The Impact of Ethnicity on Antidepressant Therapy

By Day 6
Respond to at least two of your colleagues who were assigned to a different case than you. For example, if you were assigned to Case Study 1, respond to one colleague assigned to Case Study 2 and one colleague assigned to Case Study 3. Explain how you might apply knowledge gained from your colleagues case studies to you own practice in clinical settings.

If your colleagues posts influenced your understanding of these concepts, be sure to share how and why. Include additional insights you gained.
If you think your colleagues might have misunderstood these concepts, offer your alternative perspective and be sure to provide an explanation for them. Include resources to support your perspective.

TRACI’S POST
69-Year-Old Caucasian Male Case Study

This case study involves a 69-year-old male suffering from 40 years of depression, the client has had tried multiple medication trials, with wavering results.

List of Three Questions to Ask the Patient

1. Describe any of your family members who suffered from depression?

2. How do you cope with the feelings of depression?

3. Do you have enough sufficient social support to help you deal with the feelings of depression?

Rationale: I would ask these questions to gauge the patient’s condition. The purpose of asking about the disease’s family history is to determine whether the patient has a high risk based on hereditary factors (Pavlova & Uher, 2020 ). I want to know about social support to determine the kind of friends and family in the patient’s life to help him cope with the condition. More so, social support sometimes assists in taking medications.

People to speak to and assess the Patients Situation

I want to talk to anyone who has been close to the patient to understand the condition and offered any social support.

The following questions would be appropriate to ask the patients associations:

Are you aware that your friend suffers from depression, and what steps has he taken to get professional help?
In what ways do you see him cope with the condition?
During the last two years, do you recall a period for that lasted over a month when your friend showed none of the problems he described?
Rationale: Getting information from the closest person to the patient offers a perspective on the depressive symptoms

Physical Exams and Diagnostic Tests

To diagnose unipolar depression, clinicians need to evaluate/perform all of the following:

Suicide risk
General medical illness (Thombs et al., 2016 )
Physical examination
Mental status examination
Laboratory evaluation
The significance of the tests and observations is to determine the severity of the depressive symptoms, understand the risk of the condition, and offer appropriate help to the patient.

Three Differential Diagnoses for the Patient

Unipolar major depression occurs when one or multiple major depressive episodes appear without signs of hypomania or mania. The patient in the case study has shown symptoms of major depressive disorder in the last two years (Simon & Ciechanowski, 2017). The report indicates he has shown no response to treatment. A major depressive episode manifests itself through symptoms like fatigue, feeling of low energy, and decreased ability to concentrate.
Adjustment disorder with depressed mood
Schizophrenia and schizoaffective disorder
Two Pharmacologic Agents and their Dosing For the Patient

Nortriptyline at 75mg a day: The drug is a tricyclic anti-depressant which alters chemical processes in the brain. It affects balancing chemicals in the brain for a person with depression (de Graaf, 2020). The total daily dosage may be given once a day for older patients who may forget. Treatment starts at a lower dosage before it is increased gradually. However, it is vital to maintain the plasma levels at an optimum range of 50 to 150 ng/mL
Deplin at 15 mg a day: The drug known as l-methyl folate is suitable for the treatment of resistant depression. Studies have shown that a there is a significant like between folate deficiency and neuropsychiatric disorders. This prescription contains folate, B-vitamin, and helps in the neurotransmitter regulation so that the brain controls moods effectively (Kose & Sayar, 2018). The patient in the case study deals with other medical conditions that can affect their temperament, so this choice of medication is the most appropriate. The dose can be increased further depending on the reaction to the treatment at intervals of 4 and 8 weeks.
I would choose Deplin over other drugs since the patient has to switch between drugs before he gets the right one. There are different anti-depressants, and when a patient doesn’t benefit from one medicine, it is recommended to switch to another. Most importantly, Deplin is the right choice since it contains folic acid that has few side effects. The drug can help the patient cope up with general medical conditions like hypertension and enlarged prostate.

