Management of

Depressive disorders;
case presentation

By Pharm. Robinson Sarah

 TEAM MEMBERS
o Pharm. Amina Yakubu : Preceptor
o Pharm. Innocent Amoke
o Pharm. Ekiyor Yinlayefa
o Pharm. Shaga Theresa
o Pharm. Paulin Christel Tobick
o Pharm. Ajibola Omotosho
o Pharm. Munirat Mohmoh
o Pharm. Cosmas Chekwube Ugwanyi
o Pharm. Akande Omorunude
 OUTLINE
• CASE
• SUBJECTVE DATA
• OBJECTIVE DATA
• BACKGROUND OF DISEASE
• SYMPTOMS
• PATHOPHYSIOLOGY
• DIAGNOSIS
• TREATMENT
• ASSESSMENT
• PLAN
• EVALUATION
• PROGNOSIS
• CONCLUSION
• REFERENCES
THE CASE
 Case scenario

• A 62 years old female, a known hypertensive was presented to the GOPD on

the 13th of January, 2017 with complains of visual hallucination for 6months,
auditory hallucination for 6 months, lack of sleep for 1yr.
Subjective Objective Assessment Plan
 SUBJECTIVE

• JA, a 62 years old retired prison warden who

Demographics hails from Kaura LGA, Kaduna State. She is a
Christian and a known hypertensive.
• she complained of visual hallucination
for 6months, auditory hallucination for 6
months, lack of sleep for 1yr. Crying
spells, significant weight loss, and
Chief exaggerated feelings of anxiety.
complain • On admission: Urinary incontinence,
urgency, frequency, nocturia for three
months and fever for three days, which
was low grade and said to be reduced by
oral PCM and tepid sponging.

• she drinks 1 bottle of stout once in two

Social history weeks, but stopped four months prior to
presentation
 JA was an outpatient from13th of January, 2017 to 10th of
Out patient October 2017

In JA was admitted on 11th of October, 2017 and discharged

home on 20th October, 2017
patient
She is a widow, husband died 10 years ago of acute
hepatitis B
Family She delivered 4 children, adopted a child, but had 4 alive.
JA’s immediate younger brother is mentally impaired,
history started 4 years ago when he complained that ants were all
over his body which no one else saw but himself.
 SUBJECTIVE
• JA’s hallucinatory symptoms were complains
History of of seeing snakes crawling on her body,
Present which also whisper inaudible words to her,
Illness and feelings of rashes which no one else saw,
with associated itching for two years.
• three unsuccessful osteoarthritic surgery on
her right knee, which had her confined to a
Past wheel chair in the last two years prior to
Medical presentation.
• PUD
History
• She had an infection on the operation site due
to long stay on admission.

Past •cap omeprazole 20 mg 12 hrly, tab melocarp

Medication 7.5mg 12 hrly.
History
 Objective data
JA, was not pale, anicteric, acyanosed and she had no pedal edema.
• She was looking anxious, with occasional dejected feeling her speech was
spontaneous, coherent, and low in tone.

• She had a sad mood , an inappropriately reactive affect, exhibited visual and
auditory hallucination.
Her judgement was impaired, she had a poor insight, but was oriented in time, place
and person.
• Vital signs at 13th October
• PR = 86 bpm
BP = 150/90 mmHg
• RR = 32cpm
• Temp. 37.60c
 Lab results
paramet Normal unit 20/01/2017 12/10/2017 Comment
er range
LFT: Up to 49 u/L 103.5 High
ALT 64-306 136.2 Normal
ALP Up to 46 75.5 high
AST
Bilirubin: mmol/L
direct <34 10.1 5.2 Normal

total 3.4 – 17 16.9 10.3 Normal

FBG 3.9-5.8 mmol/L 4.6 5.3 Normal

urinalysis Protein - Negative Normal

Nitrites - Negative
Blood - Negative
Ascorbic Acid - Negative
Glucose - Negative
Urobilinogin - Normal
Ketones - Negative
Bilirubin - Negative
Appearance - Pale amber and
clear
parameter Normal unit 20/01/2017 12/10/2017 17/10/2017 Comment
range
Renal electrolytes
24.3
Bicarbonate (21 - 28) mmol/L Normal
96.9
Chloride (98-108) mmol/L Slightly low
3.5
Pottasium (3.5-5.5) mmol/L Normal
131.1
Sodium (135-145) mmol/L Slightly low
73.5
Creatinine (62 - 115) umol/L Normal

2.5-8.3 mmol/L Normal

Urea
3.4
Heamatology
WBC 11.4*109 High
% Neutrophil-67 Indicative of infection
% Lymphocytes-23

Differentials % Monocytes -07

% Eosinophils-03
parameter Normal range 17/10/2017 Comment

PCV 45-47 33 Low

Urine MCS Macroscopy Amber - yes Presence of klebsiella specie
Macroscopy Cloudy - yes which is inhibited by
Epith Cells Microscopy - +++ gentamycin and levofloxacin
Pus Cells Microscopy – 3-4
RBC Microscopy - +

Culture - Yielded heavy

growth of Klebsiella specie

Ceftriazone Antibiogram 1 –
Resistant
Gentamycin Antibiogram 1 -
2+
Levofloxacin Antibiogram 1 -
+
 Working Diagnosis

• Ja was diagnosed of depressive disorder with psychotic features.

