By: Danielle DeGroot      Dietetic Intern
   CDC reports:        ~1 in 10 adults report depression in the U.S.   Groups more likely to meet criteria for major de...
http://www.cdc.gov/Features/dsDepression/
• AM is a 22 year old Caucasian female.• Inpatient in the Adolescent Psychiatric Unit Readmitted because of increasing sy...
•   Current Dx:    1.   Obsessive-compulsive disorder (300.3)    2.   Depressive disorder, not elsewhere classified (311) ...
Laboratory Test         Normal Values        Patient ValuesBlood Pressure          120/80               102/64Albumin     ...
Laboratory Test        Normal Values    Patient ValuesCL                     99-108           103CO2                    22...
   Mental Status Examination     Verbal, cooperative     Normal rate and tone of speech     Depressed mood     Affect...
   Axis I: Clinical disorders; other conditions that may    be the focus of clinical attention.     Major depression, re...
•   Adderrall/Adderall XR:    •   ADHD, CNS Stimulant, Appetite Suppressant•   Zolpidem (Ambien):    •   Sleep Aid•   Quet...
 Increased  risk of:  Drug-drug interactions  “Uncertain gains for quality of care and   clinical outcomes.” Limitedsu...
 Adolescent      Stress Diet      General      Caffeine Free Is   this appropriate for A.M.?      Patient with poor P...
Schmidt, M. Brain Building Nutrition: The Healing Power of FNBand Oils. Frog; LTD. 2001.
Omega-3 Supports HealthyImmune Response. NordicNaturals 2006.
 Reportedn-3 PUFA can suppress pathophysiological features of depression (inflammation and immune reactivity markers)   ...
   N-3 PUFA deficiency linked to (all associated with    depression):     Altered neurotransmission     Decreased gluco...
 Cross-sectional                survey: 21,835 adult/elderly subjects from Norway    Significantly [(OR = 0.71 (95% CI =...
 Omega        3 supplementation    Regular intake of 1g to 2g EPA/day + DHA n-3     improves irritability    Improved d...
   Importance of a balanced diet in relation to overall    mental health and well being.     Recommend aiming 2 servings...
   1. Centers for Disease Control and Prevention. CDC Features:    Depression. Page last reviewed: March 31, 2011. Availa...
   8. Mahan LK, stump SE. Krause’s food & Nutrition Therapy.    Saunders Elsevier, St. Louis, Missouri; 2008.   9. Omega...
Danielle.Degroot.Case Study Pp
Danielle.Degroot.Case Study Pp
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  • According to the National Institute of Mental Health, women are 70% more likely to experience depression.
  • Note: IL at 9.2%-10.3%
  • Patient currently aggressive, lethargic, disheveled, loses train of thought, and is having difficulty with ADL’s such as bathing oneself daily.Chiari malformation type 1: when brain tissue protrudes into your spinal canal. It occurs when part of your skull is abnormally small or misshapen, pressing on your brain and forcing it downward (mayo clinic).
  • Albumin may be falsely normal (masked by dehydration).RBC, HGB, HCT lower rangeNA, K lower rangeNo recent labs for Mg, and Phos. As K is low it would be beneficial to have these labs to watch for refeeding syndrome when trying to A.M. to increase her calorie intake.Prealbumin would also be beneficial as it is a better marker of nutritional status.
  • BUN and CREAT low range: malnutrition CO2: high in starvation
  • The mental status examination in the USA or mental state examination in the rest of the world, abbreviated MSE, is an important part of the clinical assessmentprocess in psychiatric practice. It is a structured way of observing and describing a patient's current state of mind, under the domains of appearance, attitude, behavior, mood and affect, speech, thought process, thought content, perception, cognition, insight and judgment. Trzepacz, PT; Baker RW (1993). The Psychiatric Mental Status Examination. Oxford, U.K.: Oxford University Press. p. 202.  Used to aid in diagnosis and treatment planning.