Alterations in the Dosing

The use of Deplin has no contraindication, so the clinician should proceed with treatment. However, the clinician should check for any allergic reactions to folic acid-containing drugs. In this case study, the patient has no problem with allergic reactions, so this is a great drug to continue treatment (Kose & Sayar, 2018). No disease contraindication means the procedure is achievable without the acceleration of hypertension and hypercholesterolemia. Some of these diseases are a risk to the patient’s system, which has to transmit them through the Central Nervous System.

Therapeutic Changes

After four weeks, I would monitor the patient’s changes to determine if there is a reduction in symptoms. Depending on how effective the dose works, I would add another medication to the anti-depressant. An additional drug is useful if the current medicine is helping, but the symptoms are still persistent (Nierenberg, 2017). There is a variety of medications for augmentation and combination therapy. The goal is to help reduce the severity of the symptoms as different people react differently to a treatment.

Lessons Learnt From the Case Study

The case study has taught me to undertake thorough research on a patient’s diagnosis before recommending treatments. People react differently to medications, so a clinician must take time to understand the patient’s history. If a single treatment approach fails on the patient, the best a clinician can do is to try a different one to help the patient. Most importantly, the choice of medication for patients should aim to minimize side effects in case there are general medical conditions to treat.

References

de Graaf, L. (2020). Nortriptyline. Nursing, 26, 54-56.

Kose, S., & Sayar, K. (2018). L-methyl folate in patients with treatment-resistant depression: Fulfilling the goals of personalized psychopharmacological therapy. Psychiatry and Clinical Psychopharmacology, 28(4), 359362. https://doi-org.ezproxy.auctr.edu/10.1080/24750573.2018.1552401

Nierenberg, A. (2017). Unipolar major depression in adults: Augmentation of anti-depressants with stimulants and stimulant-like drugs. UpToDate. http://www. helsebiblioteket. no/(Sist oppdatert: 9.

Pavlova, B., & Uher, R. (2020). Assessment of Psychopathology: Is Asking Questions Good Enough?. JAMA psychiatry.

Simon, G., & Ciechanowski, P. (2017). Unipolar depression in adults and initial treatment: General principles and prognosis.

Thombs, B. D., Benedetti, A., Kloda, L. A., Levis, B., Azar, M., Riehm, K. E., … & McMillan, D. (2016). Diagnostic accuracy of the Depression subscale of the Hospital Anxiety and Depression Scale (HADS-D) for detecting major depression: protocol for a systematic review and individual patient data meta-analyses. BMJ Open, 6(4), e011913.

ANISHAS POST
Case 1: Volume 1, Case #1: The man whose antidepressants stopped working

Dear Dr . Reome and classmates,

The Impact of Ethnicity on Antidepressant Therapy

The medical term that is used to refer to the condition is tachyphylaxis. Other informal words include the ‘Prozac poop-out.’ However, numerous patients suffering from mental illnesses simply know it as the frightening retro when their antidepressants, which at one time were effectual and ceased them from nervousness and discontent abruptly, stop working. In the marketplace, there exist many antidepressants, and when prescribed and correctly taken, they can efficiently treat the symptoms associated with chronic mental disorders. However, finding an antidepressant prescription that works is not an assurance of continuous success. Studies have established that numerous patients suffering from depression ultimately relapse and become depressed again and again (Howland, 2008).). Besides being on antidepressants that were useful earlier, there is a high susceptibility of it ceasing to work.

If the patient is in my office, the following are the three questions I would ask him:

Is there any history of substance abuse?
The reason as to why I would ask this question is because, more than 50% of people diagnosed with mood disorders have at one time been alcoholic, or abused other substances like marijuana (Yasuda et al., 2008). Substance abuse such as alcoholism dramatically affects the body, therefore, making it hard for the body to respond to antidepressant medications.

Does the patient suffer from other medical conditions?
There exist numerous medical conditions that can make it very hard for the patient body to respond to antidepressant medications. Among the medical conditions that might make the patient fail to respond to antidepressants involves the Parkison’s disease, hepatitis C, Alzheimer’s disease, and multiple sclerosis.