 Background of disease
• Psychotic depression also known as depressive disorder with psychotic
features, is a serious condition that requires immediate treatment and close
monitoring by a mental health professional.

• Major depressive disorder impacts mood and behavior as well as various

physical function including appetite and sleep.

• People with this disorder often lose interest in activities they once enjoyed
and also have trouble performing daily activities
• Psychosis is characterized by a loss of contact with reality, with symptoms
like delusion and hallucination.

• These symptoms can be frightening and can increase the risk of suicide,
therefore, prompt diagnosis and treatment is critical to someone from hurting
themselves or others.
 Symptoms of psychotic depression
• Hallucinations (seeing or hearing things that aren't there)
• Delusions (false beliefs)
• Paranoia (wrongly believing that others are trying to harm them)
• Feelings of worthlessness or self hate.
• Weight loss or gain
• Trouble getting to sleep or feeling sleepy during the day
• Feelings restless and agitated, or else very sluggish and slowed down
physically or mentally
• Being tired and without energy
• Feeling worthless or guilty
• Trouble concentrating or making decisions
• Thoughts of suicide
 Pathophysiology of psychotic depression

• The exact aetiology of psychotic depression is unknown, however, a person

with family or personal history of mental disorder is at risk of developing
psychotic depression.

• Research studies have shown that neurotransmitter and hormonal imbalances

poses risk of psychotic depression.
 Diagnosis of psychotics depression

• Clinical criteria (DSM-5)

• FBC, electrolytes, and TSH, vitamin B12, and folate levels to rule out physical
disorders that can cause depression
Treatment
Drug Class Indication Adverse effect Dose
Amitriptyline Tricyclic Depression Sedation, Up to 300 mg/day
antidepressant anticholinergic PO in divided
effects (dry mouth, doses; 20–30 mg
dry eyes, urinary IM QID
retention), nausea,
nasal congestion,
blurred vision,
orthostatic
hypotension,
lethargy,
confusion,
constipation,
diarrhea

paroxetine Selective Serotonin Depression, OCD, Headache, tremors, 20-50 mg/day PO

Reuptake Inhibitors panic disorder, nervousness,
general anxiety insomnia,
disorder, social drowsiness, nausea,
anxiety disorder, diarrhea, visual
post-traumatic disturbances,
stress syndrome. sweating.
Drug Class Indication Adverse effect Dose
olanzapine Atypical Schizophrenia, Agitation, 5-20 mg/day
antipsychotic short-term dizziness, PO
treatment of nervousness,
manic episodes akathisia,
of bipolar constipation,
disorder fever, weight
gain
haloperidol Typical Psychotic Extrapyramidal 0.5-5 mg PO
antidepressant disorder; symptoms, 12 hourly.
Tourette’s akathisia, Children: 0.05-
syndrome, dystonia, 0.075
behavioral tardive mg/kg/day PO
problems in dyskinesia,
children drowsiness,
headache, dry
mouth,
orthostatic
hypotension
 Electroconvulsive therapy

• Electroconvulsive therapy (ECT) is a procedure, done under general

anesthesia, in which small electric currents are passed through the brain,
intentionally triggering a brief seizure.

• ECT seems to cause changes in brain chemistry that can quickly reverse
symptoms of certain mental illnesses.
 Side effects of ECT

• Confusion
• Memory loss
• Physical side effects e.g nausea, headache, jaw pain or muscle pain.
• Medical complication e.g increase blood pressure and heart rate that can lead
to serious heart problems, ECT is therefore poses more risk in patient with
heart problems
 Psychotherapy
• Numerous controlled trials have shown that psychotherapy, particularly
cognitive-behavioral therapy and interpersonal therapy, is effective in patients
with major depressive disorder, both to treat acute symptoms and to decrease
the likelihood of relapse.

• Patients with mild depression tend to have better outcomes than those with
more severe depression, but the magnitude of improvement is greater in those
with more severe depression.
Date Drugs prescribed Indication Comment

13/01/17 Tabs Paroxetine 20mg nocte x 2/52 Depression with psychotic okay
Tabs Olanzapine 5mg nocte x 2/52 features and anxiety
Tabs lorazepam 0.5mg nocte x 5/7

27/01/17 Tabs Paroxetine 20mg nocte x 1/12 Depression with psychotic Okay
Tabs Olanzapine 5mg nocte x 1/12 features

