Major Depressive Disorder

Major Depressive Disorder

According to the American psychiatric association (2013), major depressive disorder is one of the leading conditions in the clinical practice (American Psychiatric Association, 2013). The treatment for the condition differs based on patient factors, including culture as well as ethnicity. Therefore, being a psychiatric professional is crucial to take note of such factors to pick suitable psychopharmacological interventions. Regarding this essay or discussion, the care provider assess and treat the patient based on the given factors such as culture as well as ethnicity

Case 2: Volume 1, Case #7: The case of physician do not heal thyself

The question I will inquire is, Does the client possess either complex mood disorder, a personality disorder, or even both?

The Dilemma in this case: How do you treat a complex and long-term unstable disorder of mood in a difficult patient?

“60-year-old man, African American came into the office, Chief complaint is being unstable Patient estimates that he has spent about two-thirds of the time over the past year being in a mixed dysphoric state and about one third as depressed, but waxing and waning every few days, or even every few hours”.

The question to ask my patient

Some of the questions include;

1. in the previous three weeks, how frequently have you hopeless?” if the patient has had the same feeling for the past two weeks, then he is depressed.
2. Have you ever had any feelings of suicidal thoughts? I this question allow the physician to assess the depth or severity of depression

3: what can you say about your energy? And tell me more about your sleep? Reduction in energy level indicates the presence of depression. When the sleep is reduced by an average of two to three hours at night indicates a higher risk of depression.

People in patient’s life you need to speak to for further assistance

The people with whom a medical professional might need to talk may include: the patient’s guardian or parent, close relatives, patient’s close friends, coworkers, and spouse if married. These people will assist in giving more inside about the patient’s life and recent behavior changes (American Psychiatric Association, 2013).  In this case, I will ask his coworkers because those are the people he works with. I would like to know from these coworkers if they had noticed anything different with the patient. I will also be very careful not to break the patient’s privacy code; I cannot tell the coworkers anything regarding the patient without the patient’s consent.

Physical Exams and Diagnostic Test

I will go ahead to recommend CT scan, physical exam as well as urine test and laboratory tests. Through asking the above questions and physical examination, the physician will note if the patient has developed depression (Stahl, 2013). The condition can be ruled out through a lab test and blood test, which shows the medical condition, which may cause depressive symptoms. The blood test is used to examine the presence of illnesses such as anemia, thyroid, and the level of calcium as well as vitamin D.

Diagnosis for the patient

I believe my patient has bipolar 11 disorder episodes, and this can be evidenced by the presence of manic and depressive symptoms (Yasuda, Zhang, & Huang, 2008). Manic episodes include abnormally elevated, expansive, or irritable mood, and in our patient’s case, this is as evidenced by over talkativeness, racing thoughts, risky behavior, and euphoria. The depressive symptoms include depression and overdose attempt.

Differential Diagnosis

Major Depressive Disorder which is referred to the lack of Manic Episodes as well as Hypomanic Episodes. The availability of hypomanic, as well as manic symptoms, may be compatible with the major depressive disorder, and it is also crucial to be certain if the symptoms meet criteria for the hypomanic episode to determine if it is relevant to conduct bipolar 11 disorder diagnosis. “Bipolar I and Bipolar II Disorders which is characterized by Manic Episodes and Hypomanic Episodes, respectively. Persistent Depressive Disorder cannot be diagnosed if a Manic or Hypomanic Episode has ever been present” (Stahl, 2013). Borderline Personality Disorder is related to the symptom such as instability, unstable self-image, impulsive behaviors as well as emotional instability

Pharmacologic Agents

Lithium, as well as Lamotrigine, is efficient for the cases of mood as well as a personality disorder. Stimulant has no role in this particular scenario and antidepressant destabilizes the patient. Clients who are suffering from a major depressive episode and receive antidepressants improve in terms of symptoms. When symptoms reduce by fifty percent, then it is called recovery. “neuroscience-based Nomenclature: lithium enzyme interactions (Li-Eint) Mood stabilizer. Atypical antipsychotics (especially risperidone, olanzapine, quetiapine, ziprasidone, and aripiprazole) Valproate (with caution and at the half dose of Lamotrigine in the presence of valproate, because valproate can double Lamotrigine levels)”( Yasuda, Zhang, & Huang, 2008)

