Major depressive disorder

Major depressive disorder

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  PRESENTED BY: NUTHANSRI. V Y12PHD0430 V/VIPHARM D CASE PRESENTATION ON MAJOR DEPRESSIVE DISORDER GUIDED BY: V. D. C. SRAVAN SIR
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  INTRODUCTION: DEFINTION: • Major depressivedisorder (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.
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  • EPIDEMIOLOGY: Accordingto WHO :
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  ETIOLOGY: Other risk factorsfor 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
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  PATHOPHYSIOLOGY: Increase cortisol Decrease theexpression of post synaptic 5HT1a receptors in the hippocampus Decrease in 5HT neuro transmission Depression
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  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.
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  (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.
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  (b) Provisional Diagnosis: Thediagnosis 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”.
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  (iii) Assessment: Based onDSM(Diagnostic and Statistical Manual of Mental Disorders) IV criteria the patient was assessed that he was suffering with: MAJOR DEPRESSIVE DISORDER
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  Plan For Therapy: Patientwas given: 1. Benzodiazepines 2. Atypical antipsychotics 3. SSRI’S 4. Atypical anti-depressant
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  Day Wise Followup: • 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++.
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  DAY 2: • Patientappeared 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
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  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).
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  DAY 4: • Patientappears better today. • Decreased automatic thoughts or negative perception. • Increased sleep & appetite. • Patient feels relaxed. Fluctuation in his speech+. • Denied currently ideas of self harm.
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  DAY 5: • Decreasedautomatic 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.
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  Pharmaceutical Care Plan: DRUGNAME 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)
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  Discharge Medication: DRUG NAMEDOSE ROUTE FREQUENCY T. QUETIAPINE 25 mg PO BD T. FLUOXETINE 40 mg PO OD (MORNING) T. MIRTAZAPINE 15 mg PO OD (NIGHT)
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  Pharmacist Intervention: • MonitorClosely • 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.
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  Monitoring Parameters: • DisorderSpecific: 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.
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  Patient Counselling: About thedisease: • 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.
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  Signs and symptoms: MDDsymptoms 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.
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  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.