1. By: Danielle DeGroot
Dietetic Intern

2.  CDC reports:
 ~1 in 10 adults report depression in the U.S.
 Groups more likely to meet criteria for major depression:
 45-64 years
 Female
 African Americans, Hispanics, non-Hispanic persons of other or multiple
races
 Persons with less than a high school education
 Previously married
 Unable to work/unemployed
 Without health insurance coverage
 Similar criteria fit “other depression” category with the
exception of:
 18-24 year olds were more likely to report “other depression”
 Current medical treatment:
 Antidepressants, antipsychotics
http://www.cdc.gov/Features/dsDepression/

3. http://www.cdc.gov/Features/dsDepression/

4. • AM is a 22 year old Caucasian female.
• Inpatient in the Adolescent Psychiatric Unit
 Readmitted because of increasing symptoms
of depression, some SI, and severe difficulty
functioning.
 Admit Date: 4/11/2011
 Chart reviewed due to positive findings on
nursing admission screen – patient triggered for
history of eating disorder. Hospital course and
events leading to admission reviewed per notes.
Noted patient has been followed by EDU RD with
most recent visit in December of 2010.

5. • Current Dx:
1. Obsessive-compulsive disorder (300.3)
2. Depressive disorder, not elsewhere classified (311)
3. Anxiety state, unspecified (300.00)
• PMH includes: depressive disorder, anxiety state, eating
disorder, primary insomnia, Chiari malformation type 1,
attention deficit disorder
 Currently presents with:
 7% loss of body weight in 2 months
 Poor appetite
 Anthropometrics:
– IBW: 125 lbs; %IBW:74%; BMI:15.79

6. Laboratory Test Normal Values Patient Values
Blood Pressure 120/80 102/64
Albumin 3.5-5.0 g/dL 4.5*
WBC 4.0-10.0 7.6
RBC 4.00-5.20 4.25
HGB 12.0-16.0 12.8
HCT 36-46 38.4
PLT 150-399 280
GLUCOSE Fasting: 60-109 91
mg/dL
Nonfasting: 60-200
mg/dL
NA 137-147 138
K 3.4-5.3 3.5
*May be falsely normal

7. Laboratory Test Normal Values Patient Values
CL 99-108 103
CO2 22-29 mmol/dL 29
BUN 8-21 mg/dL 10
CREAT 0.5-1.1 mg/dL 0.6
CA 8.7-10.7 mg/dL 9.7
PROT 6.0-8.2 g/dL 7.3
TBILI 0.2-1.3 mg/dL 0.6
AST 5-55 units/L 17
ALT 3-50 units/L 13
GGT 0-51 IU/L 14
Reference ranges from EPIC

8.  Mental Status Examination
 Verbal, cooperative
 Normal rate and tone of speech
 Depressed mood
 Affect constricted
 Thought logical with no evidence for
hallucinations/delusions/homicidal ideation
 Judgment/insight fair.
 Alert/oriented x 3
 Memory grossly intact
 Intelligence in superior range

9.  Axis I: Clinical disorders; other conditions that may
be the focus of clinical attention.
 Major depression, recurrent, severe
 Axis II: Personality disorders, mental retardation.
 none
 Axis III: General medical conditions
 Insomnia
 Axis IV: Psychosocial and environmental problems
 Moderate
 Axis V: Global assessment of function (GAF: a scale
from 1 – 100)
 Past week – 30. Best in past year – 50.

10. • Adderrall/Adderall XR:
• ADHD, CNS Stimulant, Appetite Suppressant
• Zolpidem (Ambien):
• Sleep Aid
• Quetiapine (Seroquel):
• Antipsychotic
• Lorazepam (Ativan):
• Antianxiety
• Fluvoxamine (Luvox):
• OCD or Social Anxiety Disorder, Depression
• Hydroxyzine (Atrax):
• Antianxiety
• Alprazolam (Xanax/Xanax XR):
• Antianxiety, antipanic

11.  Increased risk of:
 Drug-drug interactions
 “Uncertain gains for quality of care and
clinical outcomes.”
 Limitedsupporting evidence
 Many patients continue to experience
symptoms
Mojtabai R, Olfson M. National Trends in Psychotropic Medication Polypharmacy in Office-Based Psychiatry. Arch
Gen Psychiatry. 2010;67(1):26-36.

