Week 5 Discussion 1: Depression Case Study. Reply to Jessica Murphy

Reply Post Instructions:
Critique the decision making of your peer in your response post.
1. Do you agree/disagree with their medication choice? Why?
2. Is there anything else you recommend including?
3. Compare peer’s decision making to yours—what are the advantages and disadvantages of each?
Your response should include evidence of review of the course material through proper citations using APA format.
Please refer to the Grading Rubric for details on how this discussion will be graded. The described expectations meet the passing level of 80%. Students are directed to review the Discussion Grading Rubric for criteria which exceed expectations.

Case Study: Depression. Jessica Murphy Post:
The purpose of this discussion is to view the video about depression and answer questions regarding the case study. The case study presented is about. Alison a 38-year-old female who is divorced with two small children. She is exhibiting symptoms of depression. Over the last several months she has been feeling as though things are piling up and she is fed up. She feels things are black and she reports feeling miserable.
Identification of target symptoms/problems
What information, if any, would you like to know that was not included in the case?
The video interview with Alison was thorough and provides a great depiction of Alison’s current mental state. Though, I would like to know a bit more. I would like to know Alison’s family history if any with mental illness. I would also like to know Alison’s medical history as well as any medications or treatments she may be on. The interview reveals Alison has been feeling like this for several months; I would like to gain a better understanding of the onset of her symptoms. It is important to know if Alison engages in illicit drug/alcohol use. Lastly, I would like to know if she has been hospitalized in the past for depression or any other mental illness or if she has tried any other treatments in the past.
Which psychiatric symptoms are a treatment priority for this case?
Addressing suicidal ideations are always priority for any case. Alison reveals she has attempted suicide in the past by taking pills and hoped she would fall asleep and not wake up, thus assuring Alison is safe is priority. Alison is also experiencing anhedonia, weight loss, poor appetite, inability to concentrate, overwhelmed with simply daily tasks, forgetfulness, insomnia, recurrent suicidal ideations, tearful, and fatigued. Major depressive disorder is characterized as feeling depressed most days, markedly diminished interest or pleasure in all or almost all activities, weight loss, insomnia, decreased ability to think or concentrate, psychomotor agitation, and recurrent thoughts of death (5th ed.; DSM–5; American Psychiatric Association, 2013). Based on Alison’s symptoms and the DSM-5 criteria for major depressive disorder, Alison is experiencing several if not all of the symptoms of major depression, and her symptoms are now interfering with daily functioning, thus these symptoms must be treated.

