Case 3:Volume 1, Case #29: The depressed man who thought he was out of options· Review this week's Learning Resources and reflect on the insights they provide. · Go to the Stahl Online website and exa

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

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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?

Questions to Ask

How do you cope with the changes in your life?

By asking the patient this question, it gives insight as to how and what he does to cope with changes and conflict within his life.

This question will give insight into the ways the patient uses to overcome conflict and changes that occur in his life.

You have rated yourself as a 9/10 severity, what prompted you in the last two years you to evaluate yourself this high?

From this query insight on what occurred in the last two years, making him be in such a bad state will be known.

During your relapse five years ago, did anything out of the ordinary occur? Currently, what has made you lose hope on life?

This question will help now what happen in the past, whether it was a traumatic event? Whether he stopped taking venlafaxine medication due to good response toward it

People in the Patient’s Life

Speaking to his wife is very crucial especially to understand how life at home is for him and to know why she feels she is giving up? Does she take his prescribed medicine? The wife will have a view on his interactions and ADLs with other members of his family

To find queries about his history, I will bring on board his parents and inquire whether they were aware of the patient was in depression. Hiding depression is very common among people and most signs are seen by people who are very close to them. This query will give answers to whether the patient is suffering from depression.

Physical Exams and Diagnostic Tests

Thyroid function test; since malfunction such as Blunted TSH, elevated rT3 and CSF, low T3 are some of the symptoms one suffers from depression.

Liver function test; in the body breaking down of drugs is mainly done by the liver. In many instances, liver toxicity is caused by antidepressants which lead to liver damage.

C-creative is a protein test that will help in the identification of antidepressants those result in damage to the liver.

Differential Diagnoses

A depressive disorder that is consistent

It is realistic as a significant part of the patient’s life, he has suffered from depression and in the last two years lost hope about life.

Depression
Major depression
Treatment resistant depression.

Pharmacologic Agents

Referring to the patient history of positive response to (One) Venlafaxine, it would be a good option. A dose of 450 mg XR will be right. Venlafaxine releases O-desmethyanlafaxine that inhibits serotonin and dopamine from being reuptake. Monitoring of blood pressure is crucial especially Americans of African origin because there is an increased risk of hypertension. This will be a better choice because of the previous positive response.
In treating depression that is resistant in nature, lurasidone is an option. This from 20 mg-120mg daily.CYP450 metabolizes it so it is prudent to ascertain that the patient has that particular enzyme. A psychosis symptom is a result of the antagonistic nature of benzothiazole which is highly attracted to dopamine-2 to serotonin improving psychosis symptoms. It can also be an option because the patient is giving up on life.

Learnt Lessons and Check Points

The Patience responded to venlafaxine at a higher dose. At 60 years of age, there is resistance to treatment by the patient. There is evidence of bouts of ECT that had significant side effects with time which later on reduced. Based on this, I would avoid more ECT therapy. It is essential to obtain blood levels regularly to help in the titration of ineffective dosages administered to the patient. Routine blood work from the previous caregiver of the patient would have aided in reducing the current suffering of the patient. It is always important to always try until a patient responds positively and not give up on them.

References

Yasuda SU, Zhang L, and Huang SM (2008).The Role of Ethnicity in Variability in Response to Drugs: Focus on Clinical Pharmacology Studies 84 (3) Doi: 10.1038/clpt.2008.141

Howland R H (2008). Sequenced Treatment Alternatives to Relieve Depression: Journal of Psychosocial Nursing 46(9)

Howland R H, (2008). Sequenced Treatment Alternatives to Relieve Depression: Study Outcomes. Journal of Psychosocial Nursing • 46(10)

PATIENT FILE The Case: The depressed man who thought he was out of options. http://stahlonline.cambridge.org

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