Paper Example on Overcoming MDD: A Patient's Journey & Evidence-Based Strategies

Introduction

Major depression disorder (MDD), or clinical depression, is a mood disorder characterized by persistent sadness and loss of interest. It affects how the person behaves, thinks, and feels and causes various physical and emotional problems. The disorder affects an individual's day to day activities such that the person finds it difficult to eat, work, sleep, study, and enjoy with friends. Below is an overview of an actual scenario of a major depressive disorder patient as well as evidence-based guidelines on the disorder's psychopharmacologic management.

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Overview of Initial Physical Clinical Assessment

Patient Mildred Macdonald was a 63 years old woman referred by a social worker at the senior citizen community center due to possible depression. Patient says, "I am tired of the people at the community center, and I prefer staying on the bed." The patient has lately changed from been extroverted and extremely sociable to been withdrawn and quiet. The patient says, "I have difficulty sleeping at night," she tosses and turns, and when she does fall asleep, she always wakes up very early in the morning. The patient says that she feels as if she does not have the energy to do things anymore. The patient says that her appetite has decreased is not sure whether she has lost weight or not. The patient does not feel like cooking anymore. The patient has difficulty concentrating. The patient feels sad, hopeless, and worthless. She states that her husband of 35 years has left her, and she has no children since her three-year-old son died 32 years ago. The patient has little hopes for her future, and she states that she has a bottle of pills at home.

Patients History

The patient has a known psychiatric history. She was once hospitalized for some psychiatric reasons and attempted suicide after losing her three-year-old son. Except for the incidence where she was hospitalized for taking pills, there is no other incidence of drug abuse, and she does not smoke or take alcohol. There are no reports of major depressive disorder or any other psychological disorder in the patient's family history. The patient is divorced and has no children.

Mental Status Exam (MSE)

Upon examination, the patient was cooperative but often irritable and indifferent when responding to the questions. The patient showed no eye contact throughout the interview, and her voice was low, especially when talking about sensitive issues. The patient was tearful with a paucity of speech. Her mood was labile and depressed; her affect was blunted, and her movements were sluggish. The patient had a linear thought process and had unstable thought content. The patient admitted to having very little hope for the future. The patient has poor concentration; she was also withdrawn and quiet and felt tired about the other people around her. The patient showed a lack of motivation and preferred spending most of her time in bed. The patient had difficulty sleeping at night.

Interview Questions

Questions helpful in diagnosing the major depressive disorder include; what has brought you here today? Do you have frequent or recurrent thoughts of death or wanting to take your life? How is your sleep? How is your appetite? Do you have trouble concentrating, thinking, or remembering things? Do you have feelings of hopelessness, emptiness, tearful, or sadness? How is your mood? Do you still have interest or pleasure in most of the normal activities like hobbies? Have you ever been treated for any psychiatric problem, either outpatient or inpatient, if yes, where, when, and what pharmacologic and therapy was used? What medications did you take in the past? If yes, what is the name and dose, and is there noncompliance? Have you ever used recreational drugs or alcohol? If yes, what, how much, and when was it last taken? Ask about family psychiatric and medical history. Ask about occupation, social status, relationships, job history, and living situations. Ask about current stressors, the best period of one's life, and stress overcome in the past and the coping mechanisms.

Diagnosis of Major Depressive Disorder

Gelenberg et al.,2010 argue that the diagnostic criteria for MDD as per the American Psychological Association include; (anhedonia), which refers to decreased or loss of interest and pleasure in usual activities. Significant appetite disturbance and weight change. Psychomotor retardation or agitation and sleep disturbances (hypersomnia and insomnia). In Mildred's case, the patient had been withdrawn and quiet, she had sleep problems and lacked motivation. Additionally, the patient had decreased appetite, difficulty concentrating, often felt sad, worthless, and hopeless. The patient had little hope for the future, had suicidal ideations, blunted affect, and was tearful.

