DQWEEK#8F

Adult/Geriatric Depression Hispanic Male With MDD

 

BACKGROUND INFORMATION

The client is a 70 year-old Hispanic American male who came to the United States when he was in high school with his father. His mother died back in Mexico when he was in school. He presents today to your office for an initial appointment for complaints of depression. The client was referred by his PCP after “routine” medical work-up to rule out an organic basis for his depression. He has no other health issues with the exception of some occasional back pain and “stiff” shoulders which he attributes to his current work as a laborer in a warehouse.

SUBJECTIVE

During today’s clinical interview, client reports that he always felt like an outsider as he was “teased” a lot for being “black” in high school. States that he had few friends, and basically kept to himself. He describes his home life as “good.” Stating “Dad did what he could for us, there were 8 of us.” He also reports a remarkably diminished interest in engaging in usual activities, states that he has gained 15 pounds in the last 2 months. He is also troubled with insomnia which began about 6 months ago, but have been progressively getting worse. He does report poor concentration which he reports is getting in “trouble” at work.

MENTAL STATUS EXAM

The client is alert, oriented to person, place, time, and event. He is casually dressed. Speech is clear, but soft. He does not readily make eye contact, but when he does, it is only for a few moments. He is endorsing feelings of depression. Affect is somewhat constricted, but improves as the clinical interview progresses. He denies visual or auditory hallucinations, no overt delusional or paranoid thought processes readily apparent. Judgment and insight appear grossly intact. He is currently denying suicidal or homicidal ideation. You administer the “Montgomery- Asberg Depression Rating Scale (MADRS)” and obtained a score of 51 (indicating severe depression).

RESOURCES

§ Montgomery, S. A., & Asberg, M. (1979). A new depression scale designed to be sensitive to change. British Journal of Psychiatry, 134, 382-389.

Decision Point One

Select what you should do:

Adult/Geriatric Depression Hispanic Male With MDD

 

Decision Point One

BBegin zoloft 25 mg orally dailyegin zoloft 25 mg orally daily

1A-RESULTS OF DECISION POINT ONE

·  Client returns to clinic in four weeks

·  Reports a 25% decrease in symptoms

·  Client is concerned over the new onset of erectile dysfunction

Decision Point Two

Decrease dose to 12.5 mg orally daily

ease dose to 12.5 mg orally daily

2A-RESULTS OF DECISION POINT TWO

·  Client returns to clinic in four weeks

·  Erectile dysfunction has subsided

·  Depressive symptoms have worsened

3A-Decision Point Three

Increase dose back to 25 mg orally daily

ncrease dose back to 25 mg orally daily

Guidance to Student Increasing dose back to 25 mg orally daily may be appropriate as there is no guarantee that the side effect will return. If it does return at 25 mg orally daily, then you should consider changing to another drug. Changing to Paxil 20 mg may also be appropriate at this point, as not all SSRIs have the same side effect profile. Changing to an SNRI would not be appropriate at this point as the issue is not that the client has not responded to SSRI therapy, rather, he has had a negative side effect to one drug in the class.

Decision Point One

· B

· Begin Effexor XR 37.5 mg orally dailyegin

XR 37.5 mg orally daily

1B-RESULTS OF DECISION POINT ONE

·  Client returns to clinic in four weeks

·  Client reports that there is no change in depressive symptoms at all

2B-Decision Point Two

Increase dose to 75 mg of Effexor XR orally daily

RESULTS OF DECISION POINT TWO

·  Client returns to clinic in four weeks

·  Client reports an improvement in depressive symptoms

·  Montgomery- Asberg Depression Rating Scale (MADRS) decreased from 51 to 38 (25% reduction)

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3B-Decision Point Three

Increase dose to 112.5 mg orally daily

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Guidance to Student At this point, you would have two choices to discuss with the client- the current dose of drug can be maintained if the client is feeling better and is not offering any complaints of side effects. The dose can also be increased at this point, but you must counsel client regarding the possibility of side effects. The use of an augmenting agent is not appropriate at this time as we have not reached a maximum dose with Effexor (in fact, 75 mg is still a relatively small dose), displaying primarily SSRI properties only (recall that at lower doses, Effexor exerts a greater effect on serotonergic receptors than norepinephrine at low doses).

Decision Point One

· B Begin Phenelzine 15 mg orally TIDegin Phenelzine 15 mg orally TID

1C-RESULTS OF DECISION POINT ONE

·  Client returns to clinic in four weeks

·  Client reports that he was rushed to the Emergency Room 2 weeks ago after collapsing at the warehouse where he works. He was taken by ambulance to the local community hospital. He was diagnosed with postural hypotension

·  Client was treated with fluid bolus and told to stop taking his phenelzine and to follow up with his primary care provider within one week, and you within that same time frame.

Decision Point Two

Restart Phenelzine and counsel client on dietary choices and importance of hydration

2C-RESULTS OF DECISION POINT TWO

Restart Phenelzine and counsel client on dietary choices and importance of hydration

Client reports that although he had no more episodes of passing out, he has been dizzy when he gets up at night to use the bathroom

 Client also reports that at various times throughout the day when he goes from a sitting to a standing position, he feels light-headed

Decision Point Three

Discontinue Phenelzine and start an SSRI

3C-Guidance to Student The best choice at this point would be to discontinue Phenelzine and begin SSRI therapy. While MAOIs can be powerful drugs used to treat depression, they are generally considered last-line therapy due to unfavorable side effect profiles as well as drug/food interactions. Client’s on MAOIs must be on the MAOI diet and avoid certain aged foods which contain Tyramine. Adding Midodrine would not be appropriate as you should never add a medication to treat the side effects of a medication unless there are no other alternatives. In this case, changing from an MAOI to another drug class would be reasonable and appropriate. Reduction of the Phenelizine dose could be appropriate, but decreased dosage would result in decreased likelihood of efficacy.

Decision Point Two

4A- Phenelzine is not reinitiated. Instead, we began therapy with Lexapro 20 mg orally daily after an appropriate “wash out” period (5 half-lives).

Begin Phenelzine 15 mg orally TID

·  Client returns to clinic in four weeks

·  Client reports that he was rushed to the Emergency Room 2 weeks ago after collapsing at the warehouse where he works. He was taken by ambulance to the local community hospital. He was diagnosed with postural hypotension

·  Client was treated with fluid bolus and told to stop taking his phenelzine and to follow up with his primary care provider within one week, and you within that same time frame

Decision Point Two

Decision Point Two

Re-start Phenelzine 7.5 mg orally TID

RESULTS OF DECISION POINT TWO

·  Client returns to clinic in four weeks

·  Client reported that he still has a little dizziness

·  Client also reports that that his depression has improved greatly (a 35% decrease in MADR scale from 51 to 33)

Begin zoloft 25 mg orally daily

Begin Effexor XR 37.5 mg orally daily

Begin Phenelzine 15 mg orally TID

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