12.  Adolescent Stress Diet
 General
 Caffeine Free
 Is this appropriate for A.M.?
 Patient with poor PO intake; general diet
appropriate to encourage intakes
 Caffeine interacts with several
psychotherapeutic drugs

15. Schmidt, M. Brain Building Nutrition: The Healing Power of FNB
and Oils. Frog; LTD. 2001.

16. Omega-3 Supports Healthy
Immune Response. Nordic
Naturals 2006.

17.  Reportedn-3 PUFA can suppress
pathophysiological features of depression
(inflammation and immune reactivity
markers)
 Human studies indicate that dietary
supplementation with EPA and DHA supress IL-1,
IL-2, IL-6 and TNF-a production by monocytes
 Increasing long-term DHA intakes indicates
decrease in depression
Mamalakis, G., Tornaritis, M., & Kafatos, A. (2002). Depression and adipose essential polyunsaturated fatty acids
[Abstract]. Prostaglandins, Leukotrienes, and Essential Fatty Acids, 67(5) 311-318.

18.  N-3 PUFA deficiency linked to (all associated with
depression):
 Altered neurotransmission
 Decreased glucose metabolism
 Increased production of pro-inflammatory cytokines
 Reduced levels of brain-derived neurotrophic factor
(BDNF)
 Neuronal atrophy
Liperoti, R., Landi, F., Fusco, O., Bernabei, R., & Onder, G. (2009). Omega-3 polyunsaturated fatty acids and depression:
A review of the evidence. Current Pharmaceutical Design, 15(36), 4165-4172 .

19.  Cross-sectional
survey: 21,835 adult/elderly
subjects from Norway
 Significantly [(OR = 0.71 (95% CI = 0.52 – 0.97)]
less likely to have depressive symptoms
 1000-1500 mg/d in a 2:1 EPA:DHA ratio optimal
for tx of affective disorders.
McNamara, R. K. (2009). Evaluation of docosahexaenoic acid deficiency as a preventable risk factor for recurrent
affective disorders: Current status, future directions, and dietary recommendations [Abstract]. Prostaglandins,
Leukotrienes, and Essential Fatty Acids, 81(2) 223-231.

20.  Omega 3 supplementation
 Regular intake of 1g to 2g EPA/day + DHA n-3
improves irritability
 Improved depression scores in many studies
found with supplementation of 1g: higher levels
may not show greater improvement
 6-8 oz fish/week (750-1000mg EFA/day)
 Vitamin E
Care manual

21.  Importance of a balanced diet in relation to overall
mental health and well being.
 Recommend aiming 2 servings of high n-3 containing fish at
least 2x/wk
 Recommend increasing fruits and vegetables rich in vitamins,
minerals, antioxidants
 Benefits of supplementing with Omega-3 fatty
acids/Vitamin E as it relates to patient condition.
 Recommend at least 1-2g/day
 Contraindications: Decreased hepatic fx, fish/soy allergy, pts
with implantable defibrillators (inc risk of ventricular
fibrillation/tachycardia), on blood thinners (i.e., Coumadin).
 Proper vitamin/mineral intake
 Supplement with Vitamin E

22.  1. Centers for Disease Control and Prevention. CDC Features:
Depression. Page last reviewed: March 31, 2011. Available at:
http://www.cdc.gov/Features/dsDepression/.
 2. EPIC Computer Charting.
 3. Trzepacz, PT; Baker RW (1993). The Psychiatric Mental Status
Examination. Oxford, U.K.: Oxford University Press. p. 202.
 4. Nutrition Care Manual. American Dietetic Association. 2011.
Available at: www.nutritioncaremanual.org.
 5. DSM-IV-TR Multiaxial Classification System. Des Moines Area
Community College. Available at:
http://www.dmacc.edu/Instructors/tkwilson2/Diagnosis.pdf.
 6. Pronsky ZM, Crowe JP. Food Medication Interactions 16th
Edition. Birchrunville, PA. 2010.
 7. Mojtabai R, Olfson M. National Trends in Psychotropic
Medication Polypharmacy in Office-Based Psychiatry. Arch Gen
Psychiatry. 2010;67(1):26-36.

23.  8. Mahan LK, stump SE. Krause’s food & Nutrition Therapy.
Saunders Elsevier, St. Louis, Missouri; 2008.
 9. Omega-3 Supports Healthy Immune Response. Nordic Naturals
2006.
 10. Mamalakis, G., Tornaritis, M., & Kafatos, A. (2002).
Depression and adipose essential polyunsaturated fatty acids
[Abstract]. Prostaglandins, Leukotrienes, and Essential Fatty
Acids, 67(5) 311-318.
 11. Liperoti, R., Landi, F., Fusco, O., Bernabei, R., & Onder, G.
(2009). Omega-3 polyunsaturated fatty acids and depression: A
review of the evidence. Current Pharmaceutical Design, 15(36),
4165-4172.
 12. McNamara, R. K. (2009). Evaluation of docosahexaenoic acid
deficiency as a preventable risk factor for recurrent affective
disorders: Current status, future directions, and dietary
recommendations [Abstract]. Prostaglandins, Leukotrienes, and
Essential Fatty Acids, 81(2) 223-231.