Case # 29- The depressed man who thought he was out of options.              Depression has become a common mental disorder in our elderly population. This has caused a global concern for occur, geriatric patients, as depression often results in a significant burden for families as well as communities. Elderly people who suffer from depression may have an inferior baseline and record for medical assessments than those individuals without depression. Despite consistent evidence of the effectiveness of antidepressants for many with depression, 3 particularly those with more severe depression, remission rates are disappointingly low. An AHRQ-sponsored report found that only 46% of patients experienced remission from depression during 6 to 12 weeks of treatment with second-generation antidepressants. One major reason for this issue is non-adherence to medications and treatment plans. Studies have shown that patients' age, race and ethnicity are consistently associated with predictions of outcomes. (Rossom et al., 2016).              This case study involves a 69-year old man whose chief complaint is unremitting, chronic depression. After several years of medications and treatments, he feels hopeless for a recovery from his chronic depression. This assignments seeks to explore his family and social support systems, diagnostic testing, differential diagnosis and pharmacologic treatment options for this patient.  Questions for the client How have you been sleeping lately?  How many times in the last week have you had feelings of hopelessness? Are you having thoughts of harming yourself? Do you have a plan? These questions are an important yet simple place to start when treating patients. Sleep disturbances plague much of the world's population and have shown to be a major indicator for mental health issues. Changes in sleep neurophysiology are often observed in depressive patients, and impaired sleep is, in many cases, the chief complaint of depression (Armitage, 2007). Depressed patients with sleep disturbance are likely to present more severe symptoms and difficulties in treatment. In addition, persistent insomnia is the most common residual symptom in depressed patients and is considered a vital predictor of depression relapse and may contribute to unpleasant clinical outcomes (Hinkelmann et al., 20120. Questions involving feelings of hopelessness and suicidal ideations with or without a plan relate to issues of patient safety. Across psychiatric disorders, hopelessness is associated with suicidal ideation and behavior. A meta-analysis of 166 longitudinal studies (sample size not reported) found that hopelessness was associated with an increased risk of ideation (Ribeiro, Huang, Fox, & Franklin, 2018). Family and social support system      Family and social support systems are imperative for any patient in recovery. If the patient is agreeable to discussions with family members, then a discussion with his wife would be helpful. Researc.

1. Case # 29- The depressed man who thought he was out of
options.
Depression has become a common mental disorder in
our elderly population. This has caused a global concern for
occur, geriatric patients, as depression often results in a
significant burden for families as well as communities. Elderly
people who suffer from depression may have an inferior
baseline and record for medical assessments than those
individuals without depression. Despite consistent evidence of
the effectiveness of antidepressants for many with depression,
3
particularly those with more severe depression, remission rates
are disappointingly low. An AHRQ-sponsored report found that
only 46% of patients experienced remission from depression
during 6 to 12 weeks of treatment with second-generation
antidepressants. One major reason for this issue is non-
adherence to medications and treatment plans. Studies have
shown that patients' age, race and ethnicity are consistently
associated with predictions of outcomes. (Rossom et al., 2016).
This case study involves a 69-year old man whose chief
complaint is unremitting, chronic depression. After several
years of medications and treatments, he feels hopeless for a
recovery from his chronic depression. This assignments seeks to
explore his family and social support systems, diagnostic
testing, differential diagnosis and pharmacologic treatment
options for this patient.
Questions for the client
How have you been sleeping lately?

2. How many times in the last week have you had feelings of
hopelessness?
Are you having thoughts of harming yourself? Do you have a
plan?
These questions are an important yet simple place to start when
treating patients. Sleep disturbances plague much of the world's
population and have shown to be a major indicator for mental
health issues. Changes in sleep neurophysiology are often
observed in depressive patients, and impaired sleep is, in many
cases, the chief complaint of depression (Armitage, 2007).
Depressed patients with sleep disturbance are likely to present
more severe symptoms and difficulties in treatment. In addition,
persistent insomnia is the most common residual symptom in
depressed patients and is considered a vital predictor of
depression relapse and may contribute to unpleasant clinical
outcomes (Hinkelmann et al., 20120. Questions involving
feelings of hopelessness and suicidal ideations with or without a
plan relate to issues of patient safety. Across psychiatric
disorders, hopelessness is associated with suicidal ideation and
behavior. A meta-analysis of 166 longitudinal studies (sample
size not reported) found that hopelessness was associated with
an increased risk of ideation (Ribeiro, Huang, Fox, & Franklin,
2018).
Family and social support system
Family and social support systems are imperative for any
patient in recovery. If the patient is agreeable to discussions
with family members, then a discussion with his wife would be
helpful. Research has shown that strong support systems have a
positive effect with those suffering from depression. The
perceived availability of support from others can serve as a