What are the non-pharmacologic issues in this case (problems/complaints that cannot be addressed by medication)?
Concerns with Alison that cannot be addressed pharmacologically are her inability to pay bills due to having cuts at her job. Wages being cut may be playing a major role in her depression as this causes increased anxiety and stress as she does have two young children. The relationship strain she is experiencing also cannot be addressed with medication but may benefit from couples’ therapy. Alison also carries a great deal of guilt and grief from her previous marriage that seeking counseling or therapy will be able to address.
Medication Choice 1
List one medication that would be appropriate for this case. Include the name and starting dose.
For this particular case study, I would choose escitalopram 10mg oral tablet daily, in the morning or evening (Stahl, 2017). If necessary, I would increase to 20mg daily. According to NAMI (2021), it is approved for the treatment of major depressive disorder and generalized anxiety disorder.
Describe your clinical decision making. What is your rationale for choosing this medication? Also, include the mechanism of action for this medication choice, and the neurotransmitters and areas of the brain in which the medication is proposed to act on.
Escitalopram was chosen as first-line treatment for Alison as it has a low side effect profile. Escitalopram has a goal of complete remission of symptoms and if taken consistently has been shown to reduce or even eliminate symptoms (Stahl, 2017). Though, the onset of therapeutic action is not instant and may take 2-4 works, it is been found to be efficacious and well-tolerated.
Escitalopram is a selective serotonin reuptake inhibitor it works by boosting serotonin, blocks serotonin reuptake pump, desensitizes serotonin receptors, and is also presumed to increase serotonergic transmission (Stahl, 2017). The mean terminal half-life is 27-32 hours and steady-state plasma concentrations are achieved in one week (Stahl, 2017).
What laboratory testing/monitoring is needed for safely prescribing this medication?
For healthy individuals no tests are recommended (Stahl, 2017). Although, there is no recommended testing and/or monitoring for healthy individuals; SSRI’s are known to increase suicidal thoughts, thus it is good practice to monitor for mood or behavioral changes, including suicidal ideations. Electrolyte disturbances, EKG changes such as QT prolongation may occur and should be assessed using basic metabolic panel and EKG, especially in patients 65 years or older or with a family history of arrhythmias (Landy et al., 2021).
Are there any contraindications or safety issues associated with this medication?
Fatal serotonin syndrome can occur when taking escitalopram with MAOIs, thus it is important to not taken MAOIs for at least 14 days after stopping escitalopram or any SSRI (Stahl, 2017). Also, when taking antidepressants tramadol increases the risk of seizures. A patient should be carefully monitored with when taking escitalopram with triptans as weakness, hyerreflexia, and incoordination can occur (Stahl, 2017). There is an increased risk of bleeding when taking escitalopram with anticoagulants such as NSAID’s or warfarin (Landy et al., 2021). CYP2C19 metabolizes escitalopram, thus any inhibitors can place a patient at risk for adverse effects. It is recommended to use with caution with patient populations such as severe renal impairment and it is not recommended for use in pregnancy (Stahl, 2017).
Non pharmacologic Interventions
What non-pharmacologic interventions do you recommend? Do you recommend including but not limited to psychotherapy, complimentary and holistic therapies?
Several non-pharmacological interventions that can be utilized for Alison. Alison would greatly benefit from cognitive behavior therapy. In a study conducted by Gautam et al. (2020) it was found that CBT is an effective treatment strategy for depression and combined treatment with pharmacotherapy is significantly more effective than pharmacotherapy alone. Practicing mindfulness and deep breathing techniques will also help reduce stress and allow for balance. Assuring good sleep hygiene and proper diet such as reducing sugar and complex carbohydrates that quickly lead to a crash in mood and energy, while increasing intake of omega-3 fatty acids from fatty fish, fish oil, walnuts, and flaxseeds to help improve focus, reduce fatigue, and balance mood (Smith et al., 2020). I would also recommend that Alison and her current partner seek couples’ therapy to work on the relationship strain and to get a better understanding of each other. Reaching out to support systems such as friends and family can act as a distraction and can also boost mood. Alison has expressed she has a sister to which she is able to reach out to which I feel will be necessary in the healing process. I would institute community services such as visiting nursing at least three times a week to assess her mental state assuring she is not experiencing SI/HI and also to assure she is complying with her medications as prescribed. Alison may also benefit from a partial program for the first couple months where she is able to strengthen her coping skills. Lastly, exercise such as walking 30-40 minutes a day is a great nonpharmacological option to aid in lessening depressive symptoms. Exercise supports nerve cell growth in the hippocampus, improving nerve cell connections, in turn helping decrease depression (Harvard Medical School, 2021).
Safety Risk Assessment

What are the safety concerns, if any, associated with this case? How will you address safety?
Safety concerns noted in this case include Alison’s suicidal thoughts. Though, she does not feel she will attempt to commit suicide again, she does have a history which is a cause for concern. She has two young children living with her and it is important to keep Alison safe as well as her children. Alison has reached out for help and as she reveals in the video, she is thankful she is able to seek therapy at this point. I would assure Alison has the crisis hotline number as well as information on calling 911 if at any time she is having suicidal thoughts.
When would you follow up with this patient?
I would ask to see Alison in one week from the initiation of treatment an then about every two weeks after for approximately three months. It is important to re-assess her symptoms looking for improvement and/or worsening of symptoms as well as any necessary dosing changes.

References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders
(5th ed.). https://doi.org/10.1176/appi.books.9780890425596
Gautam, M., Tripathi, A., Deshmukh, D., & Gaur, M. (2020). Cognitive Behavioral Therapy for
Depression. Indian journal of psychiatry, 62(Suppl 2), S223–S229. https://doi.org/10.4103
/psychiatry.IndianJPsychiatry_772_19
Harvard Medical School (2021). Exercise is an all-natural treatment to fight depression.
https://www.health.harvard.edu/mind-and-mood/exercise-is-an-all-natural-treatment-to-
fight-depression
Landy, K., Rosani, A., & Estevez, R. (2021). Escitalopram.https://www.ncbi.nlm.nih.gov/books
/NBK557734/
NAMI (2021). Escitalopram. https://www.nami.org/About-Mental-Illness/Treatments/Mental-
Health-Medications/Types-of-Medication/Escitalopram-(Lexapro)
Smith, M., Robinson, L., & Segal, J. (2020). Schizophrenia treatment and self-help.
https://www.helpguide.org/articles/mental-disorders/schizophrenia-treatment-and-self
help.htm
Stahl, S. (2017). Essential psychopharmacology: The prescriber’s guide (6th ed.). Cambridge,
England: Cambridge University Press.