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    Empty Nest Assignment v.2021-22

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    Rishab Chawla
    Mrs. Baker, a 49-year-old woman, developed symptoms of depression including insomnia, loss of energy, loss of interest, crying frequently, worrying obsessively, and suicidal thoughts after her youngest daughter left for college. Her symptoms meet the criteria for major depressive disorder. Her physical exam ruled out medical causes and she was prescribed an SSRI, which helped improve her symptoms except for loss of sexual interest. Her diagnosis, treatment options, and prognosis would need to be monitored long term due to her family history of depression and past suicidal ideation.

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    Empty Nest Assignment v.2021-22

    Uploaded by

    Rishab Chawla
    66 views4 pages
    Mrs. Baker, a 49-year-old woman, developed symptoms of depression including insomnia, loss of energy, loss of interest, crying frequently, worrying obsessively, and suicidal thoughts after her youngest daughter left for college. Her symptoms meet the criteria for major depressive disorder. Her physical exam ruled out medical causes and she was prescribed an SSRI, which helped improve her symptoms except for loss of sexual interest. Her diagnosis, treatment options, and prognosis would need to be monitored long term due to her family history of depression and past suicidal ideation.

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    Mrs. Baker, a 49-year-old woman, developed symptoms of depression including insomnia, loss of energy, loss of interest, crying frequently, worrying obsessively, and suicidal thoughts after her youngest daughter left for college. Her symptoms meet the criteria for major depressive disorder. Her physical exam ruled out medical causes and she was prescribed an SSRI, which helped improve her symptoms except for loss of sexual interest. Her diagnosis, treatment options, and prognosis would need to be monitored long term due to her family history of depression and past suicidal ideation.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    66 views4 pages

    Empty Nest Assignment v.2021-22

    Uploaded by

    Rishab Chawla
    Mrs. Baker, a 49-year-old woman, developed symptoms of depression including insomnia, loss of energy, loss of interest, crying frequently, worrying obsessively, and suicidal thoughts after her youngest daughter left for college. Her symptoms meet the criteria for major depressive disorder. Her physical exam ruled out medical causes and she was prescribed an SSRI, which helped improve her symptoms except for loss of sexual interest. Her diagnosis, treatment options, and prognosis would need to be monitored long term due to her family history of depression and past suicidal ideation.

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    © All Rights Reserved
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    Empty Nest Assignment

    Learning Objectives

    1. Identify the diagnostic criteria and clinical presentation for various mood disorders.
    2. Articulate the key principles of treatment for major depression including psychotherapeutic,
    pharmacological, and other somatic treatments.
    3. Understand and apply to clinical practice the risk factors associated with suicide and
    suicidal behavior.

    Mrs. Baker is a 49-year-old female who has been married for 28 years. She has three grown
    children. The two older ones are married and have left home. The youngest one, Becky, is a
    sophomore in college. Now it's only her and her husband at home.

    After Becky left, Mrs. Baker was doing fairly well, although she freely admits she was missing
    her kids and felt “at loose ends.” A few months later, however, she developed insomnia, loss of
    energy, loss of interest in things, and started to cry frequently. She could not quit worrying about
    Becky, and she kept rehearsing all kinds of bad scenarios in her mind about what might happen
    to her daughter. She started to call her daughter several times a day for reassurance, but it did not
    help. She had no appetite and lost quite a bit of weight. She felt tired all the time and started to
    feel hopeless and worthless. She even had some suicidal thoughts, which really scared her. This
    went on for about four months. She thought she might "snap out of this," but her condition just
    did not improve. This was doubly frightening to her because her mother had several bouts with
    severe depression, including two failed suicide attempts, which necessitated psychiatric
    hospitalizations. "I don't want to go down that same road!" She also worried that she may be
    medically ill. She underwent a complete physical, including blood work, which showed no
    significant medical problems, other than the beginning of menopause. Her primary care
    physician put her on an SSRI. This seemed to help. Mrs. Baker's appetite returned, ("now it's
    almost too good! I'm gaining too much weight!"), she is sleeping through the night, she has more
    energy, and her obsessive worrying has ceased. The only major concern today is that Mrs. Baker
    has absolutely no sexual interest or desire. "If this does not improve, doctor, I'm afraid for my
    marriage."