  • Five axes in multi-axial classification system published by the American Psychiatric Association. The Diagnostic and Statistical Manual of Mental Disorders (DSM)GAF scale considers only psychological, social, and occupational function on a hypothetical continuum of mental health/illness.  Does not include impairment in functioning due to physical/environmental limitations.GAF scale considers only psycholgoical, social, and occupational function on a hypothetical continuum of mental health/illness. Does not include impairment in functioning due to physical/environmental limitations. 50: "Serious symptoms (e.g., suicidal idea, severe obsessional rituals, frequent shoplifting) OR any serious impairment in social, occupational or school functioning (e.g., no friends, unable to keep a job." 30: "Behavior is considerable influenced by delusions or hallucinations OR serious impairment in communication or judgment (e.g., sometimes incoherent, acts grossly inappropriately, suicidal preoccupation) OR inability to function in almost all areas (e.g., stays in bed all day; no job, home, or friends). www.dmacc.edu 
  • Prescription of 2 or more antidepressant/antipsychotic meds. According to a study in the Archives of General Psychiatry, there has been a significant increase in polypharmacy involving antidepressant and antipsychotic meds.
  • 1. krause
  • Sixty percent of the brain’s dry weight is fat. Ideally, 25% of this fat is DHA. Omega-3 fatty acids appear to be the type of fat preferred by the brain and nervous system. Three forms of n-3 fatty acids have beenstudied with respect to mental health: a-Linolenic acid (ALA), docosahexaenoic acid (DHA), and eicosapentaenoic acid (EPA). Healthy neurotransmitter (responsible for thought processes, emotions, sleep, energy, fear) function, as with the densities of dopamine and serotonin receptors, are dependent on DHA levels in the brain. While ALA can be converted to EPA and DHA, this conversion requires optimal nutrition conditions. Diets lacking in vitamins and minerals limit theconversion of ALA to EPA and DHA significantly and those with mental health disorders are often deficient in vitamins and minerals and activity of some neurotransmitters can be enhanced or limited by diet (Krause/Care Manual).  
  • Vitamins and minerals help produce neurotransmitters, enhance their activity and protect from damage.Function can be disrupted by stress, poor diet, chemicals, infections, genetics.Imbalanced neurotransmitter levels can result in: sadness, anxiousness, behavioral problems.Food and nutrients directly influence nerve cell fx (Care Manual Info)
  • Omega-3 produces antiinflammatory enzymes. Increase in dietary omega-6 fatty acid intake and reduction in n-3. Typical Westernized diet is closer to 20:1 ratio of n-6:n-3 -- Promotes inflammation and oxidation, resulting in an increase in mental illnessRecommended at a ratio of 2:1
  • Specifically show
  • Patients should supplement LCFA with vitamin E, which will help to keep the LCFA from being oxidized, which would make them ineffective (Krause)
  • Importance to increase antioxidants in the diet to help combat the oxidation of n-3 fatty acids. Diets rich in fruits and vegetables contain many vitamins, minerals and antioxidants (Krause).
  • Danielle.Degroot.Case Study Pp

    1. 1. By: Danielle DeGroot Dietetic Intern
    2. 2.  CDC reports:  ~1 in 10 adults report depression in the U.S. Groups more likely to meet criteria for major depression:  45-64 years  Female  African Americans, Hispanics, non-Hispanic persons of other or multiple races  Persons with less than a high school education  Previously married  Unable to work/unemployed  Without health insurance coverage Similar criteria fit “other depression” category with the exception of:  18-24 year olds were more likely to report “other depression” Current medical treatment:  Antidepressants, antipsychotics http://www.cdc.gov/Features/dsDepression/
    3. 3. http://www.cdc.gov/Features/dsDepression/
    4. 4. • AM is a 22 year old Caucasian female.• Inpatient in the Adolescent Psychiatric Unit Readmitted because of increasing symptoms of depression, some SI, and severe difficulty functioning. Admit Date: 4/11/2011  Chart reviewed due to positive findings on nursing admission screen – patient triggered for history of eating disorder. Hospital course and events leading to admission reviewed per notes. Noted patient has been followed by EDU RD with most recent visit in December of 2010.
