Depression Assessment and Treatment: Case Study Analysis

QUESTION

James is a 55-year old widower.  He lives alone in an apartment and has a 32-year-old married daughter who lives 1000 miles away.  Three months ago, James was forced to take early retirement from his job in middle management at a computer firm.  Over the past month he has exhibited depressed affect and has become so withdrawn that he no longer attends church or his weekly evening out with his friends.  He reports difficulty falling asleep and staying asleep, agitation, a weight loss of 15 pounds in 1 month, difficulty concentrating and making decisions, and ruminations and guilt about his wife’s death 10 years ago.  He was admitted to the hospital after his neighbor brought him to the emergency department.  There, James admitted plans to kill himself with a handgun he kept at home.  He had one previous episode of major depression at age 45, about the time of his wife’s death.  He has never made an actual suicide attempt.  James has been in the hospital for 13 days.  He has been taking sertraline (Zoloft) 100 mg every day and amitriptyline (Elavil) 100 mg before bed, and is being considered for discharge.

1. Identify four SSRI’s and three tricyclics that would be options for treating James’ depression.  Give both generic and trade names.

Generic Trade

1. Compare and contrast the onset of action, action and major side effect of the

SSRI’s and Tricyclics that James is being treated with.

SSRI’s Tricyclics

Onset

Action

Side Effect

1. Since James is suicidal what safety concern should be addressed when he is given a prescription
2. In discharge teaching with James what should he be told about stopping his medication without medical supervision?

Because James has not responded well to the tricyclic medication it was discontinued and a MAOI, tranylcypromine (Parnate) was added

1. How is the action of a MAOI similar and different to that of an SSRI and Tricyclic?
2. James is discharged and in two weeks you follow-up with a home visit. When you arrive, James is in the middle of lunch that includes the following: A grilled cheese sandwich with a side salad.  On the kitchen counter is an open bottle of Chianti wine.  What is the outcome of your discharge dietary teaching?  Why?
3. James reports that he has had a cold and last night took an over the counter cold preparation for sleep.  What actions do you take?

8. James starts to get up from the table and suddenly looses his balance.  Explain why this would be happening to James and what nursing action you would take.

ANSWER

Depression Assessment and Treatment: Case Study Analysis

Introduction

This essay delves into the case study of James, a 55-year-old widower experiencing depression and suicidal thoughts. It will address his treatment options, safety concerns, medication discontinuation, and dietary interactions. Moreover, it will explore the implications of an over-the-counter cold medication and the possible cause of his sudden loss of balance.

Treatment Options

SSRIs (Selective Serotonin Reuptake Inhibitors)
Fluoxetine (Prozac)
Sertraline (Zoloft)
Paroxetine (Paxil)
Escitalopram (Lexapro)

Tricyclics

Amitriptyline (Elavil)
Imipramine (Tofranil)
Nortriptyline (Pamelor)

Comparison of SSRIs and Tricyclics

Onset: SSRIs generally have a quicker onset of action compared to tricyclics.
Action: SSRIs primarily work by inhibiting serotonin reuptake, while tricyclics block reuptake of both serotonin and norepinephrine.
Side Effects: SSRIs tend to have fewer anticholinergic side effects than tricyclics, which often cause dry mouth, blurred vision, and constipation.

Safety Concern for Prescription

James should be educated about the risk of medication overdose due to suicidal thoughts. A small supply of medication should be given at a time, and he should be advised to store them safely.

Discontinuation of Medication

James should be informed that stopping antidepressants abruptly can lead to withdrawal symptoms and a potential relapse of depressive symptoms. Discontinuation should be done under medical supervision.

MAOI (Monoamine Oxidase Inhibitor)

MAOIs like tranylcypromine (Parnate) inhibit the breakdown of neurotransmitters, including serotonin, norepinephrine, and dopamine. Unlike SSRIs and tricyclics, they require dietary restrictions to prevent a hypertensive crisis, which can occur if foods rich in tyramine are consumed.

Dietary Teaching Outcome

James’ lunch includes a Chianti wine, which contains tyramine. MAOIs interact with tyramine, potentially leading to hypertensive crisis. Therefore, the outcome of the dietary teaching should be that James should avoid foods and beverages high in tyramine, including wine and aged cheeses.

Over-the-Counter Cold Medication

James took an over-the-counter cold medication, which could contain sympathomimetic agents. Given his history of agitation, this could exacerbate his symptoms. The nurse should inquire about the specific ingredients and consult with the healthcare provider.

Sudden Loss of Balance

James’ sudden loss of balance could be due to orthostatic hypotension, a side effect of tricyclics and MAOIs. The nurse should assess his blood pressure and heart rate, ensure a gradual change of position, and inform the healthcare provider if necessary.

Conclusion

James’ case highlights the complexity of treating depression and the importance of considering medication interactions, dietary restrictions, and potential side effects. By addressing these factors and ensuring proper education and follow-up, healthcare professionals can contribute to his overall well-being and safety.