Discussion: The Impact of Ethnicity on Antidepressant Therapy – The depressed man who thought he was out of options – Adult and Geriatric Antidepressant Therapy essay assignment discussion
Week 3: Adult and Geriatric Antidepressant Therapy
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Discussion: The Impact of Ethnicity on Antidepressant Therapy
Major depressive disorder is one of the most prevalent disorders you will see in clinical practice. Treatment for this disorder, however, can vary greatly depending on client factors, such as ethnicity and culture. As a psychiatric mental health professional, you must understand the influence of these factors to select appropriate psychopharmacologic interventions. For this Discussion, consider how you might assess and treat the individuals in the case studies based on the provided client factors, including ethnicity and culture. Discussion: The Impact of Ethnicity on Antidepressant Therapy – The depressed man who thought he was out of options – Adult and Geriatric Antidepressant Therapy essay assignment discussion
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To prepare for this Discussion:
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)
SELECT CASE #3- VOLUME 1- CASE #29 ON STAHL’S ONLINE WEBSITE ABOVE
• Review this week’s Learning Resources and reflect on the insights they provide.
• Go to the Stahl Online website and examine the case study you were assigned ( CASE #3) AS ATTACHED SEPARATELY. .
• Take the pretest for the case study.
• Review the patient intake documentation, psychiatric history, patient file, medication history, etc. As you progress through each section, formulate a list of questions that you might ask the patient if he or she were in your office.
• Based on the patient’s case history, consider other people in his or her life that you would need to speak to or get feedback from (i.e., family members, teachers, nursing home aides, etc.). Discussion: The Impact of Ethnicity on Antidepressant Therapy – The depressed man who thought he was out of options – Adult and Geriatric Antidepressant Therapy essay assignment discussion
• Consider whether any additional physical exams or diagnostic testing may be necessary for the patient.
• Develop a differential diagnoses for the patient. Refer to the DSM-5 in this week’s Learning Resources for guidance.
• Review the patient’s past and current medications. Refer to Stahl’s Prescriber’s Guide and consider medications you might select for this patient.
• Review the posttest for the case study.
QUESTION
Post a response to the following:
• Provide the case number in the subject line of the Discussion thread.
• List three questions you might ask the patient if he or she were in your office. Provide a rationale for why you might ask these questions.
• Identify people in the patient’s life you would need to speak to or get feedback from to further assess the patient’s situation. Include specific questions you might ask these people and why.
• Explain what physical exams and diagnostic tests would be appropriate for the patient and how the results would be used. Discussion: The Impact of Ethnicity on Antidepressant Therapy – The depressed man who thought he was out of options – Adult and Geriatric Antidepressant Therapy essay assignment discussion.
• List three differential diagnoses for the patient. Identify the one that you think is most likely and explain why.
• List two pharmacologic agents and their dosing that would be appropriate for the patient’s antidepressant therapy based on pharmacokinetics and pharmacodynamics. From a mechanism of action perspective, provide a rationale for why you might choose one agent over the other.
• For the drug therapy you select, identify any contraindications to use or alterations in dosing that may need to be considered based on the client’s ethnicity. Discuss why the contraindication/alteration you identify exists. That is, what would be problematic with the use of this drug in individuals of other ethnicities?
• If your assigned case includes “check points” (i.e., follow-up data at week 4, 8, 12, etc.), indicate any therapeutic changes that you might make based on the data provided.
Discussion: The Impact of Ethnicity on Antidepressant Therapy – The depressed man who thought he was out of options – Adult and Geriatric Antidepressant Therapy essay assignment discussion
• Explain “lessons learned” from this case study, including how you might apply this case to your own practice when providing care to patients with similar clinical presentations
Week 3: Adult and Geriatric Antidepressant Therapy
The National Institute of Mental Health estimates that approximately 15.7 million adults in the United States have depression (NIMH, 2014), making depression one of the most common disorders you will treat in practice. Although this disorder is so prevalent, antidepressant therapy must be as unique as each individual you treat. There are dozens of antidepressant medications on the market, and you must be able to identify which medication or combinations of medications will result in the best outcomes for your clients.
This week, as you study antidepressant therapies, you examine the assessment and treatment of clients with mood disorders. You also explore ethical and legal implications of these therapies. Discussion: The Impact of Ethnicity on Antidepressant Therapy – The depressed man who thought he was out of options – Adult and Geriatric Antidepressant Therapy essay assignment discussion
Photo Credit: Comstock Images/Getty Images
Discussion: The Impact of Ethnicity on Antidepressant Therapy
Major depressive disorder is one of the most prevalent disorders you will see in clinical practice. Treatment for this disorder, however, can vary greatly depending on client factors, such as ethnicity and culture. As a psychiatric mental health professional, you must understand the influence of these factors to select appropriate psychopharmacologic interventions. For this Discussion, consider how you might assess and treat the individuals in the case studies based on the provided client factors, including ethnicity and culture.
To prepare for this Discussion:
Note:
By Day 1 of this week, your Instructor will have assigned you to one of the following case studies to review for this Discussion. To access the following case studies, click on the Case Studies tab on the Stahl Online website and select the appropriate volume and case number.
Case 1:
Volume 1, Case #1: The man whose antidepressants stopped working
Case 2:
Volume 1, Case #7: The case of physician do not heal thyself
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? Discussion: The Impact of Ethnicity on Antidepressant Therapy – The depressed man who thought he was out of options – Adult and Geriatric Antidepressant Therapy essay assignment discussion
The Dilemma:
What do you do when even ECT and MAOIs do not work)
Review this week’s Learning Resources and reflect on the insights they provide.
