The man whose antidepressants stopped working

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

Questions

One of the most effective medical interventions to significantly improve the health of patients doesn’t require the latest technology or expensive medication, but it involves helping them take their existing medicines as prescribed.

When you feel like your depression is under control, do you sometimes stop taking your medicine? The patient discontinued his Effexor although it appeared to be effective. It is essential to find out the patient’s reason for not adhering to prescribed medication and come up with a solution together.

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Taking medication every day is a real inconvenience for some people. Do you ever feel hassled about sticking to your antidepressant? 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. The man whose antidepressants stopped working.

How often do you have difficulty remembering to take your antidepressant medication? Health literacy plays a key role as well. It is difficult for patients to take a medicine when they do not understand why it is prescribed, what conditions or diseases it treats, or what preventive effects it provides.

As a Nurse practitioner, when patients reveal nonadherence, it is essential to assure them that it is a positive step that they felt comfortable talking about it.  Emphasis should be on collaboration to identify the challenges and decide how to achieve mutually agreed-upon goals (Brown, & Bussell, 2011).

Family

The patient is married, the questions I would ask the wife specifically,

Do you know what medication your husband is taking? And do you know why he is taking it? Family support is vital in patients with depression, in situations when patients forget or are not motivated to take the medication. What side effects is the patient experiencing? The patient’s family may notice symptoms that the patient is not reporting that may need to be addressed. The man whose antidepressants stopped working.

Physical examination and diagnostic tests

Appearance and affect

Most patients with major depressive disorder present with a normal appearance. In patients with more severe symptoms, a decline in grooming and hygiene can be observed, as well as a change in weight. Patients may show psychomotor retardation, which manifests as a slowing or loss of spontaneous movement and reactivity, as well as demonstrate a flattening or loss of reactivity in the patient’s affect, i.e., emotional expression (Halverson,2018).

Speech may be normal, slow, monotonic, or lacking in spontaneity and content. Pressured speech may suggest anxiety or mania, whereas disorganized speech should prompt an evaluation for psychosis. Racing thoughts could also be an indication of anxiety, mania, or hypomania (Halverson, 2018).

These laboratory studies might include the following: Complete blood cell (CBC) count, thyroid-stimulating hormone (TSH), Vitamin B-12, Dexamethasone suppression test (Cushing disease, but also positive in depression), Electrolytes, including calcium, phosphate, and magnesium levels (Halverson,2018) The man whose antidepressants stopped working.

Differential diagnosis

Hypothyroidism:  is often associated with altered cognitive function and depression. The patient is experiencing psychomotor retardation, fatigue, and sluggishness, all of that may cause depression.

Manic-depressive episode

Hyperthyroidism

Pharmacological agents and dosing

Add Seroquel as an augment.  Seroquel is also used together with antidepressant medications to treat major depressive disorder in adults (Drugs, com, 2018). Seroquel 50 mg/day and increased the dose as recommended in increments of 50 mg/day depending on the clinical response and tolerability of the patient up to 300 mg a day (Drugs.com, 2018). 1st day 50 mg, 2nd day 100 mg, 3rd day 200 mg and 4th day 300 mg (Drugs.com 2018). According to drugs.com (2018). Seroquel acts on numerous receptors in the brain to calm and help diminish psychotic thoughts. It is can also be used in addition to antidepressants and anxiety (Drugs.com, 2018). It may be beneficial for this patient because of the patient’s anxiety and sleep difficulties. Patients on Seroquel show improvement within one week although it may take several weeks for behavior and cognition to stabilize (Stahl, 2013).

Increase Buspirone to 60 mg/day, 30 mg in the morning and 30 mg in at bed time. BuSpar is used to treat symptoms of anxiety (Drugs.com, 2018). Certain people respond well to lower doses, while others require higher dosages to get a good effect. In this particular case, the patient is on a low dose; dose may need to be increased for a therapeutic effect The man whose antidepressants stopped working.

Contraindications

There are no specific contraindications related to ethnicity in buspirone but, the CNS effects in any individual patient affects function. Therefore, individuals may not operate machinery or automobile (drugs.com, 2018).

No specific contraindication related to ethnicity that I found with Seroquel, but Anaphylactic reactions have been reported in patients treated with Seroquel. Therefore, Seroquel should not be used in patients hypersensitive to quetiapine (Drugs.com, 2018).

Check points

The patient needs to follow up in 4 weeks to check on symptom improvement and a blood pressure check due to Seroquel. Quetiapine may cause a lowering of blood pressure when rising from a sitting or lying position, or a racing heart rate (Stahl, 2013). Another follow up check is for fasting plasma glucose, fasting lipids within three months and then annually, but earlier and more frequently if the patient has gained more than 5% of initial weight (Stahl, 2013).

Taper off Ativan to 1 mg daily for one week, 0.5 mg daily for one week then discontinue medication to prevent withdrawal symptoms.  The man whose antidepressants stopped working Ativan needs to be discontinued because of its sedation effects. With added Seroquel and clonazepam on medication list, the patient does not need another sedative to the regimen. Another reason to discontinue Ativan is, can intensify cognitive slowing, cause dependence and produce changes in equilibrium that can contribute to increased risk of falls and fractures. Long-term use can lead to habituation and dependence (drug.com, 2018).

Lessons learned

Ethnic or regional differences can potentially contribute to differences in drug response (Yasundu, Zhang, & Huang, 2008). As a nurse practitioner, application of this information will be one factor that can contribute to the consideration of the risk-benefit ratio of drug therapy in a specific patient (Yasundu et al., 2008).

