The Impact of Ethnicity on Anti-depressant Therapy

The Case: The man whose antidepressant stopped working. 

Gathering information on physical assessment is essential in the management and treatment of the patient’s conditions like depression. The participation of a family is vital in the overall treatment of a person who has a mental disorder.

The three questions necessary to ask the patient with depression are: “How do you feel about being retired?” ; “Can you tell me about your family?”; and “ Are you having thoughts of harming yourself?” The first question will explore the extent of financial demand on the patient and will assess the feeling of guilt regarding financial constraints related to his chronic disease. The importance of financial challenge appeared as the primary stressor on the study on chronic disease and depression (Chan & Corvin, 2016). The second question determines how family relations affect the patient’s condition, whether he has a sound support system. The third question explores the patient’s plan for himself.

The patient’s wife in the scenario is his support person. Family and social interactions appeared crucial to coping strategy even without resolution on the problem (Chan & Corvin, 2016). The following questions are necessary to determine how supportive is the patient’s wife: “Do you keep track of your husband’s medication regimen?” ; “ What are the things that you and your husband like to do?”; and “How do you feel about your husband’s illness?”

The first question determines the wife’s involvement in patient care and whether the patient is compliant with his schedules of medication. The second question explore the things that both patient and wife enjoy. The third question assesses how the patient’s wife handles his husband’s illness. The wife can be a husband’s caregiver, and such a job involves managing the patient’s treatment, side effects, and symptoms, which providing such care can be emotionally difficult (Nik Jaafar et al., 2014). Greater caregiver burden is associated with older adults with long-standing depressive manifestations (Marshe et al., 2017).

Physical Examination and Diagnostic Tests

Physical assessment on the patient’s head, thyroid, and nervous system is an appropriate action to rule out other causes of depression. Current studies affirmed a significant correlation between thyroid hormone imbalance in patients with MDD (Shen et al., 2019). The result of a physical examination will enable the provider to treat any condition that might have contributed to the patient’s depression. The patient may also benefit from HAM-D6 or melancholia sub-scale. The HAM-D6 is a focused version of the Hamilton Depression Rating Scale (HAM-D), an outcome measure in MDD (Dunlop et al., 2019). The test result helps identify the effect of an antidepressant (Dunlop et al., 2019). The result is beneficial and helpful in medication decision management. 

Three Differential Diagnosis

The three differential diagnoses for the patients’ case is adjustment disorder with depressed mood, mood disorder due to another medical condition, and anxiety disorder. Although all the differential diagnosis applies to the patient, the most appropriate one is the adjustment disorder with depressed mood. It is an episode that happens in reply to a psychosocial stressor (American Psychiatric Association, 2013). Although the patient’s depression originated after an A-fib experience, based on the patient’s history, his condition improved, and his A-fib is well managed with medication. The second depression started at the beginning of the patient’s retirement life, improved when he went back to work, and again retired. This depression is linked to a psychosocial stressor.

Pharmacologic Agents

Venlafaxine and sertraline are anti-depressants with a different class that are appropriate for patient’s therapy. Either sertraline 200 mg or venlafaxine 150 mg can be given to the patient considering his history. Sertraline is an antidepressant medication that acts by preventing the serotonin transporter (SERT) in the presynaptic terminals and belongs to the family of selective serotonin reuptake inhibitors (SSRIs) (Saiz-Rodriguez et al., 2018). It prevents the reuptake of 5-HT (Rosenthal & Burchum, 2018). Sertraline (Zoloft) manage depression by elevating the serotonergic activity (Up To Date, Inc, 2019). It has a dopamine neurotransmission blocking ability that gives its therapeutic action (Potter, 2020).

Venlafaxine is a serotonin-norepinephrine reuptake inhibitor (SNRI) use to treat late-life depression and is usually prescribed between 75 and 300 mg in a day, which dosage of 150 or higher is enough to generate noradrenergic activity (Marshe et al., 2017). In a study, there was no ethnicity correlation with patients’ remission status found (Marshe et al., 2017).

Sertraline and venlafaxine would both be appropriate choices for the treatment of depression in this patient. However, I would choose sertraline over venlafaxine because SSRI is commonly tolerated and has a decrease rate of treatment disruption (Bauer, Severus, & Moller, 2017). Venlafaxine has been known to raise blood pressure in patients (Up To Date Inc., 2020). This patient has hypertension. It would require frequent monitoring of the patient’s blood pressure, checking it on time, and knowing the reportable changes would increase the patient and family burden, which is already high in this case. Using sertraline would be effective and would be more comfortable with the family because it would not require frequent blood monitoring. In this case, the has a history of hypertension, but it does not say whether it is or it is not uncontrolled and may only infrequently check his blood pressure at physician appointments or other wellness checks. 

In addition to lesser side effects in sertraline, it has an anxiolytic action that elevates the mood, energy, and concentration (Stahl, 2013). Also, when used as a single therapy, the chance of serotonin syndrome is significantly low (Dwyer & Bloch, 2019). Moreover, it is seldom fatal in single therapy overdose, and long-term use is safe (Potter, 2019).

