Adult and Geriatric Antidepressant Therapy essay assignment discussion
Discussion: The Impact of Ethnicity on Antidepressant Therapy – The depressed man who thought he was out of options – Adult and Geriatric Antidepressant Therapy essay assignment discussion
Week 3: Adult and Geriatric Antidepressant Therapy
________________________________________
Discussion: The Impact of Ethnicity on Antidepressant Therapy
Major depressive disorder is one of the most prevalent disorders you will see in clinical practice. Treatment for this disorder, however, can vary greatly depending on client factors, such as ethnicity and culture. As a psychiatric mental health professional, you must understand the influence of these factors to select appropriate psychopharmacologic interventions. For this Discussion, consider how you might assess and treat the individuals in the case studies based on the provided client factors, including ethnicity and culture. Discussion: The Impact of Ethnicity on Antidepressant Therapy – The depressed man who thought he was out of options – Adult and Geriatric Antidepressant Therapy essay assignment discussion
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To prepare for this Discussion:
Case 3: Volume 1, Case #29: The depressed man who thought he was out of options
(The Case: The depressed man who thought he was out of options
The Question: Are some episodes of depression untreatable?
The Dilemma: What do you do when even ECT and MAOIs do not work)
SELECT CASE #3- VOLUME 1- CASE #29 ON STAHL’S ONLINE WEBSITE ABOVE
• Review this week’s Learning Resources and reflect on the insights they provide.
• Go to the Stahl Online website and examine the case study you were assigned ( CASE #3) AS ATTACHED SEPARATELY. .
• Take the pretest for the case study.
• Review the patient intake documentation, psychiatric history, patient file, medication history, etc. As you progress through each section, formulate a list of questions that you might ask the patient if he or she were in your office.
• Based on the patient’s case history, consider other people in his or her life that you would need to speak to or get feedback from (i.e., family members, teachers, nursing home aides, etc.). Discussion: The Impact of Ethnicity on Antidepressant Therapy – The depressed man who thought he was out of options – Adult and Geriatric Antidepressant Therapy essay assignment discussion
• Consider whether any additional physical exams or diagnostic testing may be necessary for the patient.
• Develop a differential diagnoses for the patient. Refer to the DSM-5 in this week’s Learning Resources for guidance.
• Review the patient’s past and current medications. Refer to Stahl’s Prescriber’s Guide and consider medications you might select for this patient.
• Review the posttest for the case study.
QUESTION
Post a response to the following:
• Provide the case number in the subject line of the Discussion thread.
• List three questions you might ask the patient if he or she were in your office. Provide a rationale for why you might ask these questions.
• Identify people in the patient’s life you would need to speak to or get feedback from to further assess the patient’s situation. Include specific questions you might ask these people and why.
• Explain what physical exams and diagnostic tests would be appropriate for the patient and how the results would be used. Discussion: The Impact of Ethnicity on Antidepressant Therapy – The depressed man who thought he was out of options – Adult and Geriatric Antidepressant Therapy essay assignment discussion.
• List three differential diagnoses for the patient. Identify the one that you think is most likely and explain why.
• List two pharmacologic agents and their dosing that would be appropriate for the patient’s antidepressant therapy based on pharmacokinetics and pharmacodynamics. From a mechanism of action perspective, provide a rationale for why you might choose one agent over the other.
• For the drug therapy you select, identify any contraindications to use or alterations in dosing that may need to be considered based on the client’s ethnicity. Discuss why the contraindication/alteration you identify exists. That is, what would be problematic with the use of this drug in individuals of other ethnicities?
• If your assigned case includes “check points” (i.e., follow-up data at week 4, 8, 12, etc.), indicate any therapeutic changes that you might make based on the data provided.
Discussion: The Impact of Ethnicity on Antidepressant Therapy – The depressed man who thought he was out of options – Adult and Geriatric Antidepressant Therapy essay assignment discussion
• Explain “lessons learned” from this case study, including how you might apply this case to your own practice when providing care to patients with similar clinical presentations
Week 3: Adult and Geriatric Antidepressant Therapy
The National Institute of Mental Health estimates that approximately 15.7 million adults in the United States have depression (NIMH, 2014), making depression one of the most common disorders you will treat in practice. Although this disorder is so prevalent, antidepressant therapy must be as unique as each individual you treat. There are dozens of antidepressant medications on the market, and you must be able to identify which medication or combinations of medications will result in the best outcomes for your clients.
