MDD

1. PRESENTED BY:
NUTHANSRI. V
Y12PHD0430
V/VI PHARM D
CASE PRESENTATION
ON
MAJOR DEPRESSIVE
DISORDER
GUIDED BY:
V. D. C. SRAVAN SIR

2. INTRODUCTION:
DEFINTION:
• Major depressive disorder (MDD), also known simply
as depression, is a mental disorder characterized by at
least two weeks of low mood that is present across
most situations.
• Major depressive disorder or clinical depression is a
common but serious mental health or mood disorder
characterised by persistently depressed mood or loss of
interest in activities, causing significant impairment in
daily life.

3. • EPIDEMIOLOGY: According to WHO :

4. ETIOLOGY:
Other risk factors for major
depressive disorder include:
• Low self-esteem
• Anxiety disorder,
• Borderline personality disorder,
• Post-traumatic stress disorder
(PTSD)
• Physical or sexual abuse
• Chronic diseases like diabetes,
multiple sclerosis, or cancer
• Alcohol or drug abuse
• Certain prescription medications
• Family history of depression

5. PATHOPHYSIOLOGY:
Increase cortisol
Decrease the expression of post
synaptic 5HT1a receptors in the
hippocampus
Decrease in 5HT neuro
transmission
Depression

6. SOAP ANALYSIS:
• Age: 20 years ; Weight: 76kgs ; Sex: Male
(i) Subjective Evidence:
C/O: College refusal, suicidal ideas – 2 years.
Decreased appetite – 4 to 5 days. Expresses idea of
absconding. No past attempts of suicide.
PH/O: Breakup love and not selected in campus
selection(may precipitated the symptoms).
MSE(Mental Status Examination): Low mood,
Hopelessness, Helplessness, Insight Fear, Risk of self
harm ++, Risk of Absconding ++ (says in frustration).
SH/O: Not a smoker & alcoholic. Nill known allergies.

7. (ii) Objective Evidence:
(a) Laboratory Investigations:
Physical Examination – Physical exam and in-depth
questions about health. In some cases health problems
may be the underlying cause.
Lab tests – There is no laboratory test for major
depression.
Psychological Evaluation - To check signs of disorder,
Mental health provider may ask questions about
symptoms, thoughts, feelings, and behaviour patterns.

8. (b) Provisional Diagnosis:
The diagnosis of major depressive disorder is
based on the person's reported experiences and
a mental status examination.
Based on the Subjective[College refusal, suicidal
ideas – 2 years. Decreased appetite – 4 to 5
days. Expresses idea of absconding. No past
attempts of suicide] and Objective evidence
[Physical Examination, Lab tests, Psychological
Evaluation] the patient was diagnosed that he
was suffering with “ Major Depressive disorder”.

9. (iii) Assessment:
Based on DSM(Diagnostic and Statistical Manual
of Mental Disorders) IV criteria the patient was
assessed that he was suffering with:
MAJOR
DEPRESSIVE
DISORDER

10. Plan For Therapy:
Patient was given:
1. Benzodiazepines
2. Atypical antipsychotics
3. SSRI’S
4. Atypical anti-depressant

11. Day Wise Follow up:
• DAY 1:
• Parents expressed concern such as : Irritability, Dull
mood. They mentioned patient idea of absconding
and suicidal tendency. Patient father says he lack of
dare to die.
• Session was focussed on educating parents about
depression and things to do to support him and
things not to do to decrease pressure on the patient.
• Patient appeared Dull mood, poor energy levels. He
had slept good yesterday. Fluctuation in his anxiety
levels++.

12. DAY 2:
• Patient appeared better intend to communicate.
Increase tone in the speech. Appetite increased.
Patient slept well.
• Patient still had suicidal ideas, wishes to die in a
passive manner(feeling to into any vehicle that would
hit and kill him). Guilty about broken relationship.
• Mood : Dull
• Anxious: Episodic

13. DAY 3:
• Appetite: reasonably fair, Increased attention.
• Patient says that he still had ideas of running away++
• Mild improvement in peace of mind.
• Slightly better in distress.
• Patient says that he wish for death++, but do not
want to commit suicide.
PLAN:
• To engage patient on different activities.
• To try JPMR(Jacobson’s progressive muscle relaxation
technique).