3. buffer against the development of a depressive episode. Positive
family relationships can improve mental ill-health, while
support from family members often facilitates recovery. In
contrast, low levels of support have long been associated with
the onset of depressive symptoms, delayed recovery, and a
tendency towards chronic depression (Lyberg, 2013).
Please tell me about your experiences with your husband on this
journey with his depression.
Have there been any significant changes or triggers recently at
home? (i.e. deaths in the family, issues with children, living
situation).
Have there been any treatments in the past where you have
noticed positive changes in your husband?
Physical exams and diagnostic tests
A complete exam, history and physical will be required
for this patient. Given his age and mental health and treatment
history, this will give the provider insight into the client’s
physical health. Depression may co-occur with medical
problems including heart disease, diabetes or cancer. Mental
health issues may increase during poor physical health and
cause difficulties in managing medical problems in addition to
mental health issues.
Full blood work analysis including Venlafaxine
therapeutic blood levels, CBC, CMP and LFT should be
conducted for indicators relating to liver function, thyroid
function, anemia, calcium and vitamin D levels. Thyroid
function tests should be conducted as there has been a known
association between hypothyroid and depressive symptoms.

4. Depression is seen in autoimmune thyroid disorders, both in
thyroiditis and normal thyroid function. The presence of thyroid
peroxidase antibodies was proposed to be a vulnerability marker
for depression (Gibney, 2012). Genotyping may be considered
as this approach has shown to be helpful in patients who remain
treatment-resistant.
Differential diagnoses
Treatment resistant depression (TRD): This is the most likely
and refers to the treatment of those with major depressive
disorder (MDD) and the failure to create acceptable outcomes.
There are several reasons why a patient may be treatment-
resistant including ethnicity, gender, age, biologic factors and
genetic variants.
Adjustment disorder
Medication-Induced Depressive Disorder
Pharmacologic agents
Venlafaxine (VLX). The client is currently on 450 mg XR with
good results. Venlafaxine (VLX) is a serotonin–norepinephrine
reuptake inhibitor marketed for the treatment of depression
disorders. It provides a reasonable second-step choice for
patients with depression and is used extensively in psychiatric
practice. VLX is primarily metabolised into the active
metabolite O-desmethyl-VLX (ODV), with serotonin and
noradrenaline reuptake inhibition properties. The mean plasma
half-lives (± SD) of VLX and ODV are 5(±2) hours and 11(±2)
hours, respectively (Lloret-Linares et al., 2017).
Pharmacodynamic and pharmacokinetic considerations include

5. the prolonged half-life and reduced clearance. Due to this
concern, it is important to continue to monitor for renal and
hepatic impairment.
Desvenlafaxine up to 200 mg dose. This SNRI inhibits the
reuptake of serotonin and norepinephrine. Desvenlafaxine, as
desvenlafaxine succinate, is a novel salt form of the isolated
major active metabolite (
O
-desmethylvenlafaxine) of the SNRI venlafaxine.
Desvenlafaxine appears to be well absorbed after oral
administration, and it has a large volume of distribution.
Desvenlafaxine can be taken without regard to meals, and the
absolute oral bioavailability after oral administration is
approximately 80%.The mean terminal half-life (
t
1/2) is approximately 11 hours, and mean time to peak plasma
concentrations (Tmax) after oral administration is
approximately 7.5 hours. The pharmacokinetics of
desvenlafaxine are minimally affected by food. Plasma protein
binding of desvenlafaxine is low (30%) and independent of drug
concentration (Liebowitz,& Tourian, 2010).
Take-home points
Take home points from this assignment are to never give up on
finding the right therapies for our clients. There may be several
reasons why a specific medication is not working as expected
and by considering Pharmacodynamic and pharmacokinetic
factors may assist in gaining insight as therapeutic drug
monitoring may offer resolve. Pharmacogenetics is a
subcategory of pharmacogenomics that refers to the role of
genetic variation in response to a drug. Pharmacogenetics
generally is used to refer to a specific DNA polymorphism or
coding variant rather than epigenetic or transcriptomic changes

