TO REPLY 1 COMMENT TO EACH POST WITH CITATION AND TWO REFERENCE EACH COMMENT APA ABOVE 2013. POST 1  Three Questions for the Patient After reviewing the material presented in this case study, there are some concerning questions regarding this patient’s psychiatric history. Additional questions would include: After each discontinuation of medication after an episode of depression, was this decision the choice of a physician or self -initiated? This question would provide knowledge of the patient’s medication compliance. For example, does the patient stop taking prescribed medication on symptoms are alleviated? What were the circumstances prior to each depressive episode? his question would enlighten the practitioner on triggers and factors that personally affect the patient before a depressive episode occurs. There appears to be history of alcohol abuse and depression in your family, has anyone in your family received treatment? This question would provide a view into the patient’s understanding of psychiatric treatment. Since the patient does not believe in psychotherapy due to religious reason, the patient may not know what treatments were, are or will be available to him.  Feedback from People in Patient’s Life The patient has been married for 33 years. Assuming his spouse is around before, during and after an episode, she may provide information the patient failed to share or may not have been honest about. The first person to be questioned would be the patient’s wife. Some of the questions for the patient’s wife would include onset of symptoms. What occurs before each episode of depression? Is there conflict between you and your spouse? Are there any stressors, such as financial plaguing your spouse and you?  The patient also has three children. All three of his children suffer from some form of depression. Questioning the patient’s children may provide a historical history of the patient. For example, the children may have noticed symptoms leading to the patient’s depression years ago. Questions for the children may include did your parent’s argue often while you were growing up? Did your father ever lose interest in your childhood years? Did you feel love or rejection while growing up from your father? What were your father’s behaviors? Did you ever notice any alcohol or drug abuse while growing up?  Physical and Diagnostic Exams for Patient Unfortunately, there is not a certain test for depression. The primary goal of physical exam and diagnostic testing would to rule out other conditions causing similar symptoms. A physical exam should be preformed assessing respiratory and cardiovascular system. Vital signs should be taken as well.  Certain labs should be assessed in the patient. The practitioner should check the patient’s thyroid levels. Thyroid hormones have been linked to depression (Stahl, 2008). Depression can be caused by an underactive or overactive thyroid.  Another lab test to consider would be dexamethasone ...

1. TO REPLY 1 COMMENT TO EACH POST WITH CITATION
AND TWO REFERENCE EACH COMMENT APA ABOVE
2013.
POST 1
Three Questions for the Patient
After reviewing the material presented in this case study, there
are some concerning questions regarding this patient’s
psychiatric history. Additional questions would include:
After each discontinuation of medication after an episode of
depression, was this decision the choice of a physician or self -
initiated? This question would provide knowledge of the
patient’s medication compliance. For example, does the patient
stop taking prescribed medication on symptoms are alleviated?
What were the circumstances prior to each depressive episode?
his question would enlighten the practitioner on triggers and
factors that personally affect the patient before a depressive
episode occurs.
There appears to be history of alcohol abuse and depression in
your family, has anyone in your family received treatment? This
question would provide a view into the patient’s understanding
of psychiatric treatment. Since the patient does not believe in
psychotherapy due to religious reason, the patient may not know
what treatments were, are or will be available to him.
Feedback from People in Patient’s Life

2. The patient has been married for 33 years. Assuming his spouse
is around before, during and after an episode, she may provide
information the patient failed to share or may not have been
honest about. The first person to be questioned would be the
patient’s wife. Some of the questions for the patient’s wife
would include onset of symptoms. What occurs before each
episode of depression? Is there conflict between you and your
spouse? Are there any stressors, such as financial plaguing your
spouse and you?
The patient also has three children. All three of his children
suffer from some form of depression. Questioning the patient’s
children may provide a historical history of the patient. For
example, the children may have noticed symptoms leading to
the patient’s depression years ago. Questions for the children
may include did your parent’s argue often while you were
growing up? Did your father ever lose interest in your
childhood years? Did you feel love or rejection while growing
up from your father? What were your father’s behaviors? Did
you ever notice any alcohol or drug abuse while growing up?
Physical and Diagnostic Exams for Patient
Unfortunately, there is not a certain test for depression. The
primary goal of physical exam and diagnostic testing would to
rule out other conditions causing similar symptoms. A physical
exam should be preformed assessing respiratory and
cardiovascular system. Vital signs should be taken as well.
Certain labs should be assessed in the patient. The practitioner
should check the patient’s thyroid levels. Thyroid hormones
have been linked to depression (Stahl, 2008). Depression can be
caused by an underactive or overactive thyroid.
Another lab test to consider would be dexamethasone