Go to the Stahl Online website and examine the case study you were assigned.
Take the pretest for the case study.
Review the patient intake documentation, psychiatric history, patient file, medication history, etc. As you progress through each section, formulate a list of questions that you might ask the patient if he or she were in your office.
Based on the patient’s case history, consider other people in his or her life that you would need to speak to or get feedback from (i.e., family members, teachers, nursing home aides, etc.).
Consider whether any additional physical exams or diagnostic testing may be necessary for the patient.
Develop a differential diagnoses for the patient. Refer to the DSM-5 in this week’s Learning Resources for guidance. Discussion: The Impact of Ethnicity on Antidepressant Therapy – The depressed man who thought he was out of options – Adult and Geriatric Antidepressant Therapy essay assignment discussion
Review the patient’s past and current medications. Refer to Stahl’s Prescriber’s Guide and consider medications you might select for this patient.
Review the posttest for the case study.
Note:
For this Discussion, you are required to complete your initial post before you will be able to view and respond to your colleagues’ postings. Discussion: The Impact of Ethnicity on Antidepressant Therapy – The depressed man who thought he was out of options – Adult and Geriatric Antidepressant Therapy essay assignment discussion. Begin by clicking on the “Post to Discussion Question” link and then select “Create Thread” to complete your initial post. Remember, once you click on Submit, you cannot delete or edit your own posts, and you cannot post anonymously. Please check your post carefully before clicking on
Submit!
By Day 3
Post
a response to the following:
Provide the case number in the subject line of the Discussion thread.
List three questions you might ask the patient if he or she were in your office. Provide a rationale for why you might ask these questions.
Identify people in the patient’s life you would need to speak to or get feedback from to further assess the patient’s situation. Include specific questions you might ask these people and why.
Explain what physical exams and diagnostic tests would be appropriate for the patient and how the results would be used.
List three differential diagnoses for the patient. Identify the one that you think is most likely and explain why.
List two pharmacologic agents and their dosing that would be appropriate for the patient’s antidepressant therapy based on pharmacokinetics and pharmacodynamics. Discussion: The Impact of Ethnicity on Antidepressant Therapy – The depressed man who thought he was out of options – Adult and Geriatric Antidepressant Therapy essay assignment discussion. From a mechanism of action perspective, provide a rationale for why you might choose one agent over the other.
For the drug therapy you select, identify any contraindications to use or alterations in dosing that may need to be considered based on the client’s ethnicity. Discuss why the contraindication/alteration you identify exists. That is, what would be problematic with the use of this drug in individuals of other ethnicities?
If your assigned case includes “check points” (i.e., follow-up data at week 4, 8, 12, etc.), indicate any therapeutic changes that you might make based on the data provided.
Explain “lessons learned” from this case study, including how you might apply this case to your own practice when providing care to patients with similar clinical presentations
Read
a selection of your colleagues’ responses.
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. Discussion: The Impact of Ethnicity on Antidepressant Therapy – The depressed man who thought he was out of options – Adult and Geriatric Antidepressant Therapy essay assignment discussion.
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.
Learning Objectives
Students will:
Assess client factors and history to develop personalized plans of antidepressant therapy for adult and geriatric clients
Analyze factors that influence pharmacokinetic and pharmacodynamic processes in adult and geriatric clients requiring antidepressant therapy
Analyze the impact of ethnicity on antidepressant therapy
Evaluate efficacy of treatment plans
Apply knowledge of providing care to adult and geriatric clients presenting for antidepressant therapy
Adult and Geriatric Antidepressant Therapy
Student’s Name
Institutional Affiliations
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Adult and Geriatric Antidepressant Therapy
Case 3: Volume 1, Case #29: The depressed man who thought he was out of options
Treating adults and geriatric patients with a major depressive disorder can be very challenging due to variations in patient factors such as culture and ethnicity Discussion: The Impact of Ethnicity on Antidepressant Therapy – The depressed man who thought he was out of options – Adult and Geriatric Antidepressant Therapy essay assignment discussion. Therefore, for the mental health professionals to select the most appropriate interventions for such patients, they must have a comprehensive understanding of the influence of specific client factors on drug response (Stahl, 2013). The given case study describes the treatment process for a 69-year-old man who presents with depressive symptoms. If the patient was in my office, I would ask him three pertinent questions as part of history taking. First, I would ask him to explain the specific signs and symptoms that he has been having and for what period of time. Second, I would want to know whether any of his family members have suffered depression before. Third, I would ask about the types of drugs he is using at the moment. The rationale for why I might ask these questions is that knowledge of the patient’s symptoms, family medical history, and of the drugs he is using is very crucial for the selection of the most appropriate intervention for him (Stahl, 2013).
The patient’s wife, one of his children, and the clinician who has been providing care to him act as very good sources of information to allow a further assessment of his situation. The patient’s wife and child would be asked if they have noticed any changes in his behavior in the recent past. The clinician would be asked whether the patient has been responding positively to drugs. The physical exams that would be appropriate for the child include obtaining his weight, blood pressure, body mass index, body temperature, and pulse rate. The most appropriate diagnostic test is performing a magnetic resonance imaging (MRI) to assess brain function. The results of these tests will be used to determine the severity of the patient’s condition (Stahl, 2013).