6. across the genome. In practice, pharmacogenetics and
pharmacogenomics are often used interchangeably.
Pharmacokinetics (PK) refers to how a drug moves through an
individual's body. A drug's PK includes its absorption,
distribution, metabolism, and elimination, all of which affect
the drug's effect by altering the drug's concentration at its site
of action. (Preskorn & Hatt, 2013). The importance of this lies
with how much of the drug is reaching the brain, not necessarily
how much of the drug is taken orally.
References
Armitage R. Sleep and circadian rhythms in mood
disorders. Acta Psychiatric Scand Suppl. 2007;115(433):104–
115.
Gibney SM, Drexhage HA. Evidence for a dysregulated immune
system in the etiology of psychiatric disorders. J Neuroimmune
Pharmacol. 2013;8(4):900–920. doi: 10.1007/s11481-013-9462-
8.
Hinkelmann K, Moritz S, Botzenhardt J, et al. Changes in
cortisol secretion during antidepressive treatment and cognitive
improvement in patients with major depression: a longitudinal
study. Psychoneuroendocrinology. 2012;37(5):685–692.
Liebowitz, M. R., & Tourian, K. A. (2010). Efficacy, safety,
and tolerability of Desvenlafaxine 50 mg/d for the treatment of
major depressive disorder:a systematic review of clinical trials.
Primary care companion to the Journal of clinical psychiatry
,
12
(3), PCC.09r00845. https://doi.org/10.4088/PCC.09r00845blu
Lloret-Linares, C., Daali, Y., Chevret, S., Nieto, I., Molière, F.,
Courtet, P., Galtier, F., Richieri, R. M., Morange, S., Llorca, P.

7. M., El-Hage, W., Desmidt, T., Haesebaert, F., Vignaud, P.,
Holtzmann, J., Cracowski, J. L., Leboyer, M., Yrondi, A.,
Calvas, F., Yon, L., … Bellivier, F. (2017). Exploring
venlafaxine pharmacokinetic variability with a phenotyping
approach, a multicentric french-swiss study (MARVEL study).
BMC pharmacology & toxicology, 18(1), 70.
https://doi.org/10.1186/s40360-017-0173-2
Lyberg, A., Holm, A. L., Lassenius, E., Berggren, I., &
Severinsson, E. (2013). Older persons' experiences of
depressive ill-health and family support. Nursing research and
practice, 2013, 837529. https://doi.org/10.1155/2013/837529
Preskorn, S. H., & Hatt, C. R. (2013). How Pharmacogenomics
(PG) Are Changing Practice.
Journal of Psychiatric Practice
,
19
(2), 142–149. doi: 10.1097/01.pra.0000428559.01953.73
Rossom, R. C., Shortreed, S., Coleman, K. J., Beck, A.,
Waitzfelder, B. E., Stewart, C., Ahmedani, B. K., Zeber, J. E.,
& Simon, G. E. (2016). ANTIDEPRESSANT ADHERENCE
ACROSS DIVERSE POPULATIONS AND HEALTHCARE
SETTINGS. Depression and anxiety, 33(8), 765–774.
https://doi.org/10.1002/da.22532
Ribeiro, J., Huang, X., Fox, K., & Franklin, J. (2018).
Depression and hopelessness as risk factors for suicide ideation,
attempts and death: Meta-analysis of longitudinal studies.
British Journal of Psychiatry, 212(5), 279-286.
doi:10.1192/bjp.2018.27
I NEED A RESPONSE TO THIS ASSIGNMENT

8. ZERO PLAGIARISM
TWO REFERENCES