Discussion: The Impact of Ethnicity on Antidepressant Therapy

Case 1: The Man whose Antidepressants Stopped Working

In this case, the client exhibits symptoms of anxiety and depression (Stahl Online, n.d.). However, more information is needed to accurately diagnose this patient. In this case, it will be appropriate for the psychiatric nurse to ask the following questions given the client’s history:

1. How have your sleep and lifestyle patterns changed in the past 4 weeks? This question will help the psychiatrist nurse to understand the lifestyle patterns of the client and the behavioral trends of the patient that could be impacting the effectiveness of his medications.
2. How can you describe your depression? Do you experience suicidal thoughts? This question is aimed at understanding if the client is aware of his condition and how the disease is affecting him. It is also important to learn about the areas the client does not comprehend and how this can be improved.
3. In your own words, how you are managing your depression? Please describe. The client must be aware of the need to manage his depression including adhering to medications. This question provides more insights into the various dynamics that could be impacting the patient’s depression.

Social and Family Screening

I will direct my questions to the client’s wife because she is a key family member. The questions I will ask the client’s wife include – how has the client been dealing with depression? How have you been supporting him? What are the difficulties experienced by the client in managing his condition? Are you aware of his medications and the time he needs to take them? These questions will provide insights about the client’s social support, and what the family thinks about his condition as well as what they are doing to support him. Moreover, the children will also be asked the above questions to provide an overall observation and their own assessment of the client’s condition, including any details that the client may have missed to report.

Physical Exams and Diagnostics

In order to appropriately diagnose this client, additional physical exams will be needed. One is the physical assessments and screening of the client’s psychiatric and neurological functions. This is aimed at ruling out the other medical causes of depression (Stahl, 2013). This will involve the subjective evaluation of the client’s affect, mood, and appearance because a patient with depression may physically manifest in the form of psychomotor retardation symptoms such as slow reactivity and movement or loss of reactivity (Bennabi, et al., 2013). It will also involve psychomotor testing using available depression diagnostic tools and the DSM 5 to determine the level of depression and confirm the depression diagnosis in the client. Another diagnostic test will include hyperthyroidism tests because abnormal levels of thyroid hormones are known to have an impact on one’s moods (Stahl, 2013). A CYP450 test will also be carried out to provide insights on the antidepressant that will most likely work for this patient (Mayo Clinic, 2017).

Differential Diagnoses

1. Major depressive disorder. This is because the client has experienced severe and recurring episodes of depression, and according to the DSM 5, recurring symptoms predispose patients to treatment-resistant depression (American Psychiatric Association, 2013).
2. Bipolar disorder
3. Unipolar depression

Pharmacologic Agents for the Client

In the case study, the patient previously responded well to sertraline (Stahl Online, n.d.). As a result, sertraline will be one of the chosen medications. Sertraline is an SSRI that is well absorbed and metalized. Strapline reduces both depressive and anxiety symptoms. The recommended starting dose for sertraline is 50mg, which will be increased after one week to between 75mg and 100mg (Lewis, et al., 2019). The second antidepressant medication is venlafaxine which is also an SSRI. Studies indicate that venlafaxine’s active components are effective inhibitors of the norepinephrine and the serotine reuptake of dopamine. The initial dosage for this medication will be 75mg for the first 3-5 days then increasing the dosage to between 100mg and 225mg (Stahl, 2013).

In terms of the pharmacokinetics of the two drugs above, the two medications appear to work better in females (Gibiino, Marsano, & Serretti, 2014). However, venlafaxine seems to work better for this patient. This is because venlafaxine targets to inhibit the absorption of both serotine and norepinephrine while sertraline only targets to inhibit the reabsorption of serotine alone (Stahl, 2013). With both serotine and norepinephrine significantly impacting moods and emotions, venlafaxine is better compared to sertraline.

Contraindications of the Drugs

Studies indicate that venlafaxine may have greeter effects on Caucasians. Caucasians were found to have more positively responded to venlafaxine when compared to sertraline (Gibiino, Marsano, & Serretti, 2014). The greater effects mean that Caucasians could be extensive metabolizers and thus doses should be normalized based on this factor. While the effects of ethnicity may be minimal, it is important to monitor how this client will respond to the medication. Other ethnicities may respond more slowly to venlafaxine.

Lessons Learned

As a nurse, I have learned fundamental concepts and lessons from analyzing this case that will help deal with clients and patients with similar conditions. I have learned the nature of major depressive disorder, and the need to prescribe the appropriate treatment regimen. This is because inappropriate treatment regimens can result in the development of treatment-resistant depression. This can further complicate the management of illness in those patients. Therefore, nurses need to be careful in making prescription decisions.

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