Lamotrigine

According to Stahl (2013), “Lamotrigine is neuroscience-based Nomenclature: glutamate, voltage-gated sodium channel blocker (Glu-CB). Anticonvulsant, mood stabilizer, voltage-sensitive sodium channel antagonist. Acts as a use-dependent blocker of voltage-sensitive sodium channels Interact with the open channel conformation of voltage-sensitive sodium channels” (Stahl, 2013). The medication interacts art the particular site of alpha pore-forming the subunit of the voltage-sensitive sodium channels. It also inhibits the production of asparate and glutamate.

Dosage Range

Monotherapy for bipolar disorder: 100–200 mg/day. Adjunctive treatment for bipolar disorder: 100 mg/day in a blend of valproate; 400 mg/day in mixture with enzyme-inducing antiepileptic medicine such as carbamazepine, phenobarbital, phenytoin, and primidone

“Bipolar disorder (Monotherapy) for the first two weeks administer 25 mg/day; at week three increase to 50 mg/day; at week five increase to 100 mg/day; at week six increase to 200 mg/day; maximum dose generally 200 mg/day”(Stahl, 2013)

Bipolar disorder (an adjunct to valproate): for the first two weeks administer 25 mg daily; at week three increase to 25 mg/day; at week five increase to 50 mg/day; at week six increase to 100 mg/day; maximum dose generally 100 mg/day

Bipolar disorder (an adjunct to enzyme-inducing antiepileptic drugs): for the first two weeks administer 50 mg/day; at week three increase to 100 mg/day in divided doses; starting at week five increase by 100 mg/day each week; maximum dose generally 400 mg/day in divided doses

Reasons for selection

There is limited data based on the superiority of one medication over the other (Yasuda, Zhang, & Huang, 2008). The most important thing that usually happens is switching the medication when one has increased side effects, or there is no response at all. The evidence-based algorithm is not able to offer a guideline based on choosing antidepressants and what is to be done if it does not work.

Symptom-based antidepressant selections

Stahl (2013) states that neurobiological informed psychopharmacologist may opt for adapting a symptom-based approach to selecting or combining a series of antidepressants. The strategy results in the creation of a portfolio of different agents to treat the residual symptoms of unipolar depression until the client attains a sustainable remission (Howland, 2008). The symptoms are also developed into diagnosis and later deconstructed to a list of specific symptoms the patient is experiencing. Further, symptoms are then compared or matched with the brain circuit, which hypothetically mediates them and thereafter with the known “neuropharmacological regulation of these circuits by neurotransmitters” (Howland, 2008). Lastly, the treatment option available, which targets the neuropharmacological, is picked to eliminate the symptoms one by one.  If the symptoms do not go away, a different mechanism is applied. Whereas there is no evidence supporting the superiority of this mechanism, it appeals to neurobiological reasoning and clinical intuition.

Lessons learned

From this case study, I have learned that there are different types of bipolar disorder. Many things are to be considered before prescribing drugs or treatment to a patient (American Psychiatric Association, 2013). Personality, as well as temperament, are influential factors in bipolar disorder, and most importantly, they are a barrier to effective treatment and compliance of the disorder. Additionally, antisocial, histrionic, narcissist and borderline can easily be confused with the bipolar spectrum disorder

Conclusion

To reach a better treatment option, the psychiatrist should ask themselves what they could have done better based on the alternative used. While the superiority of some treatment options is limited, the care provider should trace the patient outcome based on the based treatment options from other patients. The psychiatric should focus on reducing the symptoms while limiting the side effects of the drugs. Then a more realistic goal for the patient should be set instead of working on assumptions.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

Howland, R. H. (2008). 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:02793695-20081001-0510.3928/02793695-20080901-06

Howland, R. H. (2008). Sequenced Treatment Alternatives to Relieve Depression (STAR*D). Part 2: Study outcomes. Journal of Psychosocial Nursing and Mental Health Services, 46(10), 21-24. doi:02793695-20081001-0510.3928/02793695-20080901-06

Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (4th ed.). New York, NY: Cambridge University Press.

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