    5. 5. • Current Dx: 1. Obsessive-compulsive disorder (300.3) 2. Depressive disorder, not elsewhere classified (311) 3. Anxiety state, unspecified (300.00)• PMH includes: depressive disorder, anxiety state, eating disorder, primary insomnia, Chiari malformation type 1, attention deficit disorder Currently presents with:  7% loss of body weight in 2 months  Poor appetite Anthropometrics: – IBW: 125 lbs; %IBW:74%; BMI:15.79
    6. 6. Laboratory Test Normal Values Patient ValuesBlood Pressure 120/80 102/64Albumin 3.5-5.0 g/dL 4.5*WBC 4.0-10.0 7.6RBC 4.00-5.20 4.25HGB 12.0-16.0 12.8HCT 36-46 38.4PLT 150-399 280GLUCOSE Fasting: 60-109 91 mg/dL Nonfasting: 60-200 mg/dLNA 137-147 138K 3.4-5.3 3.5 *May be falsely normal
    7. 7. Laboratory Test Normal Values Patient ValuesCL 99-108 103CO2 22-29 mmol/dL 29BUN 8-21 mg/dL 10CREAT 0.5-1.1 mg/dL 0.6CA 8.7-10.7 mg/dL 9.7PROT 6.0-8.2 g/dL 7.3TBILI 0.2-1.3 mg/dL 0.6AST 5-55 units/L 17ALT 3-50 units/L 13GGT 0-51 IU/L 14 Reference ranges from EPIC
    8. 8.  Mental Status Examination  Verbal, cooperative  Normal rate and tone of speech  Depressed mood  Affect constricted  Thought logical with no evidence for hallucinations/delusions/homicidal ideation  Judgment/insight fair.  Alert/oriented x 3  Memory grossly intact  Intelligence in superior range
    9. 9.  Axis I: Clinical disorders; other conditions that may be the focus of clinical attention.  Major depression, recurrent, severe Axis II: Personality disorders, mental retardation.  none Axis III: General medical conditions  Insomnia Axis IV: Psychosocial and environmental problems  Moderate Axis V: Global assessment of function (GAF: a scale from 1 – 100)  Past week – 30. Best in past year – 50.
    10. 10. • Adderrall/Adderall XR: • ADHD, CNS Stimulant, Appetite Suppressant• Zolpidem (Ambien): • Sleep Aid• Quetiapine (Seroquel): • Antipsychotic• Lorazepam (Ativan): • Antianxiety• Fluvoxamine (Luvox): • OCD or Social Anxiety Disorder, Depression• Hydroxyzine (Atrax): • Antianxiety• Alprazolam (Xanax/Xanax XR): • Antianxiety, antipanic
    11. 11.  Increased risk of:  Drug-drug interactions  “Uncertain gains for quality of care and clinical outcomes.” Limitedsupporting evidence  Many patients continue to experience symptoms Mojtabai R, Olfson M. National Trends in Psychotropic Medication Polypharmacy in Office-Based Psychiatry. Arch Gen Psychiatry. 2010;67(1):26-36.
    12. 12.  Adolescent Stress Diet  General  Caffeine Free Is this appropriate for A.M.?  Patient with poor PO intake; general diet appropriate to encourage intakes  Caffeine interacts with several psychotherapeutic drugs
    13. 13. Schmidt, M. Brain Building Nutrition: The Healing Power of FNBand Oils. Frog; LTD. 2001.
    14. 14. Omega-3 Supports HealthyImmune Response. NordicNaturals 2006.
    15. 15.  Reportedn-3 PUFA can suppress pathophysiological features of depression (inflammation and immune reactivity markers)  Human studies indicate that dietary supplementation with EPA and DHA supress IL-1, IL-2, IL-6 and TNF-a production by monocytes  Increasing long-term DHA intakes indicates decrease in depression Mamalakis, G., Tornaritis, M., & Kafatos, A. (2002). Depression and adipose essential polyunsaturated fatty acids [Abstract]. Prostaglandins, Leukotrienes, and Essential Fatty Acids, 67(5) 311-318.
