Download Patient Case - Major Depressive Disorder

Nick Wytiaz
University of Pittsburgh
APPE – Care to the Underserved
August 20, 2011
[email protected]
PATIENT CASE / DISESAE STATE DISCUSSION
Objectives
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Review diagnosis, symptoms, and risk factors of major depressive disorder
Explain treatment options and goals of therapy for depression
Develop a treatment plan for a patient with depression and comorbid conditions
Highlight patient counseling points for treatment and follow-up of depression
Patient Case
Subjective
CC: KR is a 59 yo WF presenting to pharmacy upon physician referral for help obtaining her
medications. She also complains of worsening depression, trouble sleeping (“a few hours a night”),
and increased SOB.
HPI: Depression
Patient has been depressed for at least 15 years with no history of psychosis or suicide attempts.
Stated she does have thoughts of self-harm, but has no active plan or clear intent. She reported that
she just feels “really down” and has “no one to turn to for help.” She seemed very stressed with her
current financial situation and was planning to sell her wedding ring today in order to make ends
meet. KR has been out of her meds for >2 months and just began taking Prozac again 2 week ago
after receiving sample from MD. Her previous meds include Klonopin, Xanax, Celexa, amitriptyline,
Paxil, and Prozac. PHQ-9 score of 16 (moderately severe) on 7/16/11.
COPD
KR was experiencing increased SOB since running out of her albuterol inhaler 2 weeks ago. She has
never been hospitalized for an exacerbation, but did require ER treatment once this year. Her
previous meds included Spiriva, Serevent, and albuterol, which were effective, but “way too
expensive” to continue.
PMH: COPD, Depression, Tobacco Abuse, Arthritis (rt hand, reportedly needs surgery), bilat
cataracts, degenerative joint disease (cervical spine, shoulders)
SH: Laid off 4/11. Received unemployment, until starting new job at grocery store 7/25/11.
Husband only works day-to-day, so under significant financial stress. Trouble paying bills for house,
car, meds, etc. Tobacco - 1 ppd. Denies alcohol and illicit drugs.
FH: Father – deceased (DM); Mother – deceased (arthritis, thyroid dz, CVA, CAD)
Allergies: NKDA
Meds: Prozac 20mg daily – restarted 2 wks ago
Advair 100/50 1 puff BID – not yet started
Objective (from 7/16/11)
Vitals: BP 110/70, Ht 5’4”, Wt 135.6 lbs, BMI 23.27, T 98.3, HR 77, SaO2 98%
Labs: Total Choles 269, TSH 1.3, SCr 0.73, BUN 22.1
WBC 6.7, Plt 261, Hgb 13.8, Hct 41.1
Electrolytes wnl, LFTs wnl
Depression
Definition / Diagnosis
Major Depressive Episode: > 5 symptoms during same 2-wk period, with marked change in
function; at least one symptom must be depressed mood or loss of interest / pleasure
- Depressed mood most of the day, nearly every day
- Markedly diminished interest or pleasure in nearly all activities
- Significant weight loss (not dieting) / gain or appetite change
- Sleep changes (insomnia or hypersomnia)
- Psychomotor agitation or retardation (as observed by others)
- Feelings of worthlessness or inappropriate guilt
- Fatigue or loss of energy
- Diminished ability to think / concentrate or indecisiveness
- Recurrent thoughts of death, suicidal ideation with/without specific plan, or suicide attempt
o All may be indicated by subjective report or observations by others
o Generally, sx persists “most of day, nearly every day”
o Cause significant distress or impairment in various areas of functioning
o Not due to substance abuse or other general medical condition
o Not better accounted for by bereavement or mixed episode (i.e. bipolar)
Major Depressive Disorder: 2 or more major depressive episodes (separated by > 2 months) and
not better characterized by another psychiatric condition
Epidemiology
- 2nd most common medical condition seen in general medical practice, after HTN
- 16% of US adults experience major depression at least once during lifetime
- <25% of depressed patients receive adequate treatment
- Nearly 15% of depressed patients commit suicide
Risk Factors
- Persistence of some depressive symptoms
- Prior history of multiple episodes of major depressive disorder
- Severity of initial and subsequent episodes
- Earlier age at onset
- Presence of additional nonaffective psychiatric diagnosis
- Presence of chronic general medical disorder
- Family history of psychiatric illness
- Ongoing psychosocial stressors or impairment
- Negative cognitive style
- Persistent sleep disturbances
Assessment
- Patient Health Questionnaire (PHQ-9): 9 question, self-reported, standardized, depression
rating scale used to diagnose major depression, measure severity, and assess tx response
o >20 indicates severe depression
o <6 indicates remission
o Decrease ≥ 50% indicates a significant clinical response to treatment
- Severe depression: significant distress or decrease in function, whether or not they are
suicidal, should be referred to a psychiatrist for management.
o Significant suicidal ideation in whom outpatient safety cannot be assured
o Significant weight loss or severe psychomotor retardation or agitation
o Intent to harm others
o Symptoms of psychosis (auditory hallucinations or somatic delusions)
o Patients requiring treatment for substance abuse
Goals of Therapy
- Symptom remission
- Restore function (social, occupational, etc.)