3. suppression test. This test assesses the negative affect of
dexamethasone. Once given dexamethasone, in a small dose,
cortisol levels are decreased in healthy adults, but may remain
elevated in depressed patients (Smith, et al., 2013).
Depressive disorders have been linked to certain inflammatory
biomarkers. This blood test assesses nine biomarkers, alpha-1
antitrypsin, apolipoprotein CIII, BDNF, cortisol, epidermal
growth factor, myeloperoxidase, prolactin, resin, and soluble
tumor necrosis factor α type II. These biomarkers represent the
inflammatory and metabolic pathways associated with
depression (Serra et al., 2015).
Three Differential Diagnosis
Based on the symptoms listed by the patient, there a multiple
diagnosis this patient could be suffering from. Recurrent Major
Depressive Disorder with melancholic features. This diagnosis
is due to the patient’s major depressive symptoms, such as
depressed mood most of the day, increased anxiety, and suicidal
thoughts (Zaninotto et al., 2016). The specifier of melancholic
features is based on the patient’s symptoms being worse in the
morning, inability to function and lack of pleasure (Zaninotto et
al., 2016). Other diagnoses for the is patient could be a thyroid
imbalance or panic disorder
Two pharmacologic agents
Since this patient has become resistant to first line and second
line drug therapy for depression,
Phenelzine, an MAOI should be started for this patient.
Phenelzine 45mg daily, divided into three doses throughout the
day. Another suggestion for this patient would be

4. Isocarboxazid. The dosage would start at 10mg BID, if tolerated
the dosage could increase to another 10mg every 2-4 days until
the dosage of 40 mg was achieved with tolerance. If therapeutic
response is achieved, this medication should be slowly
decreased without affecting therapeutic response (Arcangelo et
al., 2013). Due to the pharmacokinetics and pharmacodynamics
of Isocarboxazid,
Phenelzine, should be prescribed to this patient. Since there is
an increased to patients who have cardiac issues such as atrial
fibrillation. The pharmacodynamics of Isocarboxazid are not
clearly understood, but this may be due to the inhibition of
MAO to the heart (Drugs, 2018).
MAOIs and Ethnicities
With many MAOIs, hypertensive crisis is a major concern for
nay race. Since minorities are diagnosed with hypertension at
higher rates, this causes a greater concern. This is the reason for
a tyramine restricted diet. Foods such as aged chees, yeast and
tap beer should be avoided ()
Changes in Therapy
After review of further data with this patient, changes would not
be made to the suggested treatment.
Lessons Learned
Throughout this case study many lessons were present. The
lesson of medication compliance was the first lesson learned.
Another lesson learned was the lesson of proper medication
selection in a patient, especially after a recurrent episode of
depression. Assessment and presentation of psychiatric
treatment for patients was another lesson learned from this case

5. study.
Conclusion
In conclusion, this case study involved a 63-year-old male with
recurrent depression. The patient has had success and failures
with medication and treatment. These failures may be due to
medication compliance or improper cessation of medications
from a physician. After two years, the patient is finally on the
right track. Hopefully, this will continue.
References
Arcangelo, V. P., Peterson, A. M., Wilbur, V., & Reinhold, J.
A. (Eds.). (2017).
Pharmacotherapeutics for advanced practice: A practical
approach
(4th ed.). Ambler, PA: Lippincott Williams & Wilkins.
Drugs.com. (2018). Isocarboxazid. Retrieved from http:/
ttps://www.drugs.com/pro/marplan.html
Serra, F., Spoto, A., Ghisi, M., & Vidotto, G. (2015). Formal
Psychological Assessment in Evaluating Depression: A New
Methodology to Build Exhaustive and Irredundant Adaptive
Questionnaires.
PLoS ONE
,
10
(4), e0122131.
http://doi.org/10.1371/journal.pone.0122131
Smith, K. M., Renshaw, P. F., & Bilello, J. (2013). The
diagnosis of depression: current and emerging methods.
Comprehensive Psychiatry