This week, as you study antidepressant therapies, you examine the assessment and treatment of clients with mood disorders. You also explore ethical and legal implications of these therapies. Discussion: The Impact of Ethnicity on Antidepressant Therapy – The depressed man who thought he was out of options – Adult and Geriatric Antidepressant Therapy essay assignment discussion
Photo Credit: Comstock Images/Getty Images
Discussion: The Impact of Ethnicity on Antidepressant Therapy
Major depressive disorder is one of the most prevalent disorders you will see in clinical practice. Treatment for this disorder, however, can vary greatly depending on client factors, such as ethnicity and culture. As a psychiatric mental health professional, you must understand the influence of these factors to select appropriate psychopharmacologic interventions. For this Discussion, consider how you might assess and treat the individuals in the case studies based on the provided client factors, including ethnicity and culture.
To prepare for this Discussion:
Note: By Day 1 of this week, your Instructor will have assigned you to one of the following case studies to review for this Discussion. To access the following case studies, click on the Case Studies tab on the Stahl Online website and select the appropriate volume and case number.
Case 1: Volume 1, Case #1: The man whose antidepressants stopped working
Case 2: Volume 1, Case #7: The case of physician do not heal thyself
Case 3: Volume 1, Case #29: The depressed man who thought he was out of options
(The Case: The depressed man who thought he was out of options
The Question: Are some episodes of depression untreatable? Discussion: The Impact of Ethnicity on Antidepressant Therapy – The depressed man who thought he was out of options – Adult and Geriatric Antidepressant Therapy essay assignment discussion
The Dilemma: What do you do when even ECT and MAOIs do not work)
Review this week’s Learning Resources and reflect on the insights they provide.
Go to the Stahl Online website and examine the case study you were assigned.
Take the pretest for the case study.
Review the patient intake documentation, psychiatric history, patient file, medication history, etc. As you progress through each section, formulate a list of questions that you might ask the patient if he or she were in your office.
Based on the patient’s case history, consider other people in his or her life that you would need to speak to or get feedback from (i.e., family members, teachers, nursing home aides, etc.).
Consider whether any additional physical exams or diagnostic testing may be necessary for the patient.
Develop a differential diagnoses for the patient. Refer to the DSM-5 in this week’s Learning Resources for guidance. Discussion: The Impact of Ethnicity on Antidepressant Therapy – The depressed man who thought he was out of options – Adult and Geriatric Antidepressant Therapy essay assignment discussion
Review the patient’s past and current medications. Refer to Stahl’s Prescriber’s Guide and consider medications you might select for this patient.
Review the posttest for the case study.
Note: For this Discussion, you are required to complete your initial post before you will be able to view and respond to your colleagues’ postings. Discussion: The Impact of Ethnicity on Antidepressant Therapy – The depressed man who thought he was out of options – Adult and Geriatric Antidepressant Therapy essay assignment discussion. Begin by clicking on the “Post to Discussion Question” link and then select “Create Thread” to complete your initial post. Remember, once you click on Submit, you cannot delete or edit your own posts, and you cannot post anonymously. Please check your post carefully before clicking on Submit!
By Day 3
Post a response to the following:
Provide the case number in the subject line of the Discussion thread.
List three questions you might ask the patient if he or she were in your office. Provide a rationale for why you might ask these questions.
Identify people in the patient’s life you would need to speak to or get feedback from to further assess the patient’s situation. Include specific questions you might ask these people and why.
Explain what physical exams and diagnostic tests would be appropriate for the patient and how the results would be used.
List three differential diagnoses for the patient. Identify the one that you think is most likely and explain why.
List two pharmacologic agents and their dosing that would be appropriate for the patient’s antidepressant therapy based on pharmacokinetics and pharmacodynamics. Discussion: The Impact of Ethnicity on Antidepressant Therapy – The depressed man who thought he was out of options – Adult and Geriatric Antidepressant Therapy essay assignment discussion. From a mechanism of action perspective, provide a rationale for why you might choose one agent over the other.
For the drug therapy you select, identify any contraindications to use or alterations in dosing that may need to be considered based on the client’s ethnicity. Discuss why the contraindication/alteration you identify exists. That is, what would be problematic with the use of this drug in individuals of other ethnicities?
If your assigned case includes “check points” (i.e., follow-up data at week 4, 8, 12, etc.), indicate any therapeutic changes that you might make based on the data provided.
Explain “lessons learned” from this case study, including how you might apply this case to your own practice when providing care to patients with similar clinical presentations
Read a selection of your colleagues’ responses.
