Description
I NEED TO RESPND TO MY CLASSMATES DISCUSSION BOARD RESPONS
-Student # 1 Response:T. A.
Major Depressive Disorder (MDD) with psychotic features includes the symptoms of delusions and/or auditory or visual hallucinations that correlate with the theme of guilt and worthlessness (Rothschild, 2022). This gentleman was prescribed Fluoxetine 20 mg PO daily for the previous four-plus years. The apparent goal of treating MDD with psychotic features is remission, including resolving psychotic symptoms, such as auditory hallucinations and depressive symptoms (Rothschild, 2022). For the patient who does reach remission, it is reasonable to observe a significant response with stabilization of the patient’s welfare and the intensity and frequency of his psychotic symptoms (Rothschild, 2022). The latest research suggests that the hospitalized patient be monitored daily if not acutely suicidal (Rothschild, 2022). Acutely suicidal patients with a plan and inpatients should be monitored constantly (Rothschild, 2022). In the outpatient setting, patients who do not significantly reduce psychotic symptoms and depression should receive weekly follow-ups (Rothschild, 2022). At the same time, those who show improvement can be seen every two to four weeks until they reach remission (Rothschild, 2022).
The decision to increase the patient’s fluoxetine to 40 mg PO from 20 mg PO daily, add Zyprexa 2.5 mg PO nightly, and trazodone 50 mg PO nightly is a viable option for this patient. The latest research findings suggest keeping the fluoxetine at 20 mg PO daily when adding the Zyprexa 2.5 mg PO nightly for the older adult (Rothschild, 2022). This initiation dose is for caution of the side effects of weight gain, sedation, orthostasis, frequent falls, and increases in cholesterol, triglyceride, and glucose concentrations at the end of the latest trial (Rothschild, 2022). For this patient, one could consider the administration of Symbyax (olanzapine/fluoxetine combination) (Stahl, 2021). The 5HT2C antagonistic actions and the serotonin reuptake blockade of fluoxetine complement the actions of olanzapine when administered as Symbyax (Stahl, 2021). Should this patient present with partial response or treatment resistance, the recently most recommended augmentation medications include Valproic acid and other mood-stabilizing anticonvulsants such as carbamazepine, oxcarbazepine, and lamotrigine, topiramate, and lithium suggested (Stahl, 2021).
References
Rothschild, A. J., MD. (2022). Unipolar major depression with psychotic features: Acute treatment. UpToDate. Retrieved January 28, 2023, from https://www.uptodate.com/contents/unipolar-major-depression-with-psychotic-features-acute-treatmentLinks to an external site.
Stahl. (2021). Prescriber’s guide – stahl’s essential psychopharmacology (7th) by stahl, stephen [paperback (2021)] (7th ed.). Cambridge University Press.
Student #2 ResponseJ.B.
Based on the detailed patient history documented, I agree with you that major depressive disorder (MDD) with psychotic symptoms is the most likely diagnosis for this patient. The patient presented with both major depression symptoms and demonstrated a loss of touch with reality or psychosis. Studies have shown that the prognosis of major depressive disorder is poor in patients with psychotic symptoms (Bains & Abdijadid, 2022). Therefore, patients presenting with this disorder need additional evaluation and enhanced plans of care for better outcomes. Patients diagnosed with MDD with psychotic features present with usual MDD symptoms such as anhedonia, depressed mood, suicidal thoughts, and lack of motivation in addition to hallucinations, delusions, or both. The patient you encountered reported auditory hallucinations where he hears voices that he does not recognize. It is worth noting that psychotic features are common in patients with MDD. Dold et al. (2019) estimated a prevalence rate of 10.92%. The presence of psychotic features in MDD patients could increase morbidity and mortality. For example, voices may command depressed clients to commit suicide or harm others. Clinicians must be aware not to misdiagnose this condition with dementia.