24/02/17 Tabs Paroxetine 20mg nocte x 3/12 Same as above Dose of

Tabs Olanzapine10mg nocte x 3/12 olanzapine was
increased

30/06/17 Same as above Same as above

Date Drugs prescribed Indication Comment
11/10/17 Tabs Paroxetine 20mg nocte x 1/12 Same as above  Dose of olanzapine
Tabs Olanzapine 5mg nocte x 1/12 Haloperidol to tackle was increased
Haloperidol 5 mg 12 hourly x 5/7 relapse  Serious drug
interaction with
paroxetine requiring
alternative use.
 Interaction with
olanzapine requiring
close monitoring.
13/10/17 IV Normal saline 1L 8 hourly Electrolyte imbalance Okay
IV Levofloxacin 500mg 12 hourly x 7/7 UTI Wrong management
-Tab vit C 1g daily for x 7/7 General wellbeing of
Discontinue haloperidol. patient Drug interaction with
Tabs Paroxetine 20mg nocte x 2/52 levofloxacin, paroxetine
Tabs Olanzapine 5mg nocte x 2/52 and olanzapine

20/10/17 Tabs Paroxetine 20mg nocte x 2/52

Tabs Olanzapine 5mg nocte x 2/52
 ASSESSMENT
Problem list

1 • Psychotic depression

2 • Menopause

3 • Osteoarthritic Disease

4 • Adverse drug effects.

 Possible aetiolgy

• JA,s depression with psychotic features could be due to accumulation of past

event in her life: three failed osteoarthritic surgery that had her confined to a
wheel chair having been active as a prison warden.
• Long and frequent hospitalization that even caused her an infection at the
operation site.
• Genetics since her brother had a psychotic illness.
• The urinary symptoms exhibited could be side effects of both the anti
depressant and anti psychotics.
 Drug therapy problems
• Drug-drug interaction
Levofloxacin and paroxetine both increases QTc interval. This calls for use with
caution and close monitoring. This also poses such patient at risk of sudden death.
• Frequency and duration too high
Levofloxacin was dosed at 500 mg 12hrly for 7 days instead of 750mg 24hrly for
5 days in complicated UTI, or 250 mg 24hrly for 10days in same condition and 250 mg
for 3 days in uncomplicated UTI. Patient JA,s case was not a complicated one.
Wrong management
The urinary symptoms seen in JA were anticholinergic side effects of the
antidepressants and anti psychotics. The micro-organism indicative of the infection was
sensitive to gentamycin (2+) which has no interaction with her other drugs but
levofloxacin with (1+) was administered, which did not resolve the urinary symptoms
as she was discharged on bladder draining.
 PLAN
Goals of therapy
According to the National Institute on Metal Health (NIMH)
Guideline
Resolution of depressive symptoms.
To ensure a return to euthymic mood.
To prevent relapse and recurrence of depressive symptoms.
To improve patient quality of life
To improve patient’s relationship with caregivers
 Intervention

Patient focused
Advice patient to continue anti depressant and anti psychotics for at least two years due
to the risk of relapse.
Advice that care should be taken not to miss or just stop a drug due to discontinuation
symptoms which could be mild and self limiting over a week, but sever if abrupt
withdrawal of drug.
Refer to see a cognitive behavioral therapist.

Drug Focused
• Benzhexol 5 mg 24hrly to abate the urinary symptoms.
• IM gentamycin 80-160 mg daily for 3-5 days
 PATIENT EDUCATION
• Enlighten patient JA and relatives on the state of the disease condition.
• To report any sudden new symptoms immediately.
• To continue drug administration even though relieve is not seen immediately
as these drugs do not have immediate onset of action.
• To continue drugs even after symptoms have been abated to avoid relapse.
• To avoid taking drugs with antacids.
• To avoid any psychosocial issue that could affect adherence.
 EVALUATION

• Monitor patient JA closely by calling her relatives to enquire weekly progress.

• Monitor urinary symptoms so as to ensure that the side effects has been
abated.
 Prognosis

• The prognosis of this case is poor, as she was not properly followed up
monitored on the drug interaction which could have resulted in her sudden
death.
• Also considering her age and life expectancy as a contributory factor to the
poor prognosis.
 Conclusion

• Having pharmacists on ward rounds to properly checkmate issues as it relates

to the wellbeing of patients, can not be overemphasized.

• This is because a lot of hazards would be averted.

 Reference
• Cletus Nze Aguwa (2012) : Therapeutic Basis of Clinical Pharmacy in the Tropics, 4th
Edition. Pages 509-513.

• Anita Dickson (2011) : Lab Values and their Meanings, Revised Edition.
• Medscape (2016), Medscape Medical Resources ( version ) [Mobile application software].
Retrieved from http://googleplaystore.com
• Chris Obi et al (2016) :EMDEX vol 1&2; based on WHO Model Formulary & Nigeria’s
Essential Druh list. Pages 55-65.

• Mary Koda Kimble et al : Applied Therapeutics; The Clinical Use of Drugs 8th Edition.
Pages 283-285

• Bertram G. Katzung et al (2012) : Basic and Clinical Pharmacology, 12th Edition. Pages
521-539.
• www.nice.org.uk/guidance/cg90/chapter/1-guidance/#treatment-choice-based-
on-depression-subtypes-and-personal-characteristics
• Kellner C. Technique for performing electroconvulsive therapy (ECT) in
adults. http://www.uptodate.com/home. Accessed Aug. 26, 2015.
 Thank obrigado
you

Na
merci
gode

Nyaari Gracias
emi