Is there reported stress in the recent past?
Depression symptoms might linger to appear if the patient has been recently stressed. It seems more often when one is on the antidepressant prescription that has been working.

In case the patient is married, wife and children would be the individuals in the patient’s life that I would necessitate to talk to or get a response from to examine the patient’s condition further. I would ask them these kinds of questions:

Has the patient been experiencing depressive episodes?
This is because even patients who correctly take their antidepressants as well as check with their doctors sometimes suffer from tachyphylaxis. The studies have similarly established that individuals who had two or more depressive episodes are most probably to have an impending relapse.

Has the patient ever had undiagnosed bipolar disorder?
One of the reasons for this question is, most patients with bipolar disorders mostly report depressive symptoms to the doctor; however, they fail to mentions their episodes of hypomania, which they confuse with an elevated mood or irritability.
Does at any point the patient lower his dosage?
Occasionally, some patients request their doctors to reduce their antidepressant dosage after they attain remission from their depressive signs. However, studies show that patients who reduce their dosage undergo a higher rate of relapse.

The most appropriate physical exams would be a psychiatric and or medical exam. This would help to rule out other disorders that might cause comparable symptoms. Another physical exam that would be appropriate is a medical history that would help recognize the exact origin of the problems (American Psychiatric Association, 2013). The diagnostic test that would be appropriate is the depression screening test that would involve a blood test. This will examine any medical conditions that might result in depressive symptoms (Stahl, 2014b). I would utilize these tests to investigate the existence of anemia or hormones imbalance, and sometimes levels of vitamin D and calcium.

Hypothyroidism, anxiety, and bipolar disorder are the three differential diagnoses (Stahl, 2013). Hypothyroidism is the most likely as it shows that there is an acknowledged lessening of circulating free thyroid hormones or even the resistance from the thyroid hormone’s action.

Pharmacological agents refer to the several initial prescription modalities utilized for depression. The following are two pharmacological agents that would be suitable for the patient’s antidepressant therapy; Selective-Serotonin Reuptake Inhibitors and Serotonin-Norepinephrine Reuptake Inhibitors.

The patient in the case has a long history of persistent unipolar major depressive episodes. The first four episodes were correctly diagnosed with the full remission, and he ceased prescription every time several months to a year after remitting. Ultimately, his next episodes came in as an ever-escalating pattern with little and little time amongst them. The patient became resistant by his fifth episode, and he took two years to get better.

From the case, it is clear that major depression can be persistent. Shorter durations of wellness can characterize it amid successive episodes that finally occasion into diagnosis resistance. The resistance might occasion from neurotrophic influences and the modifications in the brain structure. Patients with three or more episodes of depression ought to be diagnosed with antidepressant maintenance (Yasuda et al., 2008). Despite the susceptibility linked with them, antidepressant-induced sexual dysfunction is a valid reason to terminate antidepressants.

The primary lessons learned from this case study are that the depressive episodes become harder to diagnose and more persistent over time. The maintenance of the antidepressants necessitates becoming unlimited anytime there an extreme episode of one with suicidal cases, perhaps requiring maintenance. Moreover, the antidepressant maintenance necessitates being unlimited successive to remission from three episodes of major depression. Nonetheless, I also learned that antidepressant maintenance ought to become unlimited following one episode of major depression.

References

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

Howland, R. H. (2008). Sequenced Treatment Alternatives to Relieve Depression (STAR*D). Part 1: Study design. Journal of Psychosocial Nursing and Mental Health Services, 46(9), 21-24. doi:02793695-20081001-0510.3928/02793695-20080901-06

Howland, R. H. (2008). Sequenced Treatment Alternatives to Relieve Depression (STAR*D). Part 2: Study outcomes. Journal of Psychosocial Nursing and Mental Health Services, 46(10), 21-24. doi:02793695-20081001-0510.3928/02793695-20080901-06

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.

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), 417423. Retrieved from https://web.archive.org/web/20170809004704/https://www.fda.gov/downloads/Drugs/ScienceResearch/…/UCM085502.pdf