: The man whose antidepressants stopped working Major depressive disorder is one of the most prevalent disorders we will see in our clinical practice.  Treatment options for MDD can vary greatly contingent on the appropriate psychopharmacologic interventions being adopted for our clients.  Medication nonadherence for patients with chronic diseases is extremely common, affecting as many as 40% to 50% of patients who are prescribed medications for management of chronic conditions (Kleinsinger, 2018). Nonadherence isn't a new problem.  However, offering clients valuable interventions and education to overcome any potential compliance barriers will help the provider identify any challenges and decide how to achieve mutually agreed-upon goals to improve their health.  Questions 1.  Do you ever feel that taking your medications is a nuisance or inconvenience?  Do you have a difficult time remembering to take your medications or forget?   •&νβσπ;&νβσπ;&νβσπ;&νβσπ;&νβσπ;&νβσπ;Developing a medication schedule, It is difficult to come up with a schedule to take medications every day for some patients. Collaboratively we need to come up with a convenient time to take the antidepressant and the other prescribed medication for them to be effective. 2.  Does your prescribed medications and treatment regimen still leave you feeling depressed?  Do you have a difficult time adhering to a prescribed regimen?  •&νβσπ;&νβσπ;&νβσπ;&νβσπ;&νβσπ;&νβσπ;The patient discontinued his Effexor although it appeared to be effective. It is essential to find out the patient’s reason for not following the prescribed regimen and come up with a solution together.   •&νβσπ;&νβσπ;&νβσπ;&νβσπ;&νβσπ;&νβσπ;It is crucial for the patient to take his antidepressants accordingly, as well as not skip or alter the dosage, nor terminate the medication once you start feeling better.  3.  Have the side effects of your medications been difficult to cope with or manage?  Do you sometimes stop taking your medications because of the adverse effects?  Sertraline has been prescribed in the past and discontinued several times. The patient experienced side effects of sexual dysfunction and stopped taking.  Encourage the patient to monitor any side effects, physical and emotional changes or occurrences. Stopping medications and treatment regimens prematurely or abruptly have been associated with high relapse rates and can cause serious withdrawal symptoms (Henssler, Heinz, Brandt, & Bschor, 2019). Important People  Family members and other caregivers bring personal knowledge on the suitability or lack thereof regarding different treatments for the patient's circumstances and preferences (Smith, 2013).  The patient is married, so I would address additional questions to his wife.  After getting permission to discuss his medical records with his family members, I would ask the wife if she knew what medications her husband was taking?  If she knew why he was taking them?  Informed and en.

1. : The man whose antidepressants stopped working
Major depressive disorder is one of the most prevalent disorders
we will see in our clinical practice. Treatment options for MDD
can vary greatly contingent on the appropriate
psychopharmacologic interventions being adopted for our
clients.
Medication nonadherence for patients with chronic diseases is
extremely common, affecting as many as 40% to 50% of
patients who are prescribed medications for management of
chronic conditions (Kleinsinger, 2018). Nonadherence isn't a
new problem. However, offering clients valuable interventions
and education to overcome any potential compliance barriers
will help the provider identify any challenges and decide how to
achieve mutually agreed-upon goals to improve their health.
Questions
1.
Do you ever feel that taking your medications is a nuisance or
inconvenience? Do you have a difficult time remembering to
take your medications or forget?
•&νβσπ;&νβσπ;&νβσπ;&νβσπ;&νβσπ;&νβσπ;Developing a
medication schedule, It is difficult to come up with a schedule
to take medications every day for some patients. Collaboratively
we need to come up with a convenient time to take the
antidepressant and the other prescribed medication for them to
be effective.
2.
Does your prescribed medications and treatment regimen still

2. leave you feeling depressed? Do you have a difficult time
adhering to a prescribed regimen?
•&νβσπ;&νβσπ;&νβσπ;&νβσπ;&νβσπ;&νβσπ;The patient
discontinued his Effexor although it appeared to be effective. It
is essential to find out the patient’s reason for not following the
prescribed regimen and come up with a solution together.
•&νβσπ;&νβσπ;&νβσπ;&νβσπ;&νβσπ;&νβσπ;It is crucial for the
patient to take his antidepressants accordingly, as well as not
skip or alter the dosage, nor terminate the medication once you
start feeling better.
3.
Have the side effects of your medications been difficult to
cope with or manage? Do you sometimes stop taking your
medications because of the adverse effects?
Sertraline has been prescribed in the past and discontinued
several times. The patient experienced side effects of sexual
dysfunction and stopped taking. Encourage the patient to
monitor any side effects, physical and emotional changes or
occurrences.
Stopping medications and treatment regimens prematurely or
abruptly have been associated with high relapse rates and can
cause serious withdrawal symptoms (Henssler, Heinz, Brandt, &
Bschor, 2019).
Important People
Family members and other caregivers bring personal knowledge
on the suitability or lack thereof regarding different treatments
for the patient's circumstances and preferences (Smith, 2013).