Based on the client’s symptoms, the three differential diagnoses for him include major depressive disorder, bipolar disorder, and adjustment disorder with depressed mood. I think the most likely diagnosis for him is a major depressive disorder. The reason is that the patient is severely demoralized, depressed, worthless, helpless, hopeless, and has difficulty in concentrating (American Psychiatric Association, 2013). Discussion: The Impact of Ethnicity on Antidepressant Therapy – The depressed man who thought he was out of options – Adult and Geriatric Antidepressant Therapy essay assignment discussion Based on pharmacokinetics and pharmacodynamics, the two pharmacologic agents for the patient’s antidepressant therapy are desvenlafaxine and venlafaxine at a dosage of up to 200 mg for the former and a dosing higher than 375 mg for the latter (Stahl, 2014b). From the pharmacokinetic perspective, I would choose venlafaxine over desvenlafaxine because the former drug would be metabolized faster than the latter thereby making it more effective in relieving symptoms (Stahl, 2014b; Howland, 2008a).
Based on the client’s ethnicity, the healthcare professional should not use tricyclic antidepressant (TCA) and monoamine oxidase inhibitors (MAOI) which are effective in treating patients from other cultures. Rather, the clinician must be careful to use high doses of venlafaxine if positive results are to be realized. The reason is that the patient in the given case study is resistant to TCA and MAOI. The use of high doses of venlafaxine in individuals of other ethnicities may complicate symptoms instead (Yasuda et al., 2008; Stahl, 2014b).
Based on the data provided, I would augment MAOI with a stimulant at week 20 and obtain blood level of venlafaxine while at the same time avoiding the administration of Aripiprazole at week 24. In the cases study, the named proposals have been ignored by the clinician, a factor that has delayed the patient’s recovery process (Stahl, 2013). The two lessons that have been learned from the case study are that ethnicity and culture have a great influence on some episodes of depression, and high doses of venlafaxine should be used when an electroconvulsive therapy (ECT) and MAOI have proven to be ineffective. Therefore, when providing care to patients with similar symptoms in future, I will consider a therapeutic drug monitoring earlier in the treatment. Besides, I will consider genetic testing, particularly in children and geriatric patients who might seem to be resistant to commonly used drugs. Discussion: The Impact of Ethnicity on Antidepressant Therapy – The depressed man who thought he was out of options – Adult and Geriatric Antidepressant Therapy essay assignment discussion.
References
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.
American Psychiatric Association. (2013).
Diagnostic and statistical manual of mental disorders
(5th ed.). Washington, DC: Author. Discussion: The Impact of Ethnicity on Antidepressant Therapy – The depressed man who thought he was out of options – Adult and Geriatric Antidepressant Therapy essay assignment discussion.
Howland, R. H. (2008a). Sequenced treatment alternatives to relieve depression (STAR*D). Part 2: Study outcomes.
Journal of Psychosocial Nursing and Mental Health Services, 46
(19), 21–24. doi:10.3928/02793695-20081001-05
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), 417–423. Retrieved from https://web.archive.org/web/20170809004704/https://www.fda.gov/downloads/Drugs/ScienceResearch/…/UCM085502.pdf
PATIENT FILE
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?
Pretest Self Assessment Question (answer at the end of the case)
If a patient has low blood levels of an antidepressant at standard doses,
what could this mean?Adult and Geriatric Antidepressant Therapy Essay
A. Pharmacokinetic failure
B. Genetic variant causing pharmacokinetic failure
C. Pharmacodynamic failure
D. Genetic variant causing pharmacodynamic failure
E. Noncompliance
Patient Intake
• 69-year-old man
• Chief complaint: unremitting, chronic depression
Psychiatric History
• Recurrent, unipolar major depressive episodes for the past 40 years,
with good response to treatment and good inter-episode recovery
until fi ve years ago
• Onset then of one long, waxing and waning major depressive episode
ever since
• Five years ago, relapsed on venlafaxine 225 mg after having had a
good response to it
• Two years ago had nine electroconvulsive therapy (ECT) treatments
with a partial response
• In the past few years since relapse on venlafaxine has tried
(adequate trials, no severe side effects)Adult and Geriatric Antidepressant Therapy Essay. essentially every known
antidepressant and augmentation combination known or reported
in the literature, from many capable psychiatrists and numerous
consultations from local, regional, and national psychiatrists, and
distinguished medical centers
– 5 SSRIs
– Duloxetine
– Mitazapine
– 2 TCAs
– Augmentation with 5 different atypical antipsychotics
– Augmentation with
– Lithium
– Thyroid
– Buspirone
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PATIENT FILE
324
– L-methylfolate
– Others
• Following ECT, given the MAOI phenelzine (Nardil) up to 105 mg/day
with some orthostasis, some antidepressant response, wearing off
despite increasing doses, and then all response to phenelzine wore
off
• Trials even included the controversial and heroic combination of an
monoamine oxidase inhibitor (MAOI) and a tricyclic antidepressant
(TCA) phenelzine plus nortriptyline, all ineffective
• Came to you on phenelzine 90 mg, nortriptyline 50 mg, and
occasional lorazepam, for your treatment recommendations
Medical History
• Not contributory
• Other medications:
– Boniva for osteoporosis
– Avapro for hypertension
– Lipitor for hypercholesterolemia
– Flomax for enlarged prostate
– Melloxicam for arthritis
Social and Personal History
• Married, 3 children, 8 grandchildren
• Retired engineer
• Non smoker, no drug or alcohol abuse
Family History
• Several fi rst degree relatives: depression
• No family history of suicide
Patient Intake
• Severely depressed and demoralized
• No joy or pleasure; sad, feeling helpless, hopeless, worthless,
problems concentrating
• Past two years rates himself 9/10 in severity (10 worst)
• Wife states he is letting go and giving up
Of the following choices, what would you do?