    16. 16.  N-3 PUFA deficiency linked to (all associated with depression):  Altered neurotransmission  Decreased glucose metabolism  Increased production of pro-inflammatory cytokines  Reduced levels of brain-derived neurotrophic factor (BDNF)  Neuronal atrophyLiperoti, R., Landi, F., Fusco, O., Bernabei, R., & Onder, G. (2009). Omega-3 polyunsaturated fatty acids and depression: A review of the evidence. Current Pharmaceutical Design, 15(36), 4165-4172 .
    17. 17.  Cross-sectional survey: 21,835 adult/elderly subjects from Norway  Significantly [(OR = 0.71 (95% CI = 0.52 – 0.97)] less likely to have depressive symptoms  1000-1500 mg/d in a 2:1 EPA:DHA ratio optimal for tx of affective disorders. McNamara, R. K. (2009). Evaluation of docosahexaenoic acid deficiency as a preventable risk factor for recurrent affective disorders: Current status, future directions, and dietary recommendations [Abstract]. Prostaglandins, Leukotrienes, and Essential Fatty Acids, 81(2) 223-231.
    18. 18.  Omega 3 supplementation  Regular intake of 1g to 2g EPA/day + DHA n-3 improves irritability  Improved depression scores in many studies found with supplementation of 1g: higher levels may not show greater improvement  6-8 oz fish/week (750-1000mg EFA/day)  Vitamin E Care manual
    19. 19.  Importance of a balanced diet in relation to overall mental health and well being.  Recommend aiming 2 servings of high n-3 containing fish at least 2x/wk  Recommend increasing fruits and vegetables rich in vitamins, minerals, antioxidants Benefits of supplementing with Omega-3 fatty acids/Vitamin E as it relates to patient condition.  Recommend at least 1-2g/day  Contraindications: Decreased hepatic fx, fish/soy allergy, pts with implantable defibrillators (inc risk of ventricular fibrillation/tachycardia), on blood thinners (i.e., Coumadin). Proper vitamin/mineral intake  Supplement with Vitamin E
    20. 20.  1. Centers for Disease Control and Prevention. CDC Features: Depression. Page last reviewed: March 31, 2011. Available at: http://www.cdc.gov/Features/dsDepression/. 2. EPIC Computer Charting. 3. Trzepacz, PT; Baker RW (1993). The Psychiatric Mental Status Examination. Oxford, U.K.: Oxford University Press. p. 202. 4. Nutrition Care Manual. American Dietetic Association. 2011. Available at: www.nutritioncaremanual.org. 5. DSM-IV-TR Multiaxial Classification System. Des Moines Area Community College. Available at: http://www.dmacc.edu/Instructors/tkwilson2/Diagnosis.pdf. 6. Pronsky ZM, Crowe JP. Food Medication Interactions 16th Edition. Birchrunville, PA. 2010. 7. Mojtabai R, Olfson M. National Trends in Psychotropic Medication Polypharmacy in Office-Based Psychiatry. Arch Gen Psychiatry. 2010;67(1):26-36.
    21. 21.  8. Mahan LK, stump SE. Krause’s food & Nutrition Therapy. Saunders Elsevier, St. Louis, Missouri; 2008. 9. Omega-3 Supports Healthy Immune Response. Nordic Naturals 2006. 10. Mamalakis, G., Tornaritis, M., & Kafatos, A. (2002). Depression and adipose essential polyunsaturated fatty acids [Abstract]. Prostaglandins, Leukotrienes, and Essential Fatty Acids, 67(5) 311-318. 11. Liperoti, R., Landi, F., Fusco, O., Bernabei, R., & Onder, G. (2009). Omega-3 polyunsaturated fatty acids and depression: A review of the evidence. Current Pharmaceutical Design, 15(36), 4165-4172. 12. McNamara, R. K. (2009). Evaluation of docosahexaenoic acid deficiency as a preventable risk factor for recurrent affective disorders: Current status, future directions, and dietary recommendations [Abstract]. Prostaglandins, Leukotrienes, and Essential Fatty Acids, 81(2) 223-231.

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