6. ,
54
(1), 1–6.
http://doi.org/10.1016/j.comppsych.2012.06.006
Stahl, S. M. (2008). Essential Psychopharmacology Online.
Retrieved September 11, 2018 from
https://stahlonline-cambridge-
org.ezp.waldenulibrary.org/prescribers_drug.jsf?
Zaninotto, L., Solmi, M., Veronese, N., Guglielmo, R., Ioime,
L., Camardese, G., & Serretti, A. (2016). A meta-analysis of
cognitive performance in melancholic versus non-melancholic
unipolar depression.
Journal of affective disorders
,
201
, 15-24.
POST 2
Three questions that I might ask our patient are:
Tell me when you take your medication? [The reason for this
question is to establish his adherence to his medication.
Tachyphylaxis aka poop out, may occur due to medication
nonadherence. It is therefore important to assess if the client is
experiencing tachyphylaxis related to medication nonadherence]
(Targum, 2014).
Do you feel a lack of motivation about life? [The Rothschild
Scale for Antidepressant Tachyphylaxis suggests a

7. conceptualization of antidepressant tachyphylaxis that is
characterized by symptoms of apathy.] (Targum, 2014).
Are you experiencing patterns of sleep disturbance? [This is
also a symptom of poop out. It is important to assess these
symptoms in order to proceed with his plan of care. Another
important question is to assess the client for is substance abuse
which was already addressed within the case study.)
According to our case study, our client is a 69-year-old retired
male who is married with children and grandchildren. In my
opinion, it would be most important to speak to those that are
the closest to him (his wife) who can observe him for any signs
of activation of bipolar disorder such as: lack of impulse
control, irritable and agitated mood lasting longer than a week
(Bail, Dains, Flynn, Solomon, & Stewart, 2015). Activation of
bipolar disorder would require his antidepressant to be
discontinued and switched to a mood stabilizer (Stahl, 2013).
Physical exams and diagnostic tests relevant to our client’s care
would be testing his blood pressure before/during initiating
treatment and testing for plasma levels of O-
desmethylvenlafaxine (ODV) which is an active metabolite of
venlafaxine formed as a result of CYP450 2D6 (Stahl, 2013).
Plasma levels of ODV will determine if the provider may safely
increase his dose based on results. It is imperative to assess our
client’s blood pressure related to the effects of the
norepinephrine in the SNRI. Based on the check points for his
first follow up, I would have changed his phone follow up to a
face to face follow up to assess our client better and would have
ordered his plasma ODV sooner to properly assess the
effectiveness of his medication therapy.
According to the American Psychiatric Association (2013),
three differential diagnoses that I am giving our client are: 1.

8. mood disorder due to another medical condition 2. Sadness 3.
Adjustment disorder with depressed mood. The one that I think
is more likely is sadness. My thought is sadness because our
client’s history from the case study reveals a long, waxing and
waning major depressive episode where he feels like he is out of
options (Stahl, 2013).
Two pharmacologic agents that would be appropriate for our
client’s therapy would be Mirtazapine 15 mg PO nightly or
Bupropion 75 mg PO BID. Bupropion is an NDRI which is a
good augmenting combination with Venlafaxine. It is a
powerful enhancer of noradrenergic action. Mirtazapine is a
dual serotonin and norepinephrine combination which also
works well with Venlafaxine but it may further increase his
high cholesterol; for this reason, I would choose the Bupropion.
Lessons that I learned from this case study are certain drugs
may not be as effective due to noncompliance, pharmacokinetic
failures or even genetic variants. I have also learned the
seriousness of how severe depression can be and the importance
of knowing not necessarily all of the drugs out on the market
for depression but more so the pharmacokinetics and
pharmacodynamics of how they work.
Leonie
Reference
Targum, S. D. (2014). Identification and treatment of
antidepressant tachyphylaxis.
Innovations in Clinical Neuroscience, 11
(24), 3-4. Retrieved
from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4008298/
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., &
Stewart, R. W. (2015).

9. Seidel’s guide to physical examination
(8th ed.). St. Louis, MO: Elsevier Mosby.
Stahl, S. M. (2013).
Stahl’s essential psychopharmacology: Neuroscientific basis
and practical applications
(4th ed.). New York, NY: Cambridge University Press
American Psychiatric Association. (2013).
Diagnostic and statistical manual of mental disorders
(5th ed.). Washington, DC: Author. Retrieved from Walden
Library databases.