• Add one of the new antipsychotics, asenapine, iloperidone or
lurasidone that he has not taken yet
• Augment the MAOI with a stimulant, which is one of the few
combinations he has not tried yet
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PATIENT FILE
325
• Discontinue the nortriptyline and augment the MAOI
• Discontinue the MAOI and augment the nortriptyline
• Discontinue both the TCA and the MAOI and prescribe something else
• Send to another psychopharmacologist; this patient is too sick and
the prognosis is poor
• Do a complete medical and endocrine and neurological evaluation to
see if any underlying condition has developed that has been missed
• Look into personal and family dynamics to see if this is really a
resistant depression disguising other problems
• None of the above
Further Investigation
Is there anything else you would especially like to know about this
patient?
• What about details concerning his medical and neurological status?
– During the past year the patient has had extensive medical,
endocrine and cancer workups, all negative
– During the past year has also had neurological evaluation, with
normal EEG, MRI
– Neuropsychological tests consistent with severe depression but
without signs of an early dementia
• What about personal and family dynamics?
– Patient and family are indeed quite concerned about his
depression, fearing he will die before he recovers
– Patient has a long standing supportive marriage and supportive
children and no major fi nancial problems
– Has coped with recurrent episodes of depression his whole
life, bouncing back after each setback, but now has given up,
frightening his family
– No obvious reason to suspect family or personal dynamics as the
source of his depression
– However, he does have extreme negativity and a cognitive
approach may be useful if he begins to get enough motivation to
participate in this approach
If you would give or refer him for an experimental or “off label” protocol,
test or treatment, which would you choose?
• Intravenous single injection of ketamine (NMDA N-methyl-d-aspartate
antagonist) in an experimental protocol
• Send him for experimental DBS (deep brain stimulation)
• Oral riluzole (putative inhibitor of glutamate release)
• Acetylcholinesterase inhibitor in case this is really early dementia
• Send him for a quantitative EEG
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PATIENT FILE
326Adult and Geriatric Antidepressant Therapy Essay
• Send him for pharmacogenomics testing
• Send him for therapeutic drug monitoring
• I would not prescribe experimental treatments off label, nor send him
for an experimental protocol
Attending Physician’s Mental Notes: Initial Psychiatric
Evaluation
• There are very few remaining treatment options
Acetylcholinesterase inhibitor
• No evidence of dementia
• Treatment seems a long shot for his depression
TMS
• The patient may be a candidate for TMS
• However, TMS is not well documented to work in a case this severe,
especially in a case with less than robust responses to ECT
DBS
• DBS is a possibility, but only a research protocol, even though it
might save his life
• Only a few centers offer this procedure in the US and Canada
• Unclear how this will be paid as insurance probably does not cover
• However, some promising early results in treatment resistant
depression
• Will tell patient and family and referring psychiatrist about this and
provide literature but not advise action yet
Ketamine
• Intravenous single injection of ketamine is an experimental protocol
• Available as a research test at the NIMH (National Institute of Mental
Health) and a few universities
• A number of studies confi rm effi cacy in treatment resistant major
depression
• However, it only works for a few hours and then wears off and not
practical to repeat it
• Not only ketamine, but several NMDA 2B subtype selective
antagonists (NR2B selective antagonists) are in clinical testing, some
of which are orally administered
• Too early to tell whether this will pan out and not available for open
label administration, only double blind trials
Referenced EEG
• A new type of EEG protocol, referenced EEG reports promising results,
but not in patients this severe and still considered a research tool
• Only available in a limited number of research centers and not proven
to predict clinical response to specifi c antidepressants, especially in a
case like this
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PATIENT FILE
327Adult and Geriatric Antidepressant Therapy Essay
SPECT scans
• Some commercial clinics offer older imaging technology (SPECT is
Single Photon Emission Computed Tomography) as brain scans for sale
• They do generate color pictures of brain activity that can be
impressive looking to patients
• Scans are accompanied with an algorithm claiming to predict which
drug to use
• Although this looks has a high-tech, scientifi c appearance, and raises
hope, it is not well accepted in the scientifi c community and costs
several thousand dollars not covered by insurance
Genotyping
• This approach may be useful in vulnerable populations of patients
such as children or elderly and those who do not respond to many
medications
• Genetic variants of cytochrome P450 (CYP45) drug metabolizing
enzymes can in some cases explain unusually high or unusually low
blood and brain concentrations of drugs:
– 2D6
– 2C19
– 2D9
– Others
– This might be useful here since this patient seems not to respond
to a wide number of medications now, and also has no notable
side effects from them
– Is it possible that his drug levels are low due to a drug
metabolizing enzyme variant, some variant of drug absorption, or
possibly noncompliance?