Stage I Initial Visit: Monotherapy

The first-line treatment for MDD is the SSRIs drugs, which include; fluvoxamine, paroxetine sertraline, escitalopram, citalopram, and fluoxetine. The SSRIs drugs work by blocking the reuptake of serotonin selectively to improve the serotonin in the brain synapses(Meyer & Quenzer, 2019). Some of the treatments which can be used in patients who have difficulties in responding to the initial SSRIs include; change of medication class, switch to different SSRIs drugs or switch to CBT. There is greater effectiveness in switching to SNRI like venlafaxine compared to paroxetine, fluoxetine, or citalopram.

In the patient's scenario, the first line of managing the MDD will be administering citalopram 20mg. The drug has been found to very effective in managing the symptoms associated with MDD like mood changes. The patient will have to take the medication once a day with or without eating, and since she has some trouble sleeping, it would be advisable that she takes the drug in the morning. This medication can have some disabling side effects like some problems with concentration, increased sweating and dry mouth, numbness and tingling, insomnia, and feeling shaky(Meyer & Quenzer, 2019). Effective and careful management of these side effects is a core aspect of managing MDD. The effectiveness of this medication is to be reviewed within four weeks after the initial therapy. After four weeks, titration of the citalopram 20mg was done increased and increased to a maximum of 40mg.

Stage 2: Non-Responder to Stage 1

The patient was observed on the citalopram 20mg and citalopram 40mg dose for two to six weeks. The patient showed no response to treatment in the above mentioned period. Then venlafaxine medication was given and improved to 75mg daily. The drug was to be taken through the mouth 2 to 3 times daily with food and was to be taken the same time every day(Meyer & Quenzer, 2019). This drug is effective since it improves patients' energy levels and mood and restores interest and motivation for daily living. It restores the balance between norepinephrine and serotonin in the brain. The drug's side effect include yawning, vision changes, increased sweating, nausea, and changes in appetite. These symptoms can typically go away within some weeks.

Labs and Test

After 20 weeks, the venlafaxine levels were done. This lab was opted before making the decision to pursue ECT. The lab is necessary since it has less invasiveness; it is not that costly and has no side effects like which the patient was going through then. After the lab, it was discovered that despite the fact the patient's mood was still low, there was a general increase in aphasia and mood.

Stage 3: Partial-Responder to Stage 2: Titration up

The venlafaxine medication was increased to 225mg, and there was an increase in aripiprazole to 15mg. By the time the treatment reached week 28, labs were done, and the level of venlafaxine on the 225mg dosage was done. The dosage was therefore added to 300mg and also 600mg, which was administered in heroic cases(Meyer & Quenzer, 2019). The aripiprazole got discontinued because the venlafaxine was still not at a therapeutic level.

Stage 4: Non-Responder to Stage 3

By week 32, the patient did not show any response, and therefore another blood sample from the patient was drawn. At the 36th week into the treatment, the level decreased on the 300mg dosage and was thus improved to 375mg(Meyer & Quenzer, 2019).On checking the patient's blood pressure, it appeared excellent, and she did not have side effects. The dosage increment had brought about some improvements. The dosage was then increased to 450mg, and on checking the levels by week 40, the patient mood had improved, and she was more hopeful. Patients' lab levels were now at the less therapeutic range. At the dosage of 450mg, she was still at the required dosage in incidences of the heroic case, and she was perfectly tolerating. 75mg, therefore, raised dosage in a day, the level was redrawn, and dosage was raised again to 600 still within the therapeutic range (Meyer & Quenzer, 2019). Based on Mildred's improvement as well as her ability to tolerate the different dosages, that was a good strategy. A lesson learned is that there is a need for the monitoring of therapeutic drug levels. Some causes of low levels are; noncompliance and pharmacokinetic failure, which is due to genetic variants.

References

Gelenberg, A. J., Freeman, M. P., Markowitz, J. C., Rosenbaum, J. F., Thase, M. E., Trivedi, M. H., & Van Rhoads, R. S. (2010). American Psychiatric Association practice guidelines for the treatment of patients with major depressive disorder. Am J Psychiatry, 167(Suppl. 10), 9-118.Retrieved from http://access.oakstone.com/Uploads/Public/PracticeGuidelinefortheTreatmentofPatientsWithMajorDepressiveDisorderAmericanPsychiatricAssociation.pdf

Meyer, J. S., & Quenzer, L. F. (2019). Psychopharmacology: Drugs, the brain, and behavior. Oxford University Press.