By Day 6
Respond to at least two of your colleagues who were assigned to a different case than you. For example, if you were assigned to Case Study 1, respond to one colleague assigned to Case Study 2 and one colleague assigned to Case Study 3. Explain how you might apply knowledge gained from your colleagues’ case studies to you own practice in clinical settings.
If your colleagues’ posts influenced your understanding of these concepts, be sure to share how and why. Include additional insights you gained. Discussion: The Impact of Ethnicity on Antidepressant Therapy – The depressed man who thought he was out of options – Adult and Geriatric Antidepressant Therapy essay assignment discussion.
If you think your colleagues might have misunderstood these concepts, offer your alternative perspective and be sure to provide an explanation for them. Include resources to support your perspective.
Learning Objectives
Students will:
Assess client factors and history to develop personalized plans of antidepressant therapy for adult and geriatric clients
Analyze factors that influence pharmacokinetic and pharmacodynamic processes in adult and geriatric clients requiring antidepressant therapy
Analyze the impact of ethnicity on antidepressant therapy
Evaluate efficacy of treatment plans
Apply knowledge of providing care to adult and geriatric clients presenting for antidepressant therapy
Adult and Geriatric Antidepressant Therapy
Student’s Name
Institutional Affiliations
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Adult and Geriatric Antidepressant Therapy
Case 3: Volume 1, Case #29: The depressed man who thought he was out of options
Treating adults and geriatric patients with a major depressive disorder can be very challenging due to variations in patient factors such as culture and ethnicity Discussion: The Impact of Ethnicity on Antidepressant Therapy – The depressed man who thought he was out of options – Adult and Geriatric Antidepressant Therapy essay assignment discussion. Therefore, for the mental health professionals to select the most appropriate interventions for such patients, they must have a comprehensive understanding of the influence of specific client factors on drug response (Stahl, 2013). The given case study describes the treatment process for a 69-year-old man who presents with depressive symptoms. If the patient was in my office, I would ask him three pertinent questions as part of history taking. First, I would ask him to explain the specific signs and symptoms that he has been having and for what period of time. Second, I would want to know whether any of his family members have suffered depression before. Third, I would ask about the types of drugs he is using at the moment. The rationale for why I might ask these questions is that knowledge of the patient’s symptoms, family medical history, and of the drugs he is using is very crucial for the selection of the most appropriate intervention for him (Stahl, 2013).
The patient’s wife, one of his children, and the clinician who has been providing care to him act as very good sources of information to allow a further assessment of his situation. The patient’s wife and child would be asked if they have noticed any changes in his behavior in the recent past. The clinician would be asked whether the patient has been responding positively to drugs. The physical exams that would be appropriate for the child include obtaining his weight, blood pressure, body mass index, body temperature, and pulse rate. The most appropriate diagnostic test is performing a magnetic resonance imaging (MRI) to assess brain function. The results of these tests will be used to determine the severity of the patient’s condition (Stahl, 2013).
Based on the client’s symptoms, the three differential diagnoses for him include major depressive disorder, bipolar disorder, and adjustment disorder with depressed mood. I think the most likely diagnosis for him is a major depressive disorder. The reason is that the patient is severely demoralized, depressed, worthless, helpless, hopeless, and has difficulty in concentrating (American Psychiatric Association, 2013). Discussion: The Impact of Ethnicity on Antidepressant Therapy – The depressed man who thought he was out of options – Adult and Geriatric Antidepressant Therapy essay assignment discussion Based on pharmacokinetics and pharmacodynamics, the two pharmacologic agents for the patient’s antidepressant therapy are desvenlafaxine and venlafaxine at a dosage of up to 200 mg for the former and a dosing higher than 375 mg for the latter (Stahl, 2014b). From the pharmacokinetic perspective, I would choose venlafaxine over desvenlafaxine because the former drug would be metabolized faster than the latter thereby making it more effective in relieving symptoms (Stahl, 2014b; Howland, 2008a).
Based on the client’s ethnicity, the healthcare professional should not use tricyclic antidepressant (TCA) and monoamine oxidase inhibitors (MAOI) which are effective in treating patients from other cultures. Rather, the clinician must be careful to use high doses of venlafaxine if positive results are to be realized. The reason is that the patient in the given case study is resistant to TCA and MAOI. The use of high doses of venlafaxine in individuals of other ethnicities may complicate symptoms instead (Yasuda et al., 2008; Stahl, 2014b).
