Pharmacological treatment

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Therapy with Older Adults

The primary diagnosis for this client is major depressive disorder (MDD). It is a DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, 5th Ed.) diagnosis assigned to individuals who feel down and have lost interest in activities they previously enjoyed. This depressed feeling must occur daily for at least 2 weeks for a diagnosis to be given. Those who suffer from depression experience persistent feelings of sadness and hopelessness and lose interest in activities they once enjoyed. Aside from the emotional problems caused by depression, individuals can also present with a physical symptom such as chronic pain or digestive issues.

DSM-V Coding for MDD

MDD diagnosed as having either single or recurrent episodes. The severity level, such as mild, moderate, severe and with psychotic features, is also specified to note the unique aspects of the course of the disorder. The coding for single episode include 296.21 (F32.0) Mild 296.22 (F32.0) Moderate, 296.23 (F32.2) Severe, 296.24 (F32.0) In Partial Remission, 296.26  In full Remission, 296.20 (F32.9) Unspecified. The coding for recurrent episode include 296.31 (F33.0) Mild, 296.32 (F33.1) Moderate, 296.33 (F33.2) Severe, 296.34 (F33.3) With Psychotic Features, 296.35 (F33.41) In Partial Remission, 296.36 (F33.42) In Full Remission, 296.30 (F33.9) Unspecified (American Psychiatric Association, 2013).

The rationale for the Diagnosis

The DSM-5 outlines the following criterion to make a diagnosis of depression. The individual must be experiencing five or more symptoms during the same 2-week period, and at least one of the symptoms should be either (1) depressed mood or (2) loss of interest or pleasure (American Psychiatric Association, 2013). Some of these symptoms include feelings of sadness and hopelessness, loss of interest or pleasure in activities, Loss of weight or weight gain, difficulties sleeping or excessive sleepiness, noticeable restlessness or slowness, lack of energy, troubles concentrating and indecisiveness, feeling of worthless and excessive guilt, continued thoughts of wanting to die (Wheeler, 2014). The presence of anxiety in patients may affect prognosis, treatment options, and the patient’s response to clinicians

Based on the symptoms presented in the case study, the client met the criteria for DSM-5 in several ways. First, the client reported that he experienced symptoms of depression and anxiety for few months including sleeping problems, feeling tired all the time, moving in slow motion, and stopped attending the volunteer job at the nursing home. Some of the risk factors associated with the depression reported by the client include the loose of his father who he mentions as the primary source of support and his diagnoses for prostate cancer this year (American Psychiatric Association, 2013). Besides, conditions such as hypertension and hyperlipidemia are associated with some level of depression. Depression is also considered as an inherited condition, and since mother had the condition, there is a possibility he has the condition too (Wheeler, 2014).

Diagnosis Test

Diagnostic tests and physical exam are the two primary methods used to confirm the diagnosis of clinical depression. The main goal of a physical exam is usually to rule out other medical cause for depression (Bilello, 2016). When performing the physical exam, the clinician may focus primarily on the neurological and endocrine system and try to identify any major health concerns that may be contributing to symptoms of depression. For instance, hypothyroidism caused by an underactive thyroid gland is the most common medical condition associated with depressive symptoms. Lab test such as blood tests is also used to check for a medical condition that may cause depressive symptoms such as thyroid, anemia, or possibly other hormones.

Differential diagnosis

  1. Bipolar disorders- These mood disorders include mood swings that range from highs (mania) to lows (depression). It’s sometimes difficult to distinguish between bipolar disorder and depression
  2. Cyclothymic disorder- Cyclothymic disorder involves highs and lows that are milder than those of bipolar disorder.
  3. Persistent depressive disorder- sometimes called dysthymia, this is a less severe but more chronic form of depression. While it’s usually not disabling, the persistent depressive disorder can prevent you from functioning normally in your daily routine and from living life to its fullest

(Portaccio, 2016).

Treatment Strategies for MDD

A wide range of effective treatments is available for major depressive disorder. Medication alone and brief psychotherapy (e.g., Cognitive-behavioral therapy, interpersonal therapy) alone can relieve depressive symptoms. There is also empirical support for the ability of brief psychotherapy (CBT) to prevent relapse. A study comparing the outcome rates of 7 different psychotherapies found that there was no difference in the success rate of the different psychotherapies. However, the dropout rate for cognitive-behaviour therapy was significantly higher than with the other therapies (Dold & Kasper, 2017).