• Genetic variants of multiple neurotransmitter based genes, upon which
many antidepressants act, may help explain both who responds to what
antidepressant, and who gets side effects from what antidepressant
Phenotyping
• Determining whether a patient has high or low blood levels of a drug
establishes the phenotypes of:
– Poor metabolizers
– Extensive metabolizers
– Compliance/adherence
– Pharmacokinetic variants can explain how he absorbs and
metabolizes his antidepressants and thus measurement of
genetic variants of CYP450 drug metabolizing enzymes may be
helpful in explaining why the patient is not responding, especially
if he does not generate adequate plasma and brain drug levels
(pharmacokinetic)Adult and Geriatric Antidepressant Therapy Essay
• Advised his local treating psychiatrist to augment phenelzine with
stimulant
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PATIENT FILE
328
Attending Physician’s Notes: First Interim Followup, Week 20
• Local/referring psychiatrist declined to augment MAOI with stimulant
as recommended
• Decided instead to give ECT again
• Local/referring psychiatrist thought eleven ECT treatments improved
him 60%
• Stopped MAOI prior to ECT and then started venlafaxine 225 mg/
mirtazapine 30 mg (“California rocket fuel”) as ECT began
• Post ECT, severe subjective memory problems, patient very
discouraged
• Nevertheless, given maintenance ECT; venlafaxine increased to 375
mg and mirtazapine increased to 45 mg
• After ninth maintenance ECT (20th overall), developed an expressive
aphasia, question of a stroke versus a complication of ECT; cardiac
catheterization was normal except for a possible patent foramen ovale
of unknown signifi cance
• Consulting neurologist thought patient’s aphasia was a complication
of ECT
• However, referring psychiatrist thought the patient’s aphasia was due
to a stroke so lowered venlafaxine to 225 mg, being afraid of potential
elevated BP, pulse and further cardiovascular/cerebrovascular
complications
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• BP remained normal and under control; aspirin added to treatment
Case Outcome: First Interim Followup, Week 20
• Phone consultation one month after the post-ECT “event” and 20
weeks since initial evaluation in the offi ce
• Patient was still having memory problems, speech problems, and
worsening depression
• Taking venlafaxine 225 mg, plus mirtazapine 45 mg, plus alprazolam
prn, now augmented with aripiprazole 10 mg
• Before chasing after exotic testing and treatments considered in the
mental notes during the initial psychiatric evaluation 20 weeks ago
(listed above), perhaps it would be a good idea simply to send off
blood for therapeutic drug monitoring to see how well he is absorbing
his venlafaxine and whether there is any room for a rational and safe
dose increase
• Unclear why he is no longer responding to doses of venlafaxine that
have occurred would in the past, but this is frequently observed in the
progression of major depressive episodes over many years
• Specifi cally recommended getting drug levels of venlafaxine and its
active metabolite O-desmethyl-venlafaxine, and consider increasing dose
of venlafaxine XR to 300 mg or 375 mg while monitoring BP and mood
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329Adult and Geriatric Antidepressant Therapy Essay
PATIENT FILE
Case Outcome: Second Interim Followup, Week 24
• Phone consultation in another month showed patient’s aphasia had
resolved and memory improving, but mood still low; mood as bad as it
was prior to ECT
• Seems more clear that aphasia was due to ECT and not to a stroke
• Venlafaxine blood levels not obtained and dose stayed at 225 mg
• Aripiprazole was increased to 15 mg
• Requested blood levels of venlafaxine/O-desmethylvenlafaxine again,
and then to raise venlafaxine dose to 300 mg, as advised 4 weeks ago
Case Outcome: Third Interim Followup, Week 28
• Phone consult in another month, referring psychiatrist did get
venlafaxine/O-desmethylvenlafzine blood levels, both of which were
found to be low while taking a dose of 225 mg of venlafaxine XR
• Referring psychiatrist now agrees to increase venlafaxineXR to 300
mg and to discontinue aripiprazole
Case Outcome: Fourth Interim Followup, Week 32
• No improvement in depression
• Advised getting repeat venlafaxine/O-desmethylvenlafaxine blood
levels again at 300 mg and then raising the dose to 375 mg if still low
Case Outcome: Fifth Interim Followup, Week 36
• Phone consultation in another month
• Venlafaxine/O-desmethylvenlafaxine levels still low at a dose of 300
mg of venlafaxine XR, so raised the dose to 375 mg
• “A pretty good few weeks” then followed but then patient relapsed a bit
• No increase of BP and no apparent side effects from venlafaxine
• Given that the blood levels of venlafaxine/O-desmethylvenlafaxine were
so low on a dose of 300 mg/day, advised them to increase venlafaxine
to 450 mg/day and to get another set of therapeutic drug levels
Case Outcome: Sixth Interim Followup, Week 40
• Increased venlafaxine XR dose to 450 mg/day, then got blood levels
on this dose, which are only in the low normal range of the very
broad therapeutic range suggested by the laboratory of venlafaxine/Odesmethylvenlafaxine
• Aphasia and memory better, mood defi nitely improved enough so that
patient was no longer completely demoralized and was beginning to
have hope
• Suggested raising the dose by 75 mg, getting levels again and if
necessary, raising the dose again to 600 mg
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PATIENT FILE
330Adult and Geriatric Antidepressant Therapy Essay
Case Outcome: Seventh Interim Followup, Week 52
• Dose increased to 600 mg, with full remission of depression
• However, at 600 mg dose, began to have some irritability, insomnia
and 5–10 mm BP elevation, so reduced to 525 mg, and then to 450
mg of venlafaxine XR
• Tolerated it well at this dose
• BP normal by report
• Still in remission, now fi nally a year after the original consultation
• The case continues. . . .