Based on the data provided, I would augment MAOI with a stimulant at week 20 and obtain blood level of venlafaxine while at the same time avoiding the administration of Aripiprazole at week 24. In the cases study, the named proposals have been ignored by the clinician, a factor that has delayed the patient’s recovery process (Stahl, 2013). The two lessons that have been learned from the case study are that ethnicity and culture have a great influence on some episodes of depression, and high doses of venlafaxine should be used when an electroconvulsive therapy (ECT) and MAOI have proven to be ineffective. Therefore, when providing care to patients with similar symptoms in future, I will consider a therapeutic drug monitoring earlier in the treatment. Besides, I will consider genetic testing, particularly in children and geriatric patients who might seem to be resistant to commonly used drugs. Discussion: The Impact of Ethnicity on Antidepressant Therapy – The depressed man who thought he was out of options – Adult and Geriatric Antidepressant Therapy essay assignment discussion.
References
Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (4th ed.). New York, NY: Cambridge University Press.
Stahl, S. M. (2014b). The prescriber’s guide (5th ed.). New York, NY: Cambridge University Press.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author. Discussion: The Impact of Ethnicity on Antidepressant Therapy – The depressed man who thought he was out of options – Adult and Geriatric Antidepressant Therapy essay assignment discussion.
Howland, R. H. (2008a). 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
Yasuda, S.U., Zhang, L. & Huang, S.-M. (2008). The role of ethnicity in variability in response to drugs: Focus on clinical pharmacology studies. Clinical Pharmacology & Therapeutics, 84(3), 417–423. Retrieved from https://web.archive.org/web/20170809004704/https://www.fda.gov/downloads/Drugs/ScienceResearch/…/UCM085502.pdf
PATIENT FILE
The Case: The depressed man who thought he was out of options
The Question: Are some episodes of depression untreatable?
The Dilemma: What do you do when even ECT and MAOIs do not work?
Pretest Self Assessment Question (answer at the end of the case)
If a patient has low blood levels of an antidepressant at standard doses,
what could this mean?Adult and Geriatric Antidepressant Therapy Essay
A. Pharmacokinetic failure
B. Genetic variant causing pharmacokinetic failure
C. Pharmacodynamic failure
D. Genetic variant causing pharmacodynamic failure
E. Noncompliance
Patient Intake
• 69-year-old man
• Chief complaint: unremitting, chronic depression
Psychiatric History
• Recurrent, unipolar major depressive episodes for the past 40 years,
with good response to treatment and good inter-episode recovery
until fi ve years ago
• Onset then of one long, waxing and waning major depressive episode
ever since
• Five years ago, relapsed on venlafaxine 225 mg after having had a
good response to it
• Two years ago had nine electroconvulsive therapy (ECT) treatments
with a partial response
• In the past few years since relapse on venlafaxine has tried
(adequate trials, no severe side effects)Adult and Geriatric Antidepressant Therapy Essay. essentially every known
antidepressant and augmentation combination known or reported
in the literature, from many capable psychiatrists and numerous
consultations from local, regional, and national psychiatrists, and
distinguished medical centers
– 5 SSRIs
– Duloxetine
– Mitazapine
– 2 TCAs
– Augmentation with 5 different atypical antipsychotics
– Augmentation with
– Lithium
– Thyroid
– Buspirone
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PATIENT FILE
324
– L-methylfolate
– Others
• Following ECT, given the MAOI phenelzine (Nardil) up to 105 mg/day
with some orthostasis, some antidepressant response, wearing off
despite increasing doses, and then all response to phenelzine wore
off
• Trials even included the controversial and heroic combination of an
monoamine oxidase inhibitor (MAOI) and a tricyclic antidepressant
(TCA) phenelzine plus nortriptyline, all ineffective
• Came to you on phenelzine 90 mg, nortriptyline 50 mg, and
occasional lorazepam, for your treatment recommendations
Medical History
• Not contributory
• Other medications:
– Boniva for osteoporosis
– Avapro for hypertension
– Lipitor for hypercholesterolemia
– Flomax for enlarged prostate
– Melloxicam for arthritis
Social and Personal History
• Married, 3 children, 8 grandchildren
• Retired engineer
• Non smoker, no drug or alcohol abuse
Family History
• Several fi rst degree relatives: depression
• No family history of suicide
Patient Intake
• Severely depressed and demoralized
• No joy or pleasure; sad, feeling helpless, hopeless, worthless,
problems concentrating
• Past two years rates himself 9/10 in severity (10 worst)
• Wife states he is letting go and giving up
Of the following choices, what would you do?
