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Case Study 22: Depression, Drug-Nutrient Interaction Mariah Guthrie Miami University 1. What is depression? Depression is a disorder that involves the body, mood, and thoughts. It can change the way a person eats, sleeps and how they view themselves (Nelms 632). 2. Dr. Byrd has decided to treat Ms. Geitl with Zoloft, a selective serotonin reuptake. Are there any permanent nutritional conciderations when using this medication? If taking the medication for extending periods of time ones brain can become dependent on the medication. Stopping taking medication quickly can cause headaches, nausea, dizziness or flu like symptoms. 3. How do serotonin reuptake inhibitors (SSRIs) work? SSRIs work to ease the symptoms of depression by blocking the reabsorption of serotonin neurotransmitters. This changes the chemical balance of the brain and causes the brain to flood with serotonin. SSRIs are selective by only affecting the serotonin neurotransmitter (MayoClinic). 4. During the diet history, you ask Ms. Geitl if she used any OTC vitamins, minerals, or herbal supplements. She tells you her mother suggested she try Hypericum perforatum (St. John’s wort) because in Germany it is prescribed to treat depression. Ms. Geitl did as her mother suggested, as it is available without prescription in the Unites States. What is St. John’s wort? St. John’s wort is an herb and is used to treat depression, nervousness, insomnia and infections. It is available over the counter at most supplement stores and pharmacies (St. John’s Wort). 5. How is St. John’s wort used in the United States? St. John’s wort is an herb and is used to treat depression, nervousness, insomnia and infections. It is available over the counter at most supplement stores and pharmacies. St. Johns wort is not regulated, and it often taken with food (St. Johns Wort). 6. How does St. John’s wort work as an antidepressant? St. Johns wort contains chemicals hypericin and hyperforin, they act as chemical messengers in the nervous system that regulate mood (RxList). 7. Does St. John’s wort have any side effects? Side effects can include: skin sensitivity to sunlight, rashes, feelings of fullness in the stomach and constipation. St. Johns wort can also cause allergic reacxtion although they are rare (St. Johns Wort). 8. How is St. John’s wort regulated in the United States? St. John’s Wort is not regulated in the U.S. and it is classified as a dietary supplement. 9. How is St. John’s wort used in Europe? St. Johns wort is only available by prescription in Germany and several other European countries (American Cancer Society). 10. Why do you think people are interested in alternative medicine and herbal treatments? It is very common for people to try to self medicate. A lot of people prefer taking supplements that they feel are more natural and organic than prescription medications. Supplements are also available over the counter and less expensive than prescription medications. 11. Because Ms. Geitl is ambulatory, you are able to measure her height and weight. She is 5’11” tall and weights 160 pounds. You also determine that she is of medium frame. Because Geitl is from Germany, she is used to reporting her weight in kilograms and her height in centimeters. Convert her height and weight to metric numbers. Height: 5’11”=71 inches x 2.54cm/inch = 180.34cm Weight: 160lbs = 160lbs/2.2kg/lb = 72.72kg 12. Is. Ms. Geitl’s recent weight loss anything to be worried about? Ms. Geitl only lost 5 pounds in the last 3 months, and she is still at an ideal weight for her height. Since the weight loss was fairly gradual and she’s still at a healthy weight there is not need for concern as of current. 13. Because Ms. Geitl is alert and cooperative, you ask her to complete a PatientGenerated Subjective Global Assessment (PG-SGA) of Nutritional Status. How would you score her? Sections Score Box 1 1 Box 2 1 Box 3 3 Box 4 1 Weight loss section 0 Disease section 0 Metabolic section 1 Physical section 0 Total 7 14. Using Appendix I, how would you triage nutritional intervention? Ms. Geitl has a high score for box 3 because of her lack of appetite. I would recommend that she takes in small meals thorough out the day so she will be able to take in more calories and small meals will also keep her from feeling too full too quickly. 15. What methods are available to estimate Ms. Geitl’s energy needs? The Mifflin-St. Jeor equation and Harris benedict equation can be used to calculate her energy needs. You can also estimate her energy needs based on height. 16. Calculate Ms. Geitl’s basal energy needs using one of the methods you listened in question 15. Harris Benedict Equation: REE= 655+ (9.56 x wt(gk)) + (1.85 x ht (cm))- (4.68 x age (yrs)) 655+ (9.56 x 72.73kg) = (1.85 x 180.34cm) – (4.68 x 20yrs) 655 +695 + 334 – 94 = 1590kcal 17. What is Ms. Geitl’s estimated energy expenditure? Since Ms. Geitl does not currently exercise, an activity level of 1.4 can be used. 1590kcal x 1.4 =2226 18. Evaluate her diet history and her 24-hour recall. Is she meeting her energy needs? Ivanna is clearly not taking in enough calories based on her 24 hour recall. She is not taking in enough, thus the weight loss. 19. What would you advise? Since she does not feel hungry it would be a good idea for her to take in high calorie foods and eat 5-6 small meals per day. Small meals will keep her from getting to full and allow her to take in more. She should also reduce her caffeine intake as this is a stimulant and reduces appetite. 20. List each factor from your nutritional assessment and then determine an expected outcome from each. Moderately malnourished If she does not increase her calorie intake throughout her day, she will continue to lose weight and become more malnourished. Nutrition impact symptoms If her weight loss continues she will deteriorate further, she could become ill and experience weakness and muscle wasting. She may have to be put on a supplement like ensure so she will be able to keep her weight up if her weight continues to drop. 21. What is your immediate concern regarding this patient’s use of St. John’s wort? St. Johns wort should not be taken with Zoloft or other SSRI’s because it can increase the risk of a condition called serotonin syndrome. Side effects include confusion, fever, sweating, hallucinations, seizures, nausea, vomiting and diarrhea (St. Johns Wort). 22. Review the initial nutrition note written for this patient. Is this progress note appropriate? Is it complete? Any errors? Any omissions? The note should include the nutrition education plan to make sure that she is progressing. It should also include a monitoring plan so that her progress can be tracked. The note is also not in ADIME form. Works Cited American Cancer Society. St. Johns Wort. Retrieved form http://www.cancer.org/treatment/treatmentsandsideeffects/complementaryandalt ernativemedicine/herbsvitaminsandminerals/st-johns-wort. MayoClinic. Depression. Retrieved from http://www.mayoclinic.org/diseases-conditions/depression/in-depth/ssris/art20044825. Nelms, M., Sucher, K., Lacey, K., Roth, S. Nutrition Therapy and Pathophysiology. 2/e. RxList. Retrieved from http://www.rxlist.com/st_johns_wort-page2/supplements.htm. St. Johns Wort. Drugs. (2015). Retrieved from http://www.drugs.com/cdi/st-john-swort.html.