Case Debrief
• A highly recurrent but readily treatable major depressive disorder
suddenly turned treatment-resistant in this patient’s 60s
• Not clear but hypothetically possible that this represents disease
progression secondary to changes in brain functioning
• This case was looking very complicated due to nonresponse
to standard and aggressive therapies at standard doses. Major
depressive disorder can be treatable even in the seemingly most
treatment-resistant cases
• In retrospect, this patient’s transient aphasia without evidence of
stroke was probably a rare complication of ECT
• Aggressive treatment does not have to be reckless but does have its
risks
• It is possible for experts to augment MAOIs with a stimulant, while
monitoring BP in heroic cases where the possible benefi t (which has
been reported with this combination) outweighs the risk (elevated BP,
cardio and cerebrovascular events)
• However, this did not happen here
• Another heroic if old-fashioned option is the combination of MAOI
with a TCA, well tolerated here but not effective
• Plasma drug level-guided heroic dosing of venlafaxine (or more
recently desvenlafaxine) can be useful for resistant cases as it was
here
• This may lead to venlafaxine dosing higher than 375 mg or
desvenlafaxine dosing up to 200 mg
Take-Home Points
• Never give up
• Consider therapeutic drug monitoring before exotic research options
• Therapeutic drug levels of antidepressants such as venlafaxine are
not well quantifi ed, but if absorption is low or metabolism is high (or
compliance is low), the blood levels of drug and active metabolites
can still guide dosage above the normal approved therapeutic range
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331Adult and Geriatric Antidepressant Therapy Essay
Performance in Practice: Confessions of a
Psychopharmacologist
• What could have been done better here?
– Did it take too long to get to therapeutic drug monitoring?
– Was the second set of ECT treatments not a good idea?
• Possible action item for improvement in practice
– Consider therapeutic drug monitoring earlier in the treatment
algorithm for cases where there are inadequate therapeutic actions
and low side effects
– Consider genetic testing, especially in treatment resistant cases,
the elderly and children
Tips and Pearls
• High doses of drugs taken orally sometimes deliver normal doses
of drug to the brain because of various pharmacokinetic or genetic
factors
• The point is how much drug is getting into the brain, not how much is
taken by mouth
• The future promises better guidance of drug and dose selection by
genetic tests and neuroimaging
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PATIENT FILE
332
Two-Minute Tute: A brief lesson and psychopharmacology
tutorial (tute) with relevant background material for this case
– Genotyping in depression
– Ketamine treatment of resistant depression
– Brain changes in chronic depression
– Development of treatment resistant depression
Table 1: Genotyping Neurotransmitter-Related Enzymes
and Receptors in Patients with Treatment Resistant
Depression?
• Still considered research tools by many
• However, beginning to be available for clinical practice
applications
• Published results are not always consistently replicated
• Include variants of genes for many candidates:
– Serotonin related receptors
• SERT (the serotonin transporter)
• 5HT1A receptor
• 5HT2A receptor
• 5HT2C receptor
– Various glutamate receptors
– Dopamine regulating enzymes and receptors
• COMT (catechol-O-methyl-transferase)
• MTHFR (methylene tetrahydrofolate reductase)
• D2 receptor (dopamine)
– Hypothalamic-pituitary-adrenal (HPA) axis
• CRH1 receptor (corticotrophin releasing hormone)
• CRH binding protein
• Cortisol binding protein regulators (FKBP5)
– Measuring cytochrome P450 enzyme genotypes
– Ion channels
• KCNK2
• CACNA1
– Growth factors
• BDNF (brain derived neurotrophic factor)
• Many others
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333Adult and Geriatric Antidepressant Therapy Essay
Table 2: Glutamate, Ketamine and the Future of
Treatments for Resistant Depression
• Ketamine, like PCP/phencyclidine, is an antagonist at NMDA
(N-methyl-d-aspartate) receptors
• Several groups have reported that ketamine can at least
transiently improve symptoms in patients with treatment resistant
depression
• Ketamine blocks NMDA receptors, and some experimental
treatments target a subtype of these receptors, the NR2B
receptor, hypothesizing that this is the receptor through which
ketamine acts
• A novel hypothesis has been proposed for ketamine that it
activates the mammalian target of rapamycin (mTOR) pathway
• This leads to increased synaptic signaling proteins
• It also increases the number and the function of new spine
synapses, at least in the prefrontal cortex of rats
• These effects of ketamine are the opposite to the synaptic
defi cits that result from exposure to stress and thus could be the
hypothetical mechanism of any therapeutic action of ketamine in
treatment resistant depression, where the effects of stress upon
the brain may render standard antidepressants ineffective
Table 3: Are Brain Changes Progressive in Depression?
