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Assessment and Treatment of Adults with Depression

Assessment and Treatment of Adults with Depression

Depression is currently the fourth leading cause of disability in the United States, and it is expected to become the leading cause of disability in the United States within the next 15 years, with 16% of the population experiencing a major depressive episode (Arcangelo et al., 2017; Ishikawa et al., 2014). Between 2013 and 2016, one in every twelve adults in the United States reported having depression (American Academy of Family Physicians [AAFP], 2018). The National Center for Health Statistics (NCHS) reported on February 13, 2018, that more than 8.1% of people aged 20 and older had a depressive episode in the previous two weeks (AAFP, 2018). Asian adults (3.1%) have a significantly lower prevalence of depression than Hispanic (8.2%), Black (9.2%), and White (7.9%) adults (AAFP, 2018). More importantly, Latinos currently account for approximately 16% of the U.S. population and will account for 30% by 2060. (Ishikawa, et al., 2014). Indeed, the Latino population has depression rates comparable to non-Latino whites, and up to 22% of Latino primary care patients meet the criteria for major depressive disorder (MDD) (Ishikawa et al., 2014). This paper aims to examine a case study to gain insight into the assessment and treatment of clients from various ethnic groups, including Latinos, who had severe depression.

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A Young Latino Male Suffering from Depression: A Case Study

The client, a 32-year-old Latino male, was referred by his primary care physician (PCP) to the psychiatric mental health nurse practitioner (PMHNP) for assessment and treatment of depression-related complaints (Montgomery & Asberg, 1979). The client is from Mexico and arrived in high school with his father; his mother died while he was still in high school in Mexico. Other than sporadic back pain and shoulder stiffness, which he attributes to his current work as a warehouse labourer, the client has no other health issues. During the initial interview with the PMHNP, the client stated that he had lost interest in his usual activities, had lost 15 pounds in the last two months, and had difficulty sleeping, which began six months ago. The mental status exam revealed that the client was depressed, denied visual/auditory hallucinations, and had no paranoid thoughts or delusions. The client’s judgment is sound, and he denies suicidal thoughts (or homicidal). The PMHNP administered the Montgomery-Asberg Depression Rating Scale to the client, who scored 51, indicating severe depression (Montgomery & Asberg, 1979).

Point 1 of Decision

The first three options for the PMHNP to consider were starting the client on sertraline (Zoloft) at 25 mg orally daily, venlafaxine (Effexor X.R.) at 37 mg orally daily, or phenelzine (Nardil) at 15 mg orally TID. Venlafaxine (Effexor X.R.), 37 mg orally daily, was chosen as the treatment option. It is an antidepressant in the selective serotonin-norepinephrine reuptake inhibitors (SNRIs) class (Arcangelo et al., 2017; Stahl, 2013). Weight gain with antidepressants such as venlafaxine is unusual, and short-term weight loss is possible with this medication (Abdus & Zuvekas, 2015; Stahl, 2013). In addition, in a placebo-controlled trial, venlafaxine (Effexor X.R.) was shown to reduce total scores on the Montgomery-Asberg Depression Rating Scales and lower relapse rates among venlafaxine (75 to 225 mg/day) recipients versus placebo recipients (Howland, 2008; Wellington, & Perry, 2001).

Furthermore, the decision not to prescribe the antidepressants sertraline (Zoloft) and phenelzine (Nardil) was made primarily because venlafaxine X.R. has been shown in two meta-analyses to have significantly higher success rates than sertraline and phenelzine (Howland, 2008; Wellington, & Perry, 2001). Furthermore, phenelzine is a monoamine oxidase (MAO) inhibitor and should be used in third-line therapy after first- and second-line pharmacologic agents have failed (Arcangelo et al., 2017). Furthermore, the goal of venlafaxine (Effexor X.R.) treatment is total remission of the client’s symptoms as well as prevention of any future relapses of depression for the client (Abdus & Zuvekas, 2015; Stahl, 2013; Wellington & Perry, 2001).

Point 2 of Consideration

The client returns to the clinic after four weeks and reports that his depressive symptoms have not improved, and the three decision options were (1) to increase his current venlafaxine (Effexor X.R.) dosage to 75 mg orally daily. (2) Switch to Cymbalta 30 mg once daily, or (3) add an atypical antipsychotic (Montgomery & Asberg, 1979). Because the onset of venlafaxine’s pharmacological clinical effectiveness is often delayed by 2 to 4 weeks, the decision was made not to switch antidepressants but to increase the current medication dosage of Effexor X.R. to 75 mg orally daily (Stahl, 2013). Furthermore, if tolerated, venlafaxine can be used for many years to prevent relapse of symptoms (Stahl, 2013).