One of the questions that you prompted talks about the possibility of distinguishing psychotic depression, dementia, and brief psychotic disorder in elderly patients. Yes, with a detailed patient history, it is possible to distinguish between these common mental disorders affecting older patients. As mentioned earlier, psychotic depression is diagnosed when the patient presents with psychotic features in the presence of dysthymia or major depression (Dubovsky et al., 2020). Brief psychotic disorder, as the name suggests, is diagnosed when clients present with psychotic symptoms that last one month or less. It is worth mentioning that this is usually followed by complete remission with possible future relapses. As noted earlier, clinicians must effectively distinguish between psychotic depression and dementia. Studies have shown that some older clients with dementia may become indistinguishable from depressed patients (Tetsuka, 2021). This is because both disorders may present with similar symptoms such as cognitive impairment. However, comprehensive information could help to distinguish between the two disorders. For instance, depression is mainly associated with concentration difficulties whereas dementia is associated with short-term memory problems.
References
Bains, N., & Abdijadid, S. (2022). Major depressive disorder. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK559078/Links to an external site.
Dold, M., Bartova, L., Kautzky, A., Porcelli, S., Montgomery, S., Zohar, J., Mendlewicz, J., Souery, D., Serretti, A., & Kasper, S. (2019). Psychotic features in patients with major depressive disorder: A report from the European group for the study of resistant depression. The Journal of Clinical Psychiatry, 80(1), 17m12090. https://doi.org/10.4088/JCP.17m12090Links to an external site.
Dubovsky, Steven L., Ghosh, Biswarup M., Serotte, Jordan C., & Cranwell, V. (2020). Psychotic depression: Diagnosis, differential diagnosis, and treatment. Psychotherapy and Psychosomatics, 90(3), 1–18. https://doi.org/10.1159/000511348Links to an external site.
Tetsuka S. (2021). Depression and dementia in older adults: A neuropsychological review. Aging and Disease, 12(8), 1920–1934. https://doi.org/10.14336/AD.2021.0526
Student # 3
Thank you once again for sharing your interesting grand rounds presentation. Smoking and multiple mental health disorders has been observed to be a common combination over the years. According to research a large number of individuals with mental health disorders has been reported to be smokers when compared to individuals that have no mental health problems. It was reported that smoking rates are significantly higher in individuals with chronic mental illness. It was estimated that 70-85% of individuals diagnosed with schizophrenia and approximately 50-70% of individuals diagnosed with bipolar and depression smokes. It is believed that smoking is more prevalent among these populations because the nicotine temporally decreases the effects of their symptoms of low mood, anxiety, stress, and poor concentration (“Do people with mental illness and substance use disorders use tobacco more often?,” 2022).
Smoking cessation is known to significantly affect the concentration of the antipsychotic olanzapine (Zyprexa) levels within a patient, because it induces the activity of the human cytochromes P450 (CYP) 1A2 and 2B6. The decrease of CYP1A2 activity after smoking cessation increases the toxicity of olanzapine which puts the patient at risk for adverse drug reactions (Chui et al., 2019). To determine the required dose reduction of olanzapine needed after smoking cessation can be challenging and requires regular therapeutic drug monitoring. This is because tobacco products interact by decreasing the serum concentrations of the medication by 36% to 50% which results in an increased drug clearance. Research was conducted with smokers and non-smokers, and it was found that the doses of olanzapine given for a mental disorder had to be reduced by 30% to 50% in a non-smoker to gain the same concentrations as an individual who is a smoker (Kertes et al., 2021). It is very important to monitor for drug interactions and compatibility when prescribing a medication for smokers and recreational/street drug users in comparison to non-smokers and non-drug users.
References
Chui, C. Y., Taylor, S. E., Thomas, D., & George, J. (2019). Prevalence and recognition of highly significant medication-smoking cessation interactions in a smoke-free hospital. Drug & Alcohol Dependence, 200, 78–81. https://doi.org/10.1016/j.drugalcdep.2019.03.006Links to an external site.
Do people with mental illness and substance use disorders use tobacco more often? (2022, May 25). National Institute on Drug Abuse. https://nida.nih.gov/publications/research-reports/tobacco-nicotine-e-cigarettes/do-people-mental-illness-substance-use-disorders-use-tobacco-more-oftenLinks to an external site.
Kertes, J., Stein Reisner, O., Grunhaus, L., & Neumark, Y. (2021). The Impact of Smoking Cessation on Hospitalization and Psychiatric Medication Utilization among People with Serious Mental Illness. Substance Use & Misuse, 56(10), 1543–1550. https://doi.org/10.1080/10826084.2021.1942057