14. DAY 4:
• Patient appears better today.
• Decreased automatic thoughts or negative
perception.
• Increased sleep & appetite.
• Patient feels relaxed. Fluctuation in his speech+.
• Denied currently ideas of self harm.

15. DAY 5:
• Decreased automatic thoughts, self harm ideas.
• Denied self harm idea.
• Denies risk to absconding.
DAY 6:
• Patient was encouraged to write a diary.
DAY 7:
• Practicing JPMR, doing puzzles and fair in writing.
• Recommended for Discharge.

16. Pharmaceutical Care Plan:
DRUG NAME DOSE ROUTE FREQUENCY
INJ. LORAZEPAM 2 ml IM SOS
T. LORAZEPAM 2 mg PO SOS
T. QUETIAPINE 25 mg PO BD
T. FLUOXETINE 20 mg PO OD (MORNING)
T. MIRTAZAPINE 7.5 mg PO OD (NIGHT)
T. FLUOXETINE 40 mg PO OD (MORNING)
T. MIRTAZAPINE 15 mg PO OD (NIGHT)

17. Discharge Medication:
DRUG NAME DOSE ROUTE FREQUENCY
T. QUETIAPINE 25 mg PO BD
T. FLUOXETINE 40 mg PO OD (MORNING)
T. MIRTAZAPINE 15 mg PO OD (NIGHT)

18. Pharmacist Intervention:
• Monitor Closely
• Fluoxetine + Mirtazapine - both increase
serotonin levels. Monitor Closely.
• Lorazepam + Quetiapine - both increase sedation.
Use Caution/Monitor.
• Lorazepam + Mirtazapine - both increase
sedation. Use Caution/Monitor.
• Quetiapine + Mirtazapine - both increase
sedation. Use Caution/Monitor.
• Quetiapine + Fluoxetine - increases toxicity of the
other by QTc interval. Use Caution/Monitor.

19. Monitoring Parameters:
• Disorder Specific: A minimum of 1-2years of MSE
monitoring is recommended by monthly session
follow ups.
• Drug Specific:
• Sedation is caused by drugs & patient was advised
not to ride vehicles.
• Patient with Heart problems must be monitored for
abnormal ECG values as Quetiapine and Fluoxetine
prolongs QT interval.
• CBP, Serum Creatinine, Serum Electrolytes must be
checked.

20. Patient Counselling:
About the disease:
• The Patient was counselled that he was suffering with
Major Depressive Disorder(MDD) which is a common
and serious medical illness that negatively affects how
you feel, the way you think and how you act.
• MDD causes feelings of sadness and/or a loss of
interest in activities once enjoyed.
• It can lead to a variety of emotional and physical
problems and can decrease a person’s ability to
function at work and at home.

21. Signs and symptoms:
MDD symptoms can vary from mild to severe and can
include:
• Feeling sad or having a depressed mood.
• Loss of interest or pleasure in activities once enjoyed.
• Changes in appetite — weight loss or gain unrelated to
dieting.
• Trouble sleeping or sleeping too much.
• Loss of energy or increased fatigue.
• Increase in purposeless physical activity (e.g., hand-
wringing or pacing) or slowed movements and speech
(actions observable by others)
• Feeling worthless or guilty.
• Difficulty thinking, concentrating or making decisions.
• Thoughts of death or suicide.

22. Life style modifications:
• Here are other tips that may help during treatment for
Major Depressive Disorder:
• Try to be active and exercise daily.
• Set realistic goals for yourself.
• Try to spend time with other people and confide in a
trusted friend or relative.
• Try not to isolate yourself, and let others help you.
• Expect your mood to improve gradually, not immediately.
• Postpone important decisions, such as getting married or
divorced, or changing jobs until you feel better. Discuss
decisions with others who know you well and have a
more objective view of your situation.
• Continue to educate yourself about depression.