The client was not prescribed Cymbalta because it has some unpleasant side effects; for those who discontinue abruptly, severe withdrawal symptoms such as nightmares, seizures, and electrical shock sensations can last for weeks (Fookes, 2018). Furthermore, regardless of age, those taking Cymbalta must be monitored for worsening depression and suicidal thoughts and behaviours (Arcangelo et al., 2017; Fookes, 2018). At this point in the client’s treatment, augmentation with an atypical antipsychotic is unnecessary because the client does not exhibit symptoms of psychosis (e.g., delusion, hallucination, confusion, paranoia) or any other emotional or mental condition (Arcangelo et al., 2017).

The CYP-450 genotype is common in Latinos and affects the ability of antidepressants to be metabolized in the liver, which can affect plasma drug levels and, depending on the dose, can intensify the drug response. Thus, venlafaxine concentrations are higher than in the Latino population, which may explain why low doses of venlafaxine have a better response rate (Alarcón et al., 2014). Several large-scale clinical trials have demonstrated the efficacy of first-line therapy for major antidepressant drugs, including venlafaxine (Howland, 2008; Wellington & Perry, 2001).

Point 3 of Decision

After four weeks, the client returned, and after eight weeks of antidepressant medication treatment, the client reported improvement in depressive symptoms and scored a decrease from 51 to 38, or a 25% reduction, on the Montgomery-Asberg Depression Rating Scale (Montgomery & Asberg, 1979). There were no options at this point, and the only option for decision point 3 was to continue the current venlafaxine dosage of 75 mg orally daily. However, at this point in treatment, the PMHNP should discuss with the client whether the current dosage is adequate because he feels better or if the dosage should be increased, as 75 mg/day is considered low (Stahl, 2013). The PMHNP can also advise the client on the potential side effects of venlafaxine use.

Considerations for Ethical Behavior

Advanced nurse practitioners must be informed and up to date on evidence-based research findings regarding psychopharmacologic agents, including their adverse effects, indications, and contraindications, before prescribing an antidepressant or other psychotropic medication to a patient. In addition, when prescribing medication, psychiatric mental health nurse practitioners (PMHNP) must be prepared to recommend first-line treatment based on relevant data. The PMHNP must be able to establish a trusting relationship and dialogue with the client based on informed consent.

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References

Abdus, S., & Zuvekas, S. H. (2015). Racial/ethnic differences in the relationship between obesity and depression treatment. Journal of Behavioral Health Services and Research, 42(4), 486-503. doi:10.1007/s11414-014-9391-1

Alarcón, R. D., Oquendo, M. A., & Wainberg, M. L. (2014). Depression in a Latino man in New York. The American Journal of Psychiatry, 171(5), 506–508. doi.10.1176/apps. app.2013. 13101292

American Academy of Family Physicians (AAFP). (2018). Nearly one in 12 U.S. adults reports having depression: Women are twice as likely as men to be depressed. Leawood, KS: Author. Retrieved from https://www.aafp.org/news/health-of-the- public/20180219nchsdepression.html

Arcangelo, V. P., Peterson, A. M., Wilbur, V. F., & Reinhold, J. A. (2017). Pharmacotherapeutics for advance practice: A practical approach (4th ed.). Philadelphia, PA: Wolters Kluwer.

Fookes, C. (2018). Cymbalta: Cause for concern? Drugs.com. Retrieved from https://www.drugs.com/slideshow/cymbalta-cause-for-concern–1207

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(19), 21–24. doi:10.3928/02793695-20081001-05

Ishikawa, R. Z., Cardemil, E. V., Alegria, M., Schuman, C. C., & Joseph, R. C. (2014). Uptake of depression treatment recommendation among Latino primary care patients. Psychological Services, 11(4), 421-432. doi:10.1037/a0035716

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

Stahl, S. M. (2013). The prescriber’s guide (6th ed.). New York, NY: Cambridge University Press.

Wellington, K., & Perry, C. (2001). Venlafaxine extended-release: A review of its use in managing major depression. CNS Drugs, 15(8), 643–669. Doi:10.2165/00023210–200115090-00007

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Question 


Mark had a history of depression and sought treatment after his second marriage ended. A pattern of interpersonal avoidance controlled his depression. The behaviour/activation therapist asked Mark to complete an activity record to help steer the treatment sessions.

Assessment and Treatment of Adults with Depression

Assessment and Treatment of Adults with Depression

Read Mark, a 43-year-old male (PDF, 821KB).

After reading Mark’s case, explain and describe how the therapist used behavioural therapy to help Mark with his depression.

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