3. The patient is married, so I would address additional questions
to his wife. After getting permission to discuss his medical
records with his family members, I would ask the wife if she
knew what medications her husband was taking? If she knew
why he was taking them? Informed and engaged patients,
invested in their own health care as well as in the improvement
of the broader health care system, are crucial to a learning
system (Smith, 2013). Family support is essential for patients
suffering from depression where patients are feeling less
motivated or forgetful when taking medications. Asking family
members if the patient has been experiencing any side effects or
illnesses since starting the medication emphasizes self-centered
care and mutually agreed-upon goals (Siminoff, 2013).
Physical Exams and Diagnostic Tests
CC:
worst depression and anxiety he has ever felt
HPI:
63-year-old male presents to the clinic stating his
antidepressants have stopped working. The patient has a 13-
year history of recurrent unipolar major depressive episodes.
His first 4 episodes were readily treated to full remission and he
discontinued treatment each time several months to a year after
remitting. His subsequent episodes came in an ever-escalating
pattern, with less and less time between them. By the time of
his fifth episode, he had become treatment-resistant and took
two years to get better.
Current Medications:
1 year following first depressive episode: antiarrhythmic, a
statin for cholesterol, antihypertensive, aspirin, transdermal
Selegilene 6 mg/24hrs after failing multiple SSRI and SNRI
treatments plus multiple augmentation strategies.

4. PMHx
: Atrial fibrillation age 42, resolved with medication,
hypercholesterolemia, HTN
Soc Hx
: Married 33 years, 3 children, nonsmoker, denies illicit drug or
alcohol abuse.
Fam Hx
: Mother: depression and alcohol abuse; Maternal uncle: alcohol
abuse; Son: depression; Daughters: one with mild depression,
one with postpartum depression.
ROS
:
The purpose of the physical examination is to exclude any
physical causes for the patient’s current mental health issues. A
mental health assessment often includes this evaluation as the
PMHNP reviews the patient’s past medical history and current
medications, as well as mental disorders within the family.
While asking the patient about any mental health symptoms, it
is crucial for the provider to pay attention to their appearance,
mood, and speech pattern as it can yield any clues to explaining
the symptoms. Most patients with major depressive disorder
(MDD) present with a normal appearance. Some would describe
it as “smiling depression” where the patient appears happy to
others while smiling through the pain, keeping their inner
turmoil hidden (Coward, 2016). This type of MDD results from
atypical symptoms and many don’t realize they are depressed,
nor seek help. People with smiling depression are
often partnered or married, employed and are quite
accomplished and educated. Their public, professional and
social lives are not struggling (Coward, 2016). Patients with
more severe depressive symptoms often have poor hygiene or
grooming and changes in weight. Patients may experience both

5. psychomotor impairment and agitation. Impairments can cause
issues with muscle function and speech, flat affect and
emotions. Speech patterns may be normal, monotone, or slow
lacking content. Racing thoughts and pressured speech patterns
often suggest anxiety or mania (Dailey & Saadabadi, 2020).
Diagnostic Test:
There are several diagnostic tools that can be used to screen for
depression. The Patient Health Questionaire-2 is a screening
tool for the diagnosis of major depression in the fifth edition of
the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5). The Beck Depression Inventory (BDI) is a 21-item
questionnaire that was first developed in 1961 that cover
affective, cognitive and somatic aspects of major depression.
The Geriatric Depression Scale (GDS) is a 30-item depression
questionnaire specifically designed for use in older adults to
assess the affective and cognitive aspects of major depression
(Ng, How & Ng, 2016).
Laboratory studies such as a CBC blood or urine tests may be
ordered. For example, anemia or B-12 deficiency can cause
fatigue, lack of energy and depression. Thyroid-stimulating
hormone (TSH) is often ordered when screening for depression.
Hypothyroidism is commonly found in depressed individuals.
Electrolytes, including calcium, phosphate, and magnesium
levels should be evaluated. Supplementation with magnesium
has been shown to decrease symptoms of depression in patients
with mild to moderate depression (Tarleton, Kennedy, Rose,
Crocker & Littenberg, 2019). If a nervous system problem is
suspected, a magnetic resonance imaging (MRI), an
electroencephalogram (EEG) or a computed tomography (CT)
scan may also be ordered.
Differential diagnosis