Regarding ethnic considerations, the older Hispanic population has been found to have a negative outlook regarding pharmacotherapy (Stephenson, Martin, Ortiz, & Mongomey, 2019). This potentially is attributed to other findings such as complaints concerning a lack of providers that are either Hispanic or are bilingual (Stephenson et al., 2019). This could make it harder for patients to understand directions for taking medicine, how to get refills, or understand the provider’s basic instructions (Stephenson et al., 2019).

Lesson Learned

Polypharmacy is not recommended in older adults. The patient initially responds well to sertraline. Since then, multiple changes have taken place, and various medications have been added. The patient is now older, and with that, comes a slower metabolism. A therapeutic effect may be achieved with a smaller dose because of slower metabolism. 

Evidence of depression recurrence signifies progression that may develop into treatment resistance. The learning I earned from the case study will impact my future practice by being pro-active in medical management and education in patients with similar clinical presentations. For example, I will reinforce learning and encourage patients with MDD to take maintenance medication on the third relapse of MDD to avoid relapses in the future and risking changes in the brain formation (Stahl online) development of treatment-resistant depression. According to Dwyer & Bloch (2019), the indefinite continuation of antidepressant is recommended for patients who had three depressive episodes or had high severity episode. 

References

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

Bauer, M., Severus, E., Moller, H., & Young, A. (2017). Pharmacological treatment of unipolar  depressive disorders: summary of WFSBP guidelines. International Journal of Psychiatry  in Clinical Practice, 21(3), 166-176.

https://doi-org.ezp.waldenulibrary.org/10.1080/13651501.2017.1306082

Chan, I., & Corvin, J. (2016). Chronic disease and depression among Hispanic Americans:  Reconceptualizing the masculine self. American Journal of Men’s Health, 10(6), N11- N12. doi: 10.1177/1557988315595858

Dunlop, B., Parikh, S., Rothschild, A., Tase, M., De Battista, C., Conway, C., Forester, B.,  Mondimore, F., Shelton, R., Macaluso, M., Logan, J., Traxter, P., Li, J., Johnson, H., &  Greden, J. (2019). Comparing sensitivity to change using the 6-item versus the 17-item  Hamilton depression rating scale in the GUIDED randomized controlled trial. BMC  Psychiatry, 19(1), 1-10. 

https://doi-org.ezp.waldenulibrary.org/10.1186/s12888-019-2410-2

Dwyer, J. B., & Bloch, M. H. (2019). Antidepressants for pediatrics patients. Currentpsychiatry,  18(9), 26-42F

Marshe, V., Maciukiewicz, M., Rej, S., Tiwari, A., Sibille, E., Blumberger, D., Karp, J., Lenze,  E., Reynolds, C., Kennedy, J., Mulsant, B., Muller, D. (2017). Norepinephrine transporter  gene variants and remission from depression with venlafaxine treatment in older adults.  American Journal of Psychiatry, 5, 468.

https://doi-org.ezp.waldenulibrary.org/10.1176/appi.ajp.2016.16050617

Nik Jaafar, N. R., Selma Din, S. H., S. H., Mohamed Saini, S., Ahmad, S. N. A., Midin, M., Sidi,  H., Silim, U. A., & Baharudin, A. (2014). Clinical depression while caring for loved ones  with breast cancer. Comprehensive Psychiatry, 55(Supplement 1), S52-S59.

https://doi-org.ezp.waldenulibrary.org/10.1016/j.comppsych.2013.03.003

Potter, D. R. (2019). Major depression disorder in adults: A review of antidepressants.  International Journal of Caring Sciences, 12(3), 1936-1942.

Rosenthal, L. D., & Burchum, J. R. (2018). Lehne’s pharmacotherapeutics for advanced practice  providers. St. Louis, MO: Elsevier.

Saiz-Rodriguez, M., Belmonte, C., Roman, M., Ochoa, D., Koller, D., Talegon, M., … Abad- Santos, F. (2018). Effects of polymorphisms on the pharmacokinetics,  pharmacodynamics, and safety of sertraline in healthy volunteers. Basics & Clinical  Pharmacology & Toxicology, 122(5), 501-511.

Shen, Y., Wu, F., Zhou, Y., Ma, Y., Huang, X., Ning, Y., Lang, X., Lou, X., & Zhang, X. (2019).  Association of thyroid dysfunction with suicide attempts in first-episode and drug  naive patients with major depressive disorder. Journal of Affective Disorders, 259,  180-185

https://doi-org.ezp.waldenulibrary.org/10.1016/j.jad.2019.08.067

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

Stephenson, J., Distelberg, B., Mortin, K., Ortiz, L., & Montgomery, S. (2019). Different  depression treatment recommendations and adherence for Spanish and English-speaking  patients. JAFBM, 32(6), 904-912

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