• Add one of the new antipsychotics, asenapine, iloperidone or
lurasidone that he has not taken yet
• Augment the MAOI with a stimulant, which is one of the few
combinations he has not tried yet
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PATIENT FILE
325
• Discontinue the nortriptyline and augment the MAOI
• Discontinue the MAOI and augment the nortriptyline
• Discontinue both the TCA and the MAOI and prescribe something else
• Send to another psychopharmacologist; this patient is too sick and
the prognosis is poor
• Do a complete medical and endocrine and neurological evaluation to
see if any underlying condition has developed that has been missed
• Look into personal and family dynamics to see if this is really a
resistant depression disguising other problems
• None of the above
Further Investigation
Is there anything else you would especially like to know about this
patient?
• What about details concerning his medical and neurological status?
– During the past year the patient has had extensive medical,
endocrine and cancer workups, all negative
– During the past year has also had neurological evaluation, with
normal EEG, MRI
– Neuropsychological tests consistent with severe depression but
without signs of an early dementia
• What about personal and family dynamics?
– Patient and family are indeed quite concerned about his
depression, fearing he will die before he recovers
– Patient has a long standing supportive marriage and supportive
children and no major fi nancial problems
– Has coped with recurrent episodes of depression his whole
life, bouncing back after each setback, but now has given up,
frightening his family
– No obvious reason to suspect family or personal dynamics as the
source of his depression
– However, he does have extreme negativity and a cognitive
approach may be useful if he begins to get enough motivation to
participate in this approach
If you would give or refer him for an experimental or “off label” protocol,
test or treatment, which would you choose?
• Intravenous single injection of ketamine (NMDA N-methyl-d-aspartate
antagonist) in an experimental protocol
• Send him for experimental DBS (deep brain stimulation)
• Oral riluzole (putative inhibitor of glutamate release)
• Acetylcholinesterase inhibitor in case this is really early dementia
• Send him for a quantitative EEG
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PATIENT FILE
326Adult and Geriatric Antidepressant Therapy Essay
• Send him for pharmacogenomics testing
• Send him for therapeutic drug monitoring
• I would not prescribe experimental treatments off label, nor send him
for an experimental protocol
Attending Physician’s Mental Notes: Initial Psychiatric
Evaluation
• There are very few remaining treatment options
Acetylcholinesterase inhibitor
• No evidence of dementia
• Treatment seems a long shot for his depression
TMS
• The patient may be a candidate for TMS
• However, TMS is not well documented to work in a case this severe,
especially in a case with less than robust responses to ECT
DBS
• DBS is a possibility, but only a research protocol, even though it
might save his life
• Only a few centers offer this procedure in the US and Canada
• Unclear how this will be paid as insurance probably does not cover
• However, some promising early results in treatment resistant
depression
• Will tell patient and family and referring psychiatrist about this and
provide literature but not advise action yet
Ketamine
• Intravenous single injection of ketamine is an experimental protocol
• Available as a research test at the NIMH (National Institute of Mental
Health) and a few universities
• A number of studies confi rm effi cacy in treatment resistant major
depression
• However, it only works for a few hours and then wears off and not
practical to repeat it
• Not only ketamine, but several NMDA 2B subtype selective
antagonists (NR2B selective antagonists) are in clinical testing, some
of which are orally administered
• Too early to tell whether this will pan out and not available for open
label administration, only double blind trials
Referenced EEG
• A new type of EEG protocol, referenced EEG reports promising results,
but not in patients this severe and still considered a research tool
• Only available in a limited number of research centers and not proven
to predict clinical response to specifi c antidepressants, especially in a
case like this
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PATIENT FILE
327Adult and Geriatric Antidepressant Therapy Essay
SPECT scans
• Some commercial clinics offer older imaging technology (SPECT is
Single Photon Emission Computed Tomography) as brain scans for sale
• They do generate color pictures of brain activity that can be
impressive looking to patients
• Scans are accompanied with an algorithm claiming to predict which
drug to use
• Although this looks has a high-tech, scientifi c appearance, and raises
hope, it is not well accepted in the scientifi c community and costs
several thousand dollars not covered by insurance
Genotyping
• This approach may be useful in vulnerable populations of patients
such as children or elderly and those who do not respond to many
medications
• Genetic variants of cytochrome P450 (CYP45) drug metabolizing
enzymes can in some cases explain unusually high or unusually low
blood and brain concentrations of drugs:
– 2D6
– 2C19
– 2D9
– Others
– This might be useful here since this patient seems not to respond
to a wide number of medications now, and also has no notable
side effects from them
– Is it possible that his drug levels are low due to a drug
metabolizing enzyme variant, some variant of drug absorption, or
possibly noncompliance?