Pharmacology interventions include antidepressant prescriptions such as selective serotonin reuptake inhibitors (SSRIs) and serotonin/norepinephrine reuptake inhibitors (SNRIs) (Polatin, Bevers & Gatchel, 2017). SSRIs have the advantage of the ease of dosing and low toxicity in overdose. SSRIs are greatly preferred over the other classes of antidepressants for the treatment of children and adolescents, and they are also the first-line medications for late-onset depression. SNRIs, which include venlafaxine (Effexor), desvenlafaxine (Pristiq), duloxetine (Cymbalta), and levomilnacipran (Fetzima) can be used as first-line agents, particularly in patients with significant fatigue or pain syndromes associated with the episode of depression (Polatin, Bevers & Gatchel, 2017)

Usually, 2–12 weeks at a therapeutic dose, with assumed adherence to the regimen, are needed for a clinical response to become evident. The choice of medication should be guided by anticipated safety and tolerability, which aid in compliance; physician familiarity, which aids in patient education and anticipation of adverse effects; and history of previous treatments.

Positive psychotherapy (PPI) has shown to be effective in enhancing well being and decreasing depression (Dold & Kasper, 2017) Positive psychotherapy interventions include identifying and using one’s strengths, engaging in enjoyable activities, replaying positive experiences, and socializing based on a meta-analysis of positive psychotherapy suggest that incorporating positive psychotherapy interventions into psychotherapy with depressed clients increases the effectiveness of therapy(Papadimitropoulou et al. (2017). Psychotherapy is often conducted on an outpatient basis with weekly, 60-minute sessions. Although there is wide variation in practice, psychotherapy tends to be time-limited (e.g., 16 sessions)

Exercise can be an important aspect of treating depression. Studies have shown that aerobic exercise is effective in treating depression.  Farah et al. (2016) found exercise to be as effective as antidepressant medication in treating mild to moderate depression.  Also, the authors found the positive effects of medicine occur more quickly than exercise, but the positive effects of exercise are longer lasting. People may notice that they are more quiet than usual, smile less, and are more irritable. Relationships are strained when people are easily annoyed, are less talkative and intimacy avoided. Sometimes people with depression complain about physical pain, have a low frustration tolerance and have angry outbursts (DSM-5).

Clinical Note

We all feel sad and unhappy at times. Sadness is a normal response to a loss or other upsetting events. Depression, however, is a sadness that is long-lasting and when severe, can be debilitating. It leaves people feeling sapped of energy and unable to enjoy once-pleasurable activities. When it is severe people lose all hope, are in so much pain they have thoughts of ending their life and at times take their own life (Dold & Kasper, 2017). People isolate themselves, further depriving them of the positive support that comes from being with others. Sometimes they feel overwhelmed, in a cloud, and may want to stay in bed all day.

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

Bilello, J. A. (2016). Seeking an objective diagnosis of depression. Biomarkers in medicine.

Dold, M., & Kasper, S. (2017). Evidence-based pharmacotherapy of treatment-resistant unipolar depression. International journal of psychiatry in clinical practice.

Farah, W. H., Alsawas, M., Mainou, M., Alahdab, F., Farah, M. H., Ahmed, A. T., … & Mohammed, K. (2016). Non-pharmacological treatment of depression: a systematic review and evidence map. BMJ Evidence-Based Medicine.

Polatin, P., Bevers, K., & Gatchel, R. J. (2017). Pharmacological treatment of depression in geriatric chronic pain patients: a biopsychosocial approach integrating functional restoration. Expert Review of Clinical Pharmacology.

Papadimitropoulou, K., Vossen, C., Karabis, A., Donatti, C., & Kubitz, N. (2017). Comparative efficacy and tolerability of pharmacological and somatic interventions in adult patients with treatment-resistant depression: a systematic review and network meta-analysis. Current Medical Research and Opinion.

Portaccio, E. (2016). Differential diagnosis, discerning depression from cognition. Acta Neurologica Scandinavica.

Wheeler, K. (Ed.). (2014). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice (2nd ed.). New York, NY: Springer Publishing Company.

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