Based on the case study, answer the following questions.
Identification of target symptoms/problems:
What information, if any, would you like to know that was not included in the case? This interviewer appeared to follow the PHQ – 9 depression assessment tools, which is sufficient to begin the differential diagnosis (Brown et al., 2020). The interviewer seemed to ascertain the symptoms most important to the patient. She cannot concentrate, meet expectations, enjoy life, sleep, or find the energy to care for herself. Additional medication history, alcohol use, family history, and potential triggers are pertinent to the care plan (Brown et al., 2020). Medications do not mix well with alcohol. Determining how she has used alcohol over the years is essential. She identified alcohol as a critical factor during her suicidal attempt. Her medication history should also include her previous medication adherence (Brown et al., 2020). The history of mental health problems in her family and treatments that worked for first-degree relatives is valuable information to the prescriber (Brown et al., 2020). Patient participation in the medication selection is important. Several factors help narrow the list of potential medications for depression. Such factors include other health conditions, reproductive goals for women, cost, and benefit/risk evaluations for the individual patient (Brown et al., 2020).
Which psychiatric symptoms are a treatment priority for this case? The patient identifies the impact her depressive symptoms have had on her ability to function and relationships. The patient prioritized her lack of energy, sleep difficulties, inability to concentrate, and failure to manage responsibilities as critical needs. The practitioner should also prioritize the patient’s history of suicidal behaviors and alcohol use. Although the patient accessed professional services for her mental health needs, she needed the urging of her family to act on accessing care. During the interview, she describes a previous suicide attempt and alludes to alcohol use during the break–up of her marriage.
What are the non-pharmacologic issues in this case (problems/complaints that cannot be addressed by medication)? This patient reports feeling little self-worth, utilizing limited coping skills, and struggles with intimate relationships, which adds to her sense of hopelessness. Her judgment is concerning. She appears to have friends and family support. Other psychosocial needs should be evaluated by social services to support successful care.
List one medication that would be appropriate for this case. Include the name and starting dose. Escitalopram is a substrate for CYP450 2C19 and 3A4with no significant actions on CYP 450 (Aldrich et al., 2019). With a dosage of 10 mg once daily, steady-state should be reached within a week, and the low dosage should provide some symptom relief within the first 1 – 2 weeks of administration (Aldrich et al., 2019). May take with food.
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. Depression is linked with low levels of serotonin (as well as low levels of dopamine, norepinephrine, and other brain chemicals) (Langmia et al., 2021). When the SSRI is administered, the serotonin reuptake pump is blocked (Stahl, 2013, p.p. 290 – 300). Initially, the somatodendritic area of the serotonin neuron is changed, followed by the 5HT1a autoreceptor desensitizing and downregulating (Stahl, 2013, p.p. 290 – 300). After a delay, 5HT is released in the axon terminal, thus addressing the reduced serotonin associated with depression (Stahl, 2013, p.p. 290 – 300). Postsynaptic desensitization of 5HT may explain the reduction of side – effects were seen in SSRIs over time (Stahl, 2013, p.p. 290 – 300). Escitalopram is a better version of other SSRIs because it used the best effects of s enantiomer while leaving behind the antihistamine properties and weak inhibition of CYP 2D6 (Stahl, 2013, p.p. 290 – 300). The patient is overweight, and her smoking status is unknown. Other antidepressants have potential side – effects that could make adherence to the medication more unlikely or even medically contraindicated, like weight gain (Aldrich et al., 2019). Citalopram and escitalopram have correlations with a longer QT duration than the other medications in this class (Aldrich et al., 2019). Although infrequent, medications that increase serotonin activity may cause serotonin syndrome, especially when taken with MAOIs and linezolid (Aldrich et al., 2019). Financial considerations were researched. Given a comparable occupation in this country, using a medication approved by the Medicaid formulary for a new trial antidepressant is appropriate.
