopted for our clients.\u00a0<\/p>\n Medication nonadherence for patients with chronic diseases is extremely common, affecting as many as 40% to 50% of patients who are prescribed medications for management of chronic conditions\u00a0(Kleinsinger, 2018).\u00a0Nonadherence isn’t a new problem.\u00a0 However, offering clients valuable interventions and education to overcome any potential compliance barriers will help the provider identify any challenges and decide how to achieve mutually agreed-upon goals to improve their health.\u00a0<\/p>\n Questions<\/strong><\/p>\n 1.<\/strong> \u00a0Do you ever feel that taking your medications is a nuisance or inconvenience?\u00a0 Do you have a difficult time remembering to take your medications or forget? \u00a0<\/p>\n \u2022&\u03bd\u03b2\u03c3\u03c0;&\u03bd\u03b2\u03c3\u03c0;&\u03bd\u03b2\u03c3\u03c0;&\u03bd\u03b2\u03c3\u03c0;&\u03bd\u03b2\u03c3\u03c0;&\u03bd\u03b2\u03c3\u03c0;Developing a medication schedule, It is difficult to come up with a schedule to take medications every day for some patients. Collaboratively we need to come up with a convenient time to take the antidepressant and the other prescribed medication for them to be effective.<\/p>\n 2.<\/strong> \u00a0Does your prescribed medications and treatment regimen still leave you feeling depressed? \u00a0Do you have a difficult time adhering to a prescribed regimen?\u00a0<\/p>\n \u2022&\u03bd\u03b2\u03c3\u03c0;&\u03bd\u03b2\u03c3\u03c0;&\u03bd\u03b2\u03c3\u03c0;&\u03bd\u03b2\u03c3\u03c0;&\u03bd\u03b2\u03c3\u03c0;&\u03bd\u03b2\u03c3\u03c0;The patient discontinued his Effexor although it appeared to be effective. It is essential to find out the patient\u2019s reason for not following the prescribed regimen and come up with a solution together.\u00a0\u00a0<\/p>\n \u2022&\u03bd\u03b2\u03c3\u03c0;&\u03bd\u03b2\u03c3\u03c0;&\u03bd\u03b2\u03c3\u03c0;&\u03bd\u03b2\u03c3\u03c0;&\u03bd\u03b2\u03c3\u03c0;&\u03bd\u03b2\u03c3\u03c0;It is crucial for the patient to take his antidepressants accordingly, as well as not skip or alter the dosage, nor terminate the medication once you start feeling better.\u00a0<\/p>\n 3.<\/strong> \u00a0Have the side effects of your medications been difficult to cope with or manage? \u00a0Do you sometimes stop taking your medications because of the adverse effects?\u00a0<\/p>\n Important People<\/strong><\/p>\n \u00a0Family members and other caregivers bring personal knowledge on the suitability or lack thereof regarding different treatments for the patient’s circumstances and preferences (Smith, 2013).\u00a0 The patient is married, so I would address additional questions to his wife. \u00a0After getting permission to discuss his medical records with his family members, I would ask the wife if she knew what medications her husband was taking? \u00a0If she knew why he was taking them?\u00a0 Informed and engaged patients, invested in their own health care as well as in the improvement of the broader health care system, are crucial to a learning system (Smith, 2013).\u00a0 Family support is essential for patients suffering from depression where patients are feeling less motivated or forgetful when taking medications. \u00a0Asking family members if the patient has been experiencing any side effects or illnesses since starting the medication emphasizes self-centered care and mutually agreed-upon goals (Siminoff, 2013).<\/p>\n Physical Exams and Diagnostic Tests<\/strong><\/p>\n CC:<\/strong>\u00a0worst depression and anxiety he has ever felt\u00a0<\/p>\n HPI:<\/strong> 63-year-old male presents to the clinic stating his antidepressants have stopped working. \u00a0The patient has a 13-year history of recurrent unipolar major depressive episodes.\u00a0 His first 4 episodes were readily treated to full remission and he discontinued treatment each time several months to a year after remitting.\u00a0 His subsequent episodes came in an ever-escalating pattern, with less and less time between them. \u00a0By the time of his fifth episode, he had become treatment-resistant and took two years to get better.<\/p>\n Current Medications:<\/strong> 1 year following first depressive episode: antiarrhythmic, a statin for cholesterol, antihypertensive, aspirin, transdermal Selegilene 6 mg\/24hrs after failing multiple SSRI and SNRI treatments plus multiple augmentation strategies.<\/p>\n PMHx<\/strong>: Atrial fibrillation age 42, resolved with medication, hypercholesterolemia, HTN<\/p>\n Soc Hx<\/strong>: Married 33 years, 3 children, nonsmoker, denies illicit drug or alcohol abuse.<\/p>\n Fam Hx<\/strong>: Mother: depression and alcohol abuse; Maternal uncle: alcohol abuse; Son: depression; Daughters: one with mild depression, one with postpartum depression.<\/p>\n ROS<\/strong>:<\/p>\n The purpose of the physical examination is to exclude any physical causes for the patient\u2019s current mental health issues.\u00a0 A mental health assessment often includes this Assessment as the PMHNP reviews the patient\u2019s past medical history and current medications, as well as mental disorders within the family.\u00a0 While asking the patient about any mental health symptoms, it is crucial for the provider to pay attention to their appearance, mood, and speech pattern as it can yield any clues to explaining the symptoms.\u00a0 Most patients with major depressive disorder (MDD) present with a normal appearance.\u00a0 Some would describe it as \u201csmiling depression\u201d where the patient appears happy to others while smiling through the pain, keeping their inner turmoil hidden (Coward, 2016).\u00a0 This type of MDD results from atypical symptoms and many don\u2019t realize they are depressed, nor seek help.\u00a0 People with smiling depression\u00a0are often\u00a0partnered or married, employed and are quite accomplished and educated. Their\u00a0public, professional and social lives are not struggling (Coward, 2016).