o STAR*D trial showed that patients who experienced clinical remission had a better
long-term prognosis than those with partial response,
o However, reluctance on the part of clinicians and patients to push treatment
towards full remission
Treatment Options
1. Antidepressants – treatment of choice; 50-75% response rate
- Preferred for patients with agitation, sleep or appetite changes, history of response to
antidepressant therapy, patient preference, and moderate to severe symptoms.
o SSRI (preferred): equal / greater efficacy than TCAs with fewer side effects
o Alt Monotherapy: bupropion, nefazodone, venlafaxine, mirtazapine TCA, MAOI
o Consider combination if partial or no response on monotherapy
2. Psychotherapy
– Recommended for severe depression in combo with antidepressant
– Alone or in combo for patients with mild or moderate depression
3. Alternative / Complementary Therapy
- St. John's wort or SAMe (S-adenosyl methionine)
o Not replacement for drug therapy, efficacy is unclear
- Light therapy – May speed response to antidepressants
- Exercise – Modest improvement in mood
Treatment Duration / Follow Up
- Some improvement (primarily physical) may occur within 1-2 weeks
- Emotional improvements usually 4-6 weeks – improved mood, interest, etc
- Full effect may not be seen until 12 weeks of treatment
- Re-assess therapy and consider changes if minimal or no improvement seen within 4-8
weeks at maximum tolerated dose
o Additional 4-8 week trial
o Switch to different antidepressant within same class
o Add 2nd drug from different class
- Continue antidepressant therapy for additional 4-9 months after the acute phase (6-12
weeks min) to prevent relapse once controlled
- 3 or more episodes of depression likely require maintenance therapy
o Continue acute and continuation phase medication
o Most likely remain on therapy for life
Patient Case (Con’t)
Assessment / Plan
1. Medication Access – patient unable to afford meds
- PMAPs applications for Prozac (Lilly), Advair (GSK), Ventolin (GSK), and Spiriva (BI)
- Currently has ~1 wk supply of albuterol and Prozac to last until PMAP meds arrive
2. Major Depressive Disorder – not controlled
- Goal: improve symptoms (mood, sleep, etc), restore function, PHQ-9 < 8
- Recently re-started Prozac 20mg PO qam after stopping for >2 months
o Noticed some improvement (less fatigue during day, sleeping a bit longer)
o Explained that it usually takes 4-6 wks to see full effect and may take up to 12
 Physical effects: 1-2 weeks
 Emotional effects: 4-6 weeks
o Stressed importance of compliance and adequate continuation of therapy
o Given phone # for re:solve crisis network ; agreed to call if needed
 Also encouraged follow-up with mental health provider
o KR to follow up with MD in 3 weeks or sooner if needed
3. COPD – not controlled
- Goal: improve breathing (dec SOB, dyspnea), limit rescue inhaler use (<3 x/wk)
- Previously partially controlled with albuterol prn, but increased SOB and trouble breathing
since without inhaler for 2 weeks
- Started on long-acting inhalers
o Advair 100/50 1 puff BID
o Spiriva 1 capsule inhaled daily
- PMAPs completed for all three inhalers
- Explained importance of using all inhalers to control COPD and improve breathing
- Demonstrated appropriate technique for new inhalers (Spiriva and Albuterol)
4.
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Tobacco Abuse – 1 ppd smoker. Goal: smoking cessation
Previously tried patch with no effect
Resistant to trying to again for fear of weight gain and current stress level
Recognizes negative effects of smoking, especially on breathing, but not yet willing to
change behavior (Pre-Contemplative)
5. High Cholesterol – not at goal. Goal: total cholesterol <200
- Not assessed at pharmacy visit
- Most recent MD said drug therapy not needed
o Advised decrease high fat foods in diet
o Plan fasting lipid panel in future
Follow – Up: 8/19/11 with NSCHC physician
References
American Psychiatric Association. Practice guideline for the treatment of patients with major
depressive disorder (3rd Ed). October 2010. Available at
http://www.psych.org/guidelines/mdd2010
Depression guidelines: overview of pharmacotherapy. Pharmacist's Letter/Prescriber's Letter
2010;26(11):261104.
Glick ID, Suppes T, DeBattista C, et al. Psychopharmacologic treatment strategies for depression,
bipolar disorder, and schizophrenia. Ann Intern Med. 2001;134(1):47-60.
Hirsch M and Birnbaum RJ. Antidepressant medication in adults: switching and discontinuing
medication. UpToDate (electronic). Accessed 19-21 August 2011 via
www.uptodate.com+antidepressant-medication-in-adults-switching-and-discontinuingmedication?source=see_link&anchor=H12#H17
Madhukar H, Trivedi, Maurizio F, et al. Use of treatment algorithms for depression. Prim Care
Companion J Clin Psychiatry. 2006;8(5):291–298. Available at
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1764539/
Treatment-resistant depression: an update. Pharmacist's Letter/Prescriber's Letter
2009;25(5):250510.
Wayne K and Ciechanowski P. Initial treatment of depression in adults. UpToDate (electronic).
Accessed 19-21 August 2011 via www.uptodate.com+initial-treatment-of-depression-inadults?source=see_link#H14