What laboratory testing/monitoring is needed for safely prescribing this medication? An EKG may be an option for patients with cardiac risk factors to monitor for QT prolongation and arrhythmias, weight regularly measured (adverse metabolic changes), and vital signs (Aldrich et al., 2019). In addition, anxiety, insomnia, and sexual dysfunction require regular assessment (Aldrich et al., 2019).
Are there any contraindications or safety issues associated with this medication? Seizure disorder, caution in patients with bipolar disorder, possible serotonin syndrome, and potential activation of suicidal ideation (Aldrich et al., 2019). Should side – effects become intolerable or unsatisfactory, tapering may be done in a short period of time (Langmia et al., 2021). As previously noted, citalopram and escitalopram have an increased risk of cardiotoxicity due to QT prolongation, which can progress to severe arrhythmias (Aldrich et al., 2019). Blackbox warnings increased the risk of suicidal thinking and behavior in children, adolescents, and young adults taking antidepressants for major depressive disorder (MDD) and other psychiatric disorders (Aldrich et al., 2019). Escitalopram oxalate is not approved for use in pediatric patients under 12 years of age (Aldrich et al., 2019).
Non – pharmacological
What non – pharmacological interventions do you recommend? Do you recommend psychotherapy, complementary and holistic therapies? Sunlight therapy, B vitamins, diet, and exercise have shown positive correlations with reduced depression (Ijaz et al., 2018). In a literature review, cognitive-based therapy and omega – 3 showed positive results for treating depression (Hallahan et al., 2016).
What are the safety concerns, if any, associated with this case? How will you address safety? In addition to the medication complications, the patient recounted a suicidal act during a previous personal crisis. She described an impulsive attempt fueled by alcohol. Regular suicide assessment and freedom of communication among all medical and psychiatric care providers are required to ensure a robust safety plan (Ijaz et al., 2018). She did not reach out for help during that time until now. A suicide prevention plan needs to be a partnership with the patient. Including people, she trusts is critical (Ijaz et al., 2018).
When would you follow – up with the patient? The effect of SSRIs may take up to 6 weeks before the patients feel the effects of treatment (Aldrich et al., 2019). However, if patients tolerate the current dose well, the clinician can consider increasing dosage in 10 – 12 weeks (Aldrich et al., 2019).
List your references.
Aldrich, S. L., Poweleit, E. A., Prows, C. A., Martin, L. J., Strawn, J. R., & Ramsey, L. B. (2019). Influence of CYP2C19 metabolizer status on escitalopram/citalopram tolerability and response in youth with anxiety and depressive disorders. Frontiers in Pharmacology, 10, 99. https://doi.org/10.3389/fphar.2019.00099
Brown, M. J., Adams, S. M., Vanderhoef, D., Schipani, R., & Taylor, A. (2020). Improving PHQ9 utilization rates in a primary care mental health integration setting. Journal of the American Psychiatric Nurses Association, 26(2), 206– 211.https://doi.org/10.1177/1078390319865331
Hallahan, B., Ryan, T., Hibbeln, J.R., Murray, I.T., Glynn, S., Ramsden, C.E., SanGiovanni, J.P., & Davis, J.M. (September 2016). Efficacy of Omega-3 Highly Unsaturated Fatty Acids in the Treatment of Depression. The British Journal of Psychiatry, 209 (3), 192–201. https://doi.org/10.1192/bjp.bp.114.160242
Ijaz, S., Davies, P., Williams, C.J., Kessler, D., Lewis, G., & Wiles, N. (May 2018). Psychological therapies for treatment-resistant depression in adults. The Cochrane Database of Systematic Reviews. 5(8). https://doi.org/10.1002/14651858.CD010558
Langmia, I. M., Just, K. S., Yamoune, S., Brockmöller, J., Masimirembwa, C., & Stingl, J. C. (2021). CYP2B6 functional variability in drug metabolism and exposure across populations-implication for drug safety, dosing, and individualized therapy. Frontiers in Genetics, 12, 692234. https://doi.org/10.3389/fgene.2021.692234
Stahl, S. (2013). Essential psychopharmacology: Neuroscientific basis and practical applications (4th ed.). Cambridge, England: Cambridge University Press.