    QUESTIONS:
    1. What is on her differential and what is her most likely diagnosis?

    MDD
    Adjustment Disorder
    GAD
    Bipolar Disorder
    2. What would you have to be on the lookout for as far as her medical status? Which medical
    problems might mimic depression?

    Hypothyroidism
    Dementia

    v.2021-22
    Adrenal insufficiency
    Cushing syndrome
    Vitamin D/B12 deficiency
    MS
    Hep C, HIV
    Menopause

    3. What factors would help you determine the appropriate setting for treatment: Outpatient,
    inpatient, or day treatment?

    Social support (obtain collateral)


    Degree of impairment
    Suicidality
    Admit if patient refuses to eat, has unkempt appearance, displays SI/HI, or psychosis

    4. What factors should be considered when you select an antidepressant?

    Side effect profile


    Dosage and routes of administration
    Hx and FHx of mental health disorders and treatments that have worked
    Interactions with other medications
    Cost and accessibility

    5. How long would you treat with it and how do you decide? What are the phases of treatment?

    Acute (6 – 12 weeks)
    Continuation (4 – 9 months)
    Maintenance (1 year out)
    For beyond a year, look at past number of depressive episodes in the past, hx of suicide, and
    residual symptoms, stressors and psychosocial environment

    6. At what point would you change the medication? Augment with another medication? What are
    your options for each?

    Change if side effects interfere with daily functioning.


    Can either replace or augment with bupropion if there are sexual side effects
    Augment with aripiprazole
    Augment with psychotherapy
    Lithium and clozapine (if chronic SI – to decrease suicidality)
    If comorbid hypothyroidism, supplement with levothyroxine
    If comorbid anxiety, buspirone or propranolol

    7. What about the role of psychotherapy in depression? Is there evidence that psychotherapy
    improves mood? What types of psychotherapy have been shown to be beneficial?

    Psychotherapy is an adjunct (not monotherapy) for depression that has been shown to improve

    v.2021-22
    mood.
    CBT: Breaking the negative cycle between thoughts, feelings, and behaviors
    Interpersonal therapy: Helping the patient with their relationships with others
    Behavioral therapy

    8. Is there a role for ECT or other somatic treatments in this case? When would it be considered?
    What are the contraindications? Side effects? Typical course of treatment?

    Not eligible because has not yet failed 2 antidepressant trials

    Indications:
    Catatonic schizophrenia
    Elderly patients with polypharmacy
    Depression with psychotic features
    Pregnancy

    Contra-indications:
    No absolute CIs.
    Relative – recent cardiovascular event; elevated ICP (look for papilledema)

    Side effects:
    Retrograde and anterograde amnesia
    Headaches

    Course:
    2-3x weekly for a total of 6 – 12 sessions.

    ABBREVIATIONS:
    MDD = major depressive disorder
    CVA = cerebral-vascular accident
    ECT = electroconvulsive therapy
    VNS = vagal nerve stimulations
    TMS = transcranial magnetic stimulation
    CBT = cognitive behavioral therapy
    IPT = interpersonal therapy
    MAOI = monoamine oxidase inhibitors
    SSRI = selective serotonin reuptake inhibitors

    REFERENCES:
    1. American Psychiatric Association: Practice guideline for the treatment of patients with major
    depressive disorder, 3rd edition in Supplement to the American Journal of Psychiatry, Vol 167
    (10), October 2010.
    2. Preskorn S.H. , Treatment Options for the Patient who does not respond well to initial
    antidepressant therapy, J of Psychiatric Practice Vol 15 (3), 202-210, May 2009.
    3. MCG- GHSU Psychiatry Clerkship Survival guide, 2011.

    v.2021-22
    PLEASE REFER TO THE CLERKSHIP SURVIVAL GUIDE OR ANY TEXTBOOK
    MNETIONED IN THE
    RECOMMENDED READOING LIST FOR A DESCRIPTION OF MEDICATION CLASSES
    MENTIONED
    IN THIS DISCUSSION.

    v.2021-22

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