• A frontal-limbic functional disconnection is present in depression
and correlates with the duration of the current depressive episode
• Hippocampal volume loss is greater with longer periods of
untreated depression
• The likelihood that a life stress precipitates a depressive episode
is greatest for the fi rst episode of depression and declines with
each subsequent episode, although the risk of subsequent
episodes increase as though prior episodes of depression
as well as life stressors are causing subsequent episodes of
depression
• More episodes of depression as well as residual symptoms both
predict poorer outcome in terms of more relapses
• Antidepressants may boost trophic factors, normalize brain
activity, suggesting that successful and early treatment may
attenuate progressive maladaptive brain changes and improve
the clinical course of the illness
• Symptomatic remission may be the clinician’s benchmark for
enhancing the probability of arresting disease progression
• Sustained remission may be a clinician’s benchmark for
reversing the underlying pathophysiology of major depression
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PATIENT FILE
334Adult and Geriatric Antidepressant Therapy Essay
0.0
0.2
0.4
0.6
0.8
1.0
0 50 100
Recovery
with
no symptoms 1-3 121 224
no symptoms 3+ 34 79
1+ mild symptoms 1-3 57 34
1+ mild symptoms 1-3 57 34
Previous
episodes
n
Median
weeks
well
150 200 250 300 350 400 450 500
Survival distribution function
Weeks to first relapse with any depressive
episode (major, minor, dysthymia)
Survival distribution function=cumulative proportion of cases surviving to a given interval
More episodes of major depression and residual symptoms
predict worse outcomes
Figure 1: More Episodes of Major Depression and Residual Symptoms
Predict Worse Outcomes. In other words, the depression you have,
the more depression you get. Depression begets depression. Lack of
remission begets relapse. This shows the importance of doing everything
possible to reduce the number of episodes of depression, and also to
treat every symptom to the point of remission when there is an episode of
depression. The name of the game is sustained remission in the modern
conceptualization of the treatment of depression.
Residual symptoms and episode count thus add to the complexity of
diagnosing and treating depression and can lead to worse outcomes.
• The main fi nding of this study was that depressed patients who
experienced recovery with no symptoms remained well for a median
of 4.3 years (224 weeks) before depression recurrence, compared
to approximately six months for patients who recovered with residual
symptoms. Therefore, recovery with residual symptoms from
depression was an important clinical marker associated with rapid
episode relapse in depression
• Asymptomatic recovery included those patients with at least 80%
of well interval weeks rated as the following: “Subject is returned to
‘usual self’ without any residual symptoms of the major depressive
disorder, although signifi cant symptomatology from underlying
conditions may continue.”Adult and Geriatric Antidepressant Therapy Essay
• Even the mildest residual symptoms, however, can negatively
impact outcomes. Patients with residual subthreshold depressive
symptoms (recovery with 1+ mild symptoms)—one or more mild
residual depressive symptoms—experienced on average a faster time
to relapse than did asymptomatic patients.
• Episode count, too, was a negative prognosticator. Patients with
more than three major depressive episodes (MDEs) tended to relapse
earlier than those with histories of three or fewer episodes, although
this did not reach signifi cance.
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PATIENT FILE
335
BACKGROUND
• Patients with MDD (as diagnosed using Research Diagnostic Criteria,
or RDC) were followed naturalistically for 10 years or longer.
• Patients were divided on the basis of intake MDE recovery into
recovery with residual subthreshold depressive symptoms (recovery
with 1+ mild symptoms; N=82) and asymptomatic recovery
(N=155) groups. Trained raters interviewed patients every six months
for the fi rst fi ve years and every year thereafter.
• Depressive symptomatology was rated using the Longitudinal Interval
Follow-up Evaluation (LIFE) Psychiatric Status Rating (PSR) scales.
• Recovery with 1+ mild symptoms as defi ned by the PSR includes
those experiencing one or more depressive symptoms but of no more
than a mild degree.
• P values (given according to color of lines on slide graphic): Orange vs
green, P<.0001; orange vs blue, P<.0001; orange vs red, P<.0001;
green vs blue, P=.013; green vs red, P=.004; blue vs red, P=.283.
0
2
4
6
8
10
0 1 2 3 4 5 6 7-8 9-11
Risk (odds ratio)Adult and Geriatric Antidepressant Therapy Essay
Number of previous depressive episodes
Likelihood of recent life stress
precipitating depression
Risk (OR) of depression onset per month
Figure 2: Progression of Depression: Adverse Effects of Each Episode on
Future Episodes Which Become More Spontaneous and Less Triggered
by Stress. These data are consistent with the notion that symptoms of
depression and episodes of depression “kindle” subsequent episodes of
depression.
• The kindling hypothesis states that previous episodes of depression
change the brain, making patients more likely to experience
subsequent episodes of depression
• After 4 to 5 episodes, the best predictor of subsequent episodes of
depression is the number of previous depressive episodes, not stress
• Does this suggest that recurrent depression is a progressive disease?
BACKGROUND:
• Female twins from a population-based registry (N=2,395) were
interviewed 4 times during a period of 9 years, forming a study
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PATIENT FILE
336Adult and Geriatric Antidepressant Therapy Essay
group that contained 97,515 person-months and 1380 onsets of
MDD
• To assess the interaction between life-event exposure and the number
of previous episodes of MDD in predicting future MDD episodes,
discrete-time survival, a proportional hazards model, and piece-wise
regression analyses were used
• This pattern of results was unchanged by the addition of measures
of event severity and genetic risk, as well as the restriction to
“independent stressful life events”
• The same pattern of results emerged when within-person changes in
the number of episodes were examined
HYPOMANIA
DYSTHYMIA
recurrent
poor interepisode
recovery
bipolar
spectrum
treatment
resistence
Figure 3: is Major Depressive Disorder Progressive? Studies as well as
direct observations of cases over long periods of time suggest that one
episode of major depression may not only increase the chances of having
another, but that subsequent recurrences may not be followed by remission
and only by partial treatment responses, ultimately with episodes recurring
that may become treatment resistant.Adult and Geriatric Antidepressant Therapy Essay
What proportion of major depressive disorders remit?
HYPOMANIA
DYSTHYMIA
33% 20% 6-7% 6-7%
67% remisson
after 4 treatments
47%
40%
33% nonremitters
after 4 treatments
antidepressant
treatment #4
antidepressant
treatment #3
antidepressant
treatment #2
antidepressant
treatment #1
67%
Figure 4: What proportion of major depressive disorder remit?