Major depression seems to be a recurrent illness that needs to be managed like any other chronic disease such as diabetes. Therefore, the patient may need to stay on an antidepressant for the rest of their life. And at the point of resistance, patients may need their medications augmented with other antidepressants.

Along with medications, talk therapy like cognitive-behavioral, psychodynamic, and interpersonal therapy is one of the first approaches that a person with treatment-resistant depression might try (Griffin, 2018).

Research has shown that therapy can help with treatment-resistant depression specifically. The best evidence is with cognitive-behavioral therapy (CBT), which encourages people to see how their thoughts and behaviors contribute to their depression (Griffin, 2018). The man whose antidepressants stopped working.

References

Brown, M. T., & Bussell, J. K. (2011). Medication Adherence: WHO Cares? Mayo Clinic Proceedings, 86(4), 304–314. http://doi.org/10.4065/mcp.2010.0575

Daly, E. J., & Trivedi, M. H. (2007). A review of quetiapine in combination with antidepressant therapy in patients with depression. Neuropsychiatric Disease and Treatment, 3(6), 855–867.

Drugs.com, (2018) Buspirone. Retrieved from https://www.drugs.com/buspar.html

Drugs.com, (2018). Seroquel. Retrieved from  https://www.drugs.com/tips/seroquel-patient-tips

Halverson, L. J (2018). Depression. Retrieved from https://emedicine.medscape.com/article/286759-overview

Griffin, R. M (2018). Treatment-Resistant Depression: Your Continuum of Care. Retrieved from https://www.webmd.com/depression/features/treatment-resistant-depression-your-continuum-of-care#1 The man whose antidepressants stopped working

Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (4th ed.). New York, NY: Cambridge University Press

Yasundu, 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 & Therapeuticsm, 84(3). 417-423. Retrieved from https://web.archive.org/web/20170809004704/https://www.fda.gov/downloads/Drugs/ScienceResearch/…/UCM085502.pdf The man whose antidepressants stopped working

Hi Mary,

Great discussion this week, I agree nurse practitioners must be aware of the risks of antidepressant resistance in some patients, then treat patients accordingly. Treatment-resistant depression can leave patients feeling hopeless and discouraged and demoralized because they are not getting any better.  Patients with the diagnosis of severe depression Electroconvulsive Therapy (ECT) can be a life-changing procedure. According to Miller, (2017), medications have a success rate of 50-60% of patients getting better, while ECT succeeds at a rate of 70-90%. ECT also works faster; medications typically take up to eight weeks to show improvement, while with ECT, patients start feeling better in two weeks or less (Miller, 2017).  Pop culture has long represented the procedure as painful and involuntary, most notably in Ken Kesey’s novel-turned-film “One Flew Over the Cuckoo’s Nest,” in which ECT was performed without anesthesia. Fortunately, the stigma has begun to fade away, perhaps due in part to endorsement by public figures such as Kitty Dukakis and the late Carrie Fisher, who both experienced personal success with ECT (Familydoctor.org, 2017). I believe in inviting family members into the procedure room helps to reduce the stigma and fear. Also continues to break down misunderstanding and advocate for this life-saving treatment in patients for whom multiple medications have failed. And when it comes to suicidality, its effectiveness can mean the difference between life and death. The man whose antidepressants stopped working

References

Familydoctor.org, (2017). Electroconvulsive Therapy (ECT). Retrieved from https://familydoctor.org/how-electroconvulsive-therapy-works/

Miller. S. (2017). Treating Mental Illness with Electroconvulsive Therapy. Retrieved from https://healthcare.utah.edu/healthfeed/postings/2017/02/ect.php

Reply # 2

Hi

Thank you for a great discussion this week. The patient continues to have the depression after remission. He may also benefit from cytochrome P450 (CYP450) tests to help determine how the body metabolizes a drug (Mayoclinic, 2018). The human body uses cytochrome P450 enzymes to process medications. The variations in these enzymes, medications may affect each person differently (Mayoclinic, 2011) The man whose antidepressants stopped working.

Drug-gene testing also called pharmacogenomics or pharmacogenetics is the study of how genes affect the body’s response to medication (CDC,2011). The test looks for changes or variations in the genes that determine whether a drug could be an effective treatment for or whether the patient could have side effects from a specific medication (Mayoclinic,2018).

The cytochrome P450 enzyme includes the CYP2D6 enzyme, which processes many antidepressants and antipsychotic medications. By checking DNA for certain gene variations, CYP450 tests can offer clues about how the body may respond to a particular antidepressant. CYP450 tests can also identify changes in other enzymes, such as the CYP2C19 enzyme (Mayoclinic, 2018). The man whose antidepressants stopped working.

Genotyping tests, such as cytochrome P450 tests, may speed up the identification of medications that are more likely to be better processed by the body. Ideally, better processing would lead to fewer side effects and improved effectiveness (Mayoclinic, 2018).

References

Center for Disease Control and Prevention, (CDC). CYP450 Genotyping to Predict Response to SSRIs Used to Treat Non-psychotic Depression in Adults: EGAPP Recommendation. Retrieved from https://www.cdc.gov/genomics/gtesting/egapp/recommend/cyp450.htm.

Mayoclinic, (2018) Cytochrome P450 (CYP450) tests. Retrieved from  https://www.mayoclinic.org/tests-procedures/cyp450-test/about/pac-20393711 The man whose antidepressants stopped working