6. Hypothyroidism: is often associated with altered cognitive
function and depression. A 2018 study found that about 45% of
people with depressive disorders and 30% of those with anxiety
also have autoimmune thyroiditis (Siegmann et al., 2018).
Bipolar Disorder
Generalized Anxiety Disorder
Pharmacological agents and dosing
This patient had several recurrent unipolar depressive episodes.
By the time of his fifth episode, he had become treatment-
resistant and took two years to get better. Adding Seroquel to
his treatment regimen could have prevented a fourth or fifth
episode. Seroquel works by blocking dopamine 2 receptors,
reducing positive symptoms of psychosis and stabilizing
affective symptoms (Stahl, 2014b). Psychotic and manic
symptoms can improve within 1 week, but it is recommended
that the patient wait 4-6 weeks to determine the drug's
efficiency. Many bipolar patients may experience a reduction
of symptoms by half or more, unfortunately, this patient
experienced excess daytime sleepiness. If Seroquel is
ineffective in treating the patient, I would consider adding
olanzapine. Olanzapine works by blocking dopamine 2
receptors, reducing positive symptoms of psychosis and
stabilizing affective symptoms (Stahl, 2014b). The initial dose
of olanzapine is 5–10 mg once daily orally; increase by 5
mg/day once a week until desired efficacy is reached; the
maximum approved dose is 20 mg/day.
Contraindications

7. There are no specific contraindications related to the patient’s
ethnicity when prescribing Seroquel or Olanzapine. However, I
would use caution with both medications in cardiac patients
because it can cause orthostatic hypotension and this patient is
already taking antihypertensive medication. A lower dosage
may be sufficient when treating manic/mixed episodes (Stahl,
2014b).
Check points
When adding any new medications, it is recommended that the
patient follow up within 4-6 weeks after starting the prescribed
regimen. The patient will need to be monitored for any
improvements in his symptoms, as well as any adverse reactions
or side effects he may experience. Obtaining baseline and
checkpoints at follow-up appointments for weight/BMI, fasting
triglycerides, blood pressure, and fasting serum glucose with
Seroquel. Quetiapine may increase the risk of diabetes and
dyslipidemia, weight gain, dizziness, and sedation (Stahl,
2014b). Olanzapine is approved for long-term maintenance of
the bipolar disorder. Zyprexa should be used with caution in
patients with conditions that predispose to hypotension and it
may increase the effect of antihypertensive agents (Stahl,
2014b).
Lessons learned
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. Improving
adherence requires an active process of behavioral change,
which is nearly always a challenge. It requires education,
motivation, tools, support, monitoring, and evaluation. Many

8. factors can potentially contribute to a drug’s efficiency. The
prevalence of depression is increasing, representing an
important public health problem (Tarleton et al., 2019). The
treatment method that ultimately leads to an acceptable level of
improvement in depressive symptoms for any individual is
unpredictable. Combining antidepressant medication with
therapy and self-help measures can often be more effective than
taking medication alone. Finding the right treatment options
may take time.
References
Coward, L. (2016). NAMI. Retrieved from
https://www.nami.org/Blogs/NAMI-
Blog/September-2016/What-You-Need-to-Know-About-Smiling-
Depression”
Dailey & Saadabadi. [Updated 2020 Jan 14]. Mania. In:
StatPearls [Internet]. Treasure Island (FL): StatPearls
Publishing; 2020 Jan-. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK493168/
Henssler, J., Heinz, A., Brandt, L., & Bschor, T. (2019).
Antidepressant Withdrawal and Rebound Phenomena.
Deutsches Arzteblatt international
,
116
(20), 355–361. https://doi.org/10.3238/arztebl.2019.0355
Kleinsinger F. (2018). The Unmet Challenge of Medication
Nonadherence.
The Permanente
journal
,
22

9. , 18–033.
https://doi.org/10.7812/TPP/18-033
Ng, C. W., How, C. H., & Ng, Y. P. (2016). Major depression in
primary care: making the diagnosis.
Singapore medical journal
,
57
(11), 591–597. https://doi.org/10.11622/smedj.2016174
Siegmann E, Müller HHO, Luecke C, Philipsen A, Kornhuber J,
Grömer TW. (2018). Association of Depression and Anxiety
Disorders With Autoimmune Thyroiditis: A Systematic Review
and Meta-analysis.
JAMA Psychiatry.
2018;75(6):577–584. doi:10.1001/jamapsychiatry.2018.0190
Siminoff L. A. (2013). Incorporating patient and family
preferences into evidence-based medicine. BMC medical
informatics and decision making, 13 Suppl 3(Suppl 3), S6.
https://doi.org/10.1186/1472-6947-13-S3-S6
Smith, M. D. (2013).
Best care at lower cost: the path to continuously learning health
care in
America
. Washington, D.C.: National Academies Press.
Stahl, S. M. (2013).
Stahl’s essential psychopharmacology: Neuroscientific basis
and practical
applications
(4th ed.). New York, NY: Cambridge University Press.

10. Stahl, S. M. (2014b).
The prescriber’s guide
(5th ed.). New York, NY: Cambridge University Press.
Tarleton, E. K., Kennedy, A. G., Rose, G. L., Crocker, A., &
Littenberg, B. (2019). The Association between Serum
Magnesium Levels and Depression in an Adult Primary Care
Population.
Nutrients
,
11
(7), 1475. https://doi.org/10.3390/nu11071475
I NEED A RESPONSE FROM THIS ASSIGNMENT, 1 PAGE
2 REFERENCES - ZERO PLAGIARISM