\u00a0 Patients with more severe depressive symptoms often have poor hygiene or grooming and changes in weight.\u00a0 Patients may experience both psychomotor impairment and agitation.\u00a0 Impairments can cause issues with muscle function and speech, flat affect and emotions.\u00a0 Speech patterns may be normal, monotone, or slow lacking content.\u00a0 Racing thoughts and pressured speech patterns often suggest anxiety or mania (Dailey & Saadabadi, 2020).\u00a0\u00a0<\/p>\n Diagnostic Test:<\/strong><\/p>\n There are several diagnostic tools that can be used to screen for depression. \u00a0The Patient Health Questionaire-2 is a screening tool for the diagnosis of major depression in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).\u00a0 The Beck Depression Inventory (BDI) is a 21-item questionnaire that was first developed in 1961 that cover affective, cognitive and somatic aspects of major depression.\u00a0 The Geriatric Depression Scale (GDS) is a 30-item depression questionnaire specifically designed for use in older adults to assess the affective and cognitive aspects of major depression (Ng, How & Ng, 2016).\u00a0\u00a0<\/p>\n Laboratory studies such as a CBC blood or urine tests may be ordered.\u00a0 For example, anemia or B-12 deficiency can cause fatigue, lack of energy and depression. \u00a0Thyroid-stimulating hormone (TSH) is often ordered when screening for depression.\u00a0 Hypothyroidism is commonly found in depressed individuals.\u00a0 Electrolytes, including calcium, phosphate, and magnesium levels should be evaluated.\u00a0 Supplementation with magnesium has been shown to decrease symptoms of depression in patients with mild to moderate depression (Tarleton, Kennedy, Rose, Crocker & Littenberg, 2019). \u00a0If a nervous system problem is suspected, a magnetic resonance imaging (MRI), an electroencephalogram (EEG) or a computed tomography (CT) scan may also be ordered.\u00a0<\/p>\n Differential diagnosis<\/strong><\/p>\n Pharmacological agents and dosing<\/strong>\u00a0<\/p>\n This patient had several recurrent unipolar depressive episodes.\u00a0 By the time of his fifth episode, he had become treatment-resistant and took two years to get better.\u00a0 Adding Seroquel to his treatment regimen could have prevented a fourth or fifth episode.\u00a0 Seroquel works by blocking dopamine 2 receptors, reducing positive symptoms of psychosis and stabilizing affective symptoms (Stahl, 2014b).\u00a0 Psychotic and manic symptoms can improve within 1 week, but it is recommended that the patient wait 4-6 weeks to determine the drug’s efficiency.\u00a0 Many bipolar patients may experience a reduction of symptoms by half or more, unfortunately, this patient experienced excess daytime sleepiness.\u00a0 If Seroquel is ineffective in treating the patient, I would consider adding olanzapine.\u00a0 Olanzapine works by blocking dopamine 2 receptors, reducing positive symptoms of psychosis and stabilizing affective symptoms (Stahl, 2014b).\u00a0 The initial dose of olanzapine is 5\u201310 mg once daily orally; increase by 5 mg\/day once a week until desired efficacy is reached; the maximum approved dose is 20 mg\/day.\u00a0\u00a0<\/p>\n Contraindications<\/strong><\/p>\n There are no specific contraindications related to the patient\u2019s ethnicity when prescribing Seroquel or Olanzapine. \u00a0However, I would use caution with both medications in cardiac patients because it can cause orthostatic hypotension and this patient is already taking antihypertensive medication. \u00a0A lower dosage may be sufficient when treating manic\/mixed episodes (Stahl, 2014b).\u00a0<\/p>\n Check points<\/strong>\u00a0<\/p>\n When adding any new medications, it is recommended that the patient follow up within 4-6 weeks after starting the prescribed regimen.\u00a0 The patient will need to be monitored for any improvements in his symptoms, as well as any adverse reactions or side effects he may experience.\u00a0 Obtaining baseline and checkpoints at follow-up appointments for weight\/BMI, fasting triglycerides, blood pressure, and fasting serum glucose with Seroquel.\u00a0 Quetiapine may increase the risk of diabetes and dyslipidemia, weight gain, dizziness, and sedation (Stahl, 2014b).\u00a0 Olanzapine is approved for long-term maintenance of the bipolar disorder.\u00a0 Zyprexa should be used with caution in patients with conditions that predispose to hypotension and it may increase the effect of antihypertensive agents (Stahl, 2014b).<\/p>\n Lessons learned<\/strong>\u00a0<\/p>\n 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.\u00a0 Improving adherence requires an active process of behavioral change, which is nearly always a challenge. \u00a0It requires education, motivation, tools, support, monitoring, and Assessment.\u00a0 Many factors can potentially contribute to a drug\u2019s efficiency. \u00a0The prevalence of depression is increasing, representing an important public health problem (Tarleton et al., 2019).\u00a0 The treatment method that ultimately leads to an acceptable level of improvement in depressive symptoms for any individual is unpredictable. \u00a0Combining antidepressant medication with therapy and self-help measures can often be more effective than taking medication alone.\u00a0 Finding the right treatment options may take time.<\/p>\n References<\/p>\n Coward, L. (2016). NAMI. Retrieved from https:\/\/www.nami.org\/Blogs\/NAMI-<\/u><\/a>Blog\/September-2016\/What-You-Need-to-Know-About-Smiling-Depression\u201d<\/p>\n Dailey & Saadabadi. [Updated 2020 Jan 14]. Mania. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https:\/\/www.ncbi.nlm.nih.gov\/books\/NBK493168\/<\/p>\n\n
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