Respond to at least two of your colleagues who were assigned to a different case than you.  Explain how you might apply knowledge gained from your colleagues’ case studies to you own practice in clinical settings.     If your colleagues’ posts influenced your understanding of these concepts, be sure to share how and why. Include additional insights you gained.     If you think your colleagues might have misunderstood these concepts, offer your alternative perspective and be sure to provide an explanation for them. Include resources to support your perspective. Case #29 The depressed man who thought he was out of options. The patient is a 69-year-old male with unremitting chronic depression. He has suffered from depressive episodes for 40 years and has always had a good response to treatment until 5 years ago when he relapsed on venlafaxine. Two years ago, he underwent nine treatments of ECT with partial response. He has tried every known antidepressant and augmentation available in the past few years. The patient should be asked about recent stressful life events, consumption of illicit drugs, alcohol abuse, current medical conditions and prescribed medications (Preda, 2018). If the patient was in my office, I would also want to ask questions to gain an understanding of the severity of his depression. It is important to assess the overall severity of depression symptoms because symptom severity corelates with suicide risk (Preda, 2018). The PHQ-9 screening could be used, and this screening asks about feelings of hopelessness, loss of pleasure in doing things, and feelings of being better off dead. A focused severity assessment for hopelessness, suicidal ideation, and psychotic symptoms is recommended; these symptoms independently increase the risk for suicide (Preda, 2018). This patient reports feeling severely depressed and demoralized, as well as, helplessness, hopelessness, and worthlessness. His depression is the worst it has ever been.             Family members are helpful informers, they can ensure medication compliance, and can encourage patients to change behaviors that continue depression (Halverson, 2019). Some questions I would ask family members would include whether the patient is taking their medication and I would ask the family to provide some insight as to how the patient behaves at home. The wife reports that she feels he is letting go and giving up. There are no lab tests that will confirm depressive disorder, however, labs can be ordered to rule out illnesses that may present as depressive disorder such as endocrinological or neurological diseases. Labs tests may include TSH, B12, RPR, HIV test, electrolytes, BUN and creatinine, blood alcohol, and blood and urine toxicology screening. Neuroimaging can help clarify the nature of the neurologic illness that may produce psychiatric symptoms, but these studies are costly and may be of questionable value in patients without discrete neurologic deficits (Halvers.

1. Respond to at least two of your colleagues who were assigned to
a different case than you. Explain how you might apply
knowledge gained from your colleagues’ case studies to you
own practice in clinical settings.
If your colleagues’ posts influenced your understanding of
these concepts, be sure to share how and why. Include
additional insights you gained.
If you think your colleagues might have misunderstood these
concepts, offer your alternative perspective and be sure to
provide an explanation for them. Include resources to support
your perspective.
Case #29 The depressed man who thought he was out of options.
The patient is a 69-year-old male with unremitting chronic
depression. He has suffered from depressive episodes for 40
years and has always had a good response to treatment until 5
years ago when he relapsed on venlafaxine. Two years ago, he
underwent nine treatments of ECT with partial response. He has
tried every known antidepressant and augmentation available in
the past few years.
The patient should be asked about recent stressful life events,
consumption of illicit drugs, alcohol abuse, current medical
conditions and prescribed medications (Preda, 2018). If the
patient was in my office, I would also want to ask questions to

2. gain an understanding of the severity of his depression. It is
important to assess the overall severity of depression symptoms
because symptom severity corelates with suicide risk (Preda,
2018). The PHQ-9 screening could be used, and this screening
asks about feelings of hopelessness, loss of pleasure in doing
things, and feelings of being better off dead. A focused severity
assessment for hopelessness, suicidal ideation, and psychotic
symptoms is recommended; these symptoms independently
increase the risk for suicide (Preda, 2018). This patient reports
feeling severely depressed and demoralized, as well as,
helplessness, hopelessness, and worthlessness. His depression is
the worst it has ever been.
Family members are helpful informers, they can ensure
medication compliance, and can encourage patients to change
behaviors that continue depression (Halverson, 2019). Some
questions I would ask family members would include whether
the patient is taking their medication and I would ask the family
to provide some insight as to how the patient behaves at home.
The wife reports that she feels he is letting go and giving up.
There are no lab tests that will confirm depressive disorder,
however, labs can be ordered to rule out illnesses that may
present as depressive disorder such as endocrinological or
neurological diseases. Labs tests may include TSH, B12, RPR,
HIV test, electrolytes, BUN and creatinine, blood alcohol, and
blood and urine toxicology screening. Neuroimaging can help
clarify the nature of the neurologic illness that may produce
psychiatric symptoms, but these studies are costly and may be
of questionable value in patients without discrete neurologic
deficits (Halverson, 2019). CT scanning or MRI of the brain
should be ordered for suspected organic brain syndrome. PET
scans provide a means for studying receptor binding of certain
ligands and the effect a compound may have on receptors