• Genetic variants of multiple neurotransmitter based genes, upon which
many antidepressants act, may help explain both who responds to what
antidepressant, and who gets side effects from what antidepressant
Phenotyping
• Determining whether a patient has high or low blood levels of a drug
establishes the phenotypes of:
– Poor metabolizers
– Extensive metabolizers
– Compliance/adherence
– Pharmacokinetic variants can explain how he absorbs and
metabolizes his antidepressants and thus measurement of
genetic variants of CYP450 drug metabolizing enzymes may be
helpful in explaining why the patient is not responding, especially
if he does not generate adequate plasma and brain drug levels
(pharmacokinetic)Adult and Geriatric Antidepressant Therapy Essay
• Advised his local treating psychiatrist to augment phenelzine with
stimulant
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PATIENT FILE
328
Attending Physician’s Notes: First Interim Followup, Week 20
• Local/referring psychiatrist declined to augment MAOI with stimulant
as recommended
• Decided instead to give ECT again
• Local/referring psychiatrist thought eleven ECT treatments improved
him 60%
• Stopped MAOI prior to ECT and then started venlafaxine 225 mg/
mirtazapine 30 mg (“California rocket fuel”) as ECT began
• Post ECT, severe subjective memory problems, patient very
discouraged
• Nevertheless, given maintenance ECT; venlafaxine increased to 375
mg and mirtazapine increased to 45 mg
• After ninth maintenance ECT (20th overall), developed an expressive
aphasia, question of a stroke versus a complication of ECT; cardiac
catheterization was normal except for a possible patent foramen ovale
of unknown signifi cance
• Consulting neurologist thought patient’s aphasia was a complication
of ECT
• However, referring psychiatrist thought the patient’s aphasia was due
to a stroke so lowered venlafaxine to 225 mg, being afraid of potential
elevated BP, pulse and further cardiovascular/cerebrovascular
complications
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• BP remained normal and under control; aspirin added to treatment
Case Outcome: First Interim Followup, Week 20
• Phone consultation one month after the post-ECT “event” and 20
weeks since initial evaluation in the offi ce
• Patient was still having memory problems, speech problems, and
worsening depression
• Taking venlafaxine 225 mg, plus mirtazapine 45 mg, plus alprazolam
prn, now augmented with aripiprazole 10 mg
• Before chasing after exotic testing and treatments considered in the
mental notes during the initial psychiatric evaluation 20 weeks ago
(listed above), perhaps it would be a good idea simply to send off
blood for therapeutic drug monitoring to see how well he is absorbing
his venlafaxine and whether there is any room for a rational and safe
dose increase
• Unclear why he is no longer responding to doses of venlafaxine that
have occurred would in the past, but this is frequently observed in the
progression of major depressive episodes over many years
• Specifi cally recommended getting drug levels of venlafaxine and its
active metabolite O-desmethyl-venlafaxine, and consider increasing dose
of venlafaxine XR to 300 mg or 375 mg while monitoring BP and mood
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329Adult and Geriatric Antidepressant Therapy Essay
PATIENT FILE
Case Outcome: Second Interim Followup, Week 24
• Phone consultation in another month showed patient’s aphasia had
resolved and memory improving, but mood still low; mood as bad as it
was prior to ECT
• Seems more clear that aphasia was due to ECT and not to a stroke
• Venlafaxine blood levels not obtained and dose stayed at 225 mg
• Aripiprazole was increased to 15 mg
• Requested blood levels of venlafaxine/O-desmethylvenlafaxine again,
and then to raise venlafaxine dose to 300 mg, as advised 4 weeks ago
Case Outcome: Third Interim Followup, Week 28
• Phone consult in another month, referring psychiatrist did get
venlafaxine/O-desmethylvenlafzine blood levels, both of which were
found to be low while taking a dose of 225 mg of venlafaxine XR
• Referring psychiatrist now agrees to increase venlafaxineXR to 300
mg and to discontinue aripiprazole
Case Outcome: Fourth Interim Followup, Week 32
• No improvement in depression
• Advised getting repeat venlafaxine/O-desme
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