Approximately one-third of depressed patients will remit during treatment
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PATIENT FILE
337Adult and Geriatric Antidepressant Therapy Essay
with any antidepressant initially. Unfortunately, for those who fail to remit
the likelihood of remission with another antidepressant monotherapy goes
down with each successive trial. Thus, after a year of treatment with four
sequential antidepressants taken for twelve weeks each, only two-thirds of
patients will have achieved remission.
100%
0%
3
months
not in
remission
60%
6
months
12
months
Relapse rate
After 1 treatment
in remission
33%
100%
0%
3
months
not in
remission
67%
6Adult and Geriatric Antidepressant Therapy Essay
months
12
months
Relapse rate
After 2 treatments
in remission
50%
100%
0%
3
months
not in
remission
70%
50%
6
months
12
months
Relapse rate
After 3 treatments
in remission
50%
100%
0%
3
months
not in
remission
6
mo Adult and Geriatric Antidepressant Therapy Essay nths
12
months
Relapse rate
After 4 treatments
in remission
70%
30%
Figure 5: What Proportion of Major Depressive Disorders Relapse? The
rate of relapse of major depression is signifi cantly less for patients who
achieve remission. However, there is still risk of relapse even in remitters,
and the likelihood increases with the number of treatments it takes to get
the patient to remit. Thus, the relapse rate for patients who do not remit
ranges from 60% at twelve months after one treatment to 70% at six months
after four treatments, but for those who do remit it ranges from only 33%
at twelve months after one treatment all the way to 70% at six months after
four treatments. In other words, the protective nature of remission virtually
disappears once it takes four treatments to achieve remission.Adult and Geriatric Antidepressant Therapy Essay
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PATIENT FILE
338Adult and Geriatric Antidepressant Therapy Essay
Posttest Self Assessment Question: Answer
If a patient has low blood levels of an antidepressant at standard doses,
what could this mean?
A. Pharmacokinetic failure
– Pharmacokinetics is the body acting upon a drug; so, if the
body does not absorb or metabolize a drug in a way that normal
therapeutic levels are delivered to the brain via the blood, a low
blood level at standard doses can mean a pharmacokinetic failure
B. Genetic variant causing pharmacokinetic failure
– Genetic variants of CYP450 enzymes can cause excessive
metabolism of a drug and thus pharmacokinetic failure
C. Pharmacodynamic failure
– Pharmacodynamics is the drug acting upon the body, in this case,
transporters in the brain; so, if a patient has low blood levels of an
antidepressant, there is not adequate opportunity to see if the drug
will work, and this is not considered a pharmacodynamic failure; a
pharmacodynamic failure occurs when the brain does not respond
to normal levels of drug
D. Genetic variant causing pharmacodynamic failure
– Genetic variants are considered to cause pharmacodynamic
failures when despite adequate levels of drug, there is no
therapeutic response
E. Noncompliance
– low blood levels are more often caused by noncompliance/
nonadherence than they are by pharmacokinetic failures
Answer: A, B and E
References
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2. Stahl SM, Antidepressants, in Stahl’s Essential
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Prescriber’s Guide, 3rd edition, Cambridge University Press, New
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340Adult and Geriatric Antidepressant Therapy Essay
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All rights reserved. Not for commercial use or unauthorized distribution. Adult and Geriatric Antidepressant Therapy Essay
Learning Resources
Note:
To access this week’s required library resources, please click on the link to the Course Readings List, found in the
Course Materials
section of your Syllabus.
Required Readings
Note: All Stahl resources can be accessed through the Walden Library using this link. This link will take you to a log-in page for the Walden Library. Once you log into the library, the Stahl website will appear.
Stahl, S. M. (2013).
Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications
(4th ed.). New York, NY: Cambridge University Press. Discussion: The Impact of Ethnicity on Antidepressant Therapy – The depressed man who thought he was out of options – Adult and Geriatric Antidepressant Therapy essay assignment discussion.
ORDER A CUSTOM-WRITTEN PAPER NOW
Note:
To access the following chapters, click on the
Essential Psychopharmacology, 4th ed
tab on the Stahl Online website and select the appropriate chapter. Be sure to read all sections on the left navigation bar for each chapter.
Chapter 7, “Antidepressants”
Stahl, S. M. (2014b).
The prescriber’s guide
(5th ed.). New York, NY: Cambridge University Press.
American Psychiatric Association. (2013).
Diagnostic and statistical manual of mental disorders
(5th ed.). Washington, DC: Author.
Note:
Retrieved from Walden Library databases.
Howland, R. H. (2008a). 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:10.3928/02793695-20080901-06
Note:
Retrieved from Walden Library databases.
Howland, R. H. (2008a). Sequenced treatment alternatives to relieve depression (STAR*D). Part 2: Study outcomes.
Journal of Psychosocial Nursing and Mental Health Services, 46
(19), 21–24. doi:10.3928/02793695-20081001-05
Note:
Retrieved from Walden Library databases.
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), 417–423. Retrieved from https://web.archive.org/web/20170809004704/https://www.fda.gov/downloads/Drugs/ScienceResearch/…/UCM085502.pdf
Discussion: The Impact of Ethnicity on Antidepressant Therapy – The depressed man who thought he was out of options – Adult and Geriatric Antidepressant Therapy essay assignment discussion