3. (Halverson, 2019).
Differential diagnosis would include major depressive disorder,
bipolar disorder, and/or poor or rapid metabolism. From 25-50%
of cases of Treatment Resistant Depression (TRD) are
associated with bipolar disorder; this is by far the most common
individual cause of TRD (Preda, 2018). The remaining 50-75%
are associated with noncompliance, poor or rapid metabolism,
or misdiagnosis (Preda, 2018). This patient is exhibiting signs
and symptoms consistent with major depressive disorder, such
as anhedonia, loss of energy, feelings of worthlessness,
depressed mood, which have been consistent for more than a
two week period. TRD is defined as MDD that fails to respond
to at least two antidepressant trials that are of adequate dose
and duration; the two antidepressants may belong either to the
same class or to different classes (Preda, 2018).
SSRIs, which include fluoxetine, sertraline, paroxetine,
citalopram, escitalopram, and fluvoxamine, have become the
first-line treatment for major depression (Brown, 2011). SSRIs
work by selectively blocking the reuptake of serotonin to
increase the amount of serotonin available in synapses in the
brain (Brown, 2011). The STAR*D trial examined various
strategies for treatment resistant depression in patients who did
not respond to an initial SSRI, including switching to another
SSRI antidepressant, changing medication class, and switching
to CBT. Fair quality studies have indicated a trend toward
greater effectiveness when switching to an SNRI such as
venlafaxine than with citalopram, fluoxetine, or paroxetine
(Halverson, 2019).
For patients with major depressive disorder, I would start the
patient on citalopram 20mg and increase the dose to a maximum

4. of 40mg. If the patient failed to respond, I would change to
venlafaxine 75mg daily extended release tablet and increase
dose if tolerated. I could not find any contraindications or
dosing alterations needed for Citalopram or venlafaxine related
to ethnicity.
Week 20 follow-up concluded with ordering venlafaxine levels.
This had been considered 20 weeks prior. I agree with ordering
this lab and I would have opted to do this before pursuing ECT.
A lab is much less invasive, less expensive, and without the side
effects he is experiencing at this point.
The patient’s aphasia and mood are improving but his mood is
still low. He hadn’t had labs completed. The venlafaxine stayed
at 225mg and aripiprazole was increased. Aripiprazole was
increased to 15mg. When used to augment treatment with an
SSRI or SNRI for depression, the dose would be no greater than
10mg. I disagree with this change.
By week 28 the patient labs show low levels of venlafaxine on a
225mg dose. The dose was increased to 300mg. Up to
600mg/day has been given for heroic cases (Stahl, 2014). I
agree with this change. His aripiprazole was discontinued. I
agree with discontinuing since the venlafaxine was not at a
therapeutic level.
The patient was still not showing improvement by week 32.
Another blood level was drawn. At week 36, the level was low
on a 300mg dose. The dose was increased to 375mg. The
patients BP is good and there have not been any side effects. He
has shown some improvement after the dose increase. An
increase to 450mg was made and levels ordered. By week 40,

5. the patient was feeling hopeful and mood was improving. His
lab values were in the low therapeutic range. At 450mg/day, the
patient was still within the dosage for a heroic case. He was
tolerating well. The suggestion at this point was to raise dose by
75mg/day, redraw level and raise again to 600mg if still in
therapeutic range. I think this is a good strategy based on the
patient’s improvement and his ability to tolerate the dose.
Lessons learned include the importance of therapeutic drug
level monitoring when this is an option. Possible reasons for
low levels could be: pharmacokinetic failure, genetic variant
causing pharmacokinetic failure, or noncompliance. Finally,
never give up.
References
Bienenfeld, David. (2018). Screening tests for depression.
Medscape. Retrieved from
https://emedicine.medscape.com/article/1859039-overview
Brown, Charles. (2011). Pharmacotherapy of major depressive
disorder. US Pharmacist, 36(11), HS3-HS8. Retrieved from
https://www.uspharmacist.com/article/pharmacotherapy-of-
major-depressive-disorder
Halverson, Jerry. (2019). Depression. Medscape. Retrieved from
https://emedicine.medscape.com/article/286759-overview
Howland, R. H. (2008a). Sequenced treatment alternatives to

6. relieve depression (STAR*D). Part 2: Study outcomes. Journal
of Psychosocial Nursing and Mental Health Services, 46(19),
21–24. doi:10.3928/02793695-20081001-05. Retrieved from
Walden Library databases.
Howland, R. H. (2008a). Sequenced treatment alternatives to
relieve depression (STAR*D). Part 1: Study design. Journal of
Psychosocial Nursing and Mental Health Services, 46(9), 21–24.
doi:10.3928/02793695-20080901-06. Retrieved from Walden
Library databases.
Preda, Adrian. (2018). Major depressive disorder: Disabling and
dangerous. Medscape. Retrieved from
https://reference.medscape.com/slideshow/major-depressive-
disorder
Pigott H. E. (2015). The STAR*D Trial: It Is Time to
Reexamine the Clinical Beliefs That Guide the Treatment of
Major Depression. Canadian journal of psychiatry. Revue
canadienne de psychiatrie, 60(1), 9-13.
Stahl, S. M. (2013). Stahl’s essential psychopharmacology:
Neuroscientific basis and practical applications (4th ed.). New
York, NY: Cambridge University Press.