The Case # 1: The man whose antidepressants stopped working             The 63 yr-old with the worst depression and anxiety he has ever felt.  He is married for 33 years and with 3 children.  He is a non-smoker and non-drug and alcohol abuse.  He has a medical history of Atrial fibrillation and Hypercholesterolemia.  He has a family history with depression that is the mother, son, and daughter.  Three Questions I might ask the patient if he were in my office. What is your current problem, symptoms, and thoughts? What are your interpersonal or psychosocial stressors?             Rationale:  The goal is to learn more about the patient, his current problems and symptoms; a complete history of previous symptoms; a family history; a history of significant stressful life events (psychosocial stressors); information concerning lifestyle, culture, social support structure and any suicidal thoughts or tendencies the person may be experiencing. Are you comfortable if we can involve your family members or significant other in psychoeducation and treatment? Rationale:  According to Gulf Bend Center (n.d.a.) one of the well-studied sociological factors that helps prevent depression is known as “social support.”  Social support simply refers to whether or not people have access to and make use of a network of interpersonal relationships for supportive purposes.  People receive social support from their family, friends, work, and significant others.  Social support networks provide a shoulder, guidance, love, caring, entertainment, laughs, and other types of mental and physical assistance during times of need and crisis. For your recurrence depression, can we try a combination of medication and psychotherapy? Rationale:  Psychotherapy has been recommended for the treatment of depression which  includes cognitive-behavioral therapy (CBT), interpersonal psychotherapy, and problem-solving therapy.  CBT is considered as the first-line and most evidence-based psychological therapy for depression.  CBT works by identifying any dysfunctional thoughts and replacing them with more helpful ones, with the intent of modifying negative behaviors and emotions that perpetuate the depression (Ng, How & Ng, 2017). Physical Exams and diagnostic tests appropriate for the patient and how the result would be used.             Although his vital signs are normal where we have BP normal, BMI normal and normal fasting glucose and triglycerides it is very important to do lab measurements and to screen for thyroid dysfunction and dexamethasone suppression test.  According to Samuels (2018), it should be a routine clinical practice to screen patients with depression for thyroid dysfunction.  Many patients with depression who are screened for thyroid dysfunction have mildly elevated thyrotropin (TSH) and normal free thyroxine (T4) levels (mild or subclinical hypothyroidism).  The patient and care provider may attribute the depressive symptoms to mild thyroid disorder.

1. The Case # 1: The man whose antidepressants stopped working
The 63 yr-old with the worst depression and anxiety he
has ever felt. He is married for 33 years and with 3 children.
He is a non-smoker and non-drug and alcohol abuse. He has a
medical history of Atrial fibrillation and Hypercholesterolemia.
He has a family history with depression that is the mother, son,
and daughter.
Three Questions I might ask the patient if he were in my office.
What is your current problem, symptoms, and thoughts?
What are your interpersonal or psychosocial stressors?
Rationale: The goal is to learn more about the patient,
his current problems and symptoms; a complete history of
previous symptoms; a family history; a history of significant
stressful life events (psychosocial stressors); information
concerning lifestyle, culture, social support structure and any
suicidal thoughts or tendencies the person may be experiencing.
Are you comfortable if we can involve your family members or
significant other in psychoeducation and treatment?
Rationale: According to Gulf Bend Center (n.d.a.) one of the
well-studied sociological factors that helps prevent depression
is known as “social support.” Social support simply refers to
whether or not people have access to and make use of a network

2. of interpersonal relationships for supportive purposes. People
receive social support from their family, friends, work, and
significant others. Social support networks provide a shoulder,
guidance, love, caring, entertainment, laughs, and other types of
mental and physical assistance during times of need and crisis.
For your recurrence depression, can we try a combination of
medication and psychotherapy?
Rationale: Psychotherapy has been recommended for the
treatment of depression which
includes cognitive-behavioral therapy (CBT), interpersonal
psychotherapy, and problem-solving therapy. CBT is
considered as the first-line and most evidence-based
psychological therapy for depression. CBT works by
identifying any dysfunctional thoughts and replacing them with
more helpful ones, with the intent of modifying negative
behaviors and emotions that perpetuate the depression (Ng, How
& Ng, 2017).
Physical Exams and diagnostic tests appropriate for the patient
and how the result would be used.
Although his vital signs are normal where we have BP
normal, BMI normal and normal fasting glucose and
triglycerides it is very important to do lab measurements and to
screen for thyroid dysfunction and dexamethasone suppression
test. According to Samuels (2018), it should be a routine
clinical practice to screen patients with depression for thyroid
dysfunction. Many patients with depression who are screened
for thyroid dysfunction have mildly elevated thyrotropin (TSH)
and normal free thyroxine (T4) levels (mild or subclinical
hypothyroidism). The patient and care provider may attribute

3. the depressive symptoms to mild thyroid disorder and initiate L-
T4 therapy. Also, a complete diagnostic evaluation for
depression should include tests for bacterial and viral
infections, metabolic deficiencies, and autoimmune conditions.
Depressive symptoms are sometimes measured with
general questionnaires designed to look at several different
types of mental conditions as once. The general health
questionnaire (GHQ) is a screening test for identifying minor
psychiatric disorders in the general population. It looks at the
person’s current state and asks if that is different from the usual
state. It is sensitive to short-term psychiatric disorders, but not
to long-standing characteristics of the person. This self-
administered questionnaire focuses on two major areas: the
inability to function in daily life and the appearance of new and
distressing symptoms (Gulf Bend Center, n.d.a.)
Three differential diagnoses for the patient: Identify one that is
most likely diagnoses.
According to the criteria in the fifth edition of the
Diagnostic and Statistical Manual of Mental Disorders (DSM-5)
(n.d.a.) and using the screening tools, the diagnosis established
would be Major Depressive Disorder (MDD) where the clinician
needs to differentiate and identify other conditions that may
have similar symptoms. This will help to provide information
about a person’s anticipated course of the disorder and their
prognosis (outcome).
The clinician may use the following differential diagnosis to
describe the current or most recent Major Depressive Disorder:
Mood disorder due to another medical condition.
Adjustment disorder with depressed mood.

4. Melancholic Features
The most likely diagnosis of the 63 yrs-old is MDD with
melancholic features that have been described by the most
severe stages of his five (5) episodes which include:
An inability to enjoy anything and does not react to anything
pleasurable along with a mood that is regularly worse in the
morning.
Early morning awakening (at least two hours before the usual
time)
Thinking of moving slowly.
Significant loss of appetite or unplanned weight loss.
Excessive or inappropriate guilt.
Two pharmacologic agents and their dosing that would be
appropriate for the patient’s antidepressant therapy.
According to Stahl’s (2013) adults between the ages of
25 and 64 might have the best chance of getting a good response
and with the best tolerability to an antidepressant. In his fourth
episode, he was prescribed venlafaxine XR (Effexor XR) which
worked even faster as compared with the other antidepressants
and the patient did not have sexual dysfunction but discontinued
after less than a year. This was a major mistake to discontinue
the medication because he already had a family history and
recurrent episodes of depression. Venlafaxine XR is a
Norepinephrine and dopamine reuptake inhibitors (NDRIs) work

5. in the same way as the other neurotransmitter reuptake
inhibitors. NDRIs Venlafaxine frequently seems to have greater
antidepressant efficacy as the dose increases theoretically due
to recruiting more and more Norepinephrine transporter (NET)
inhibition as the dose is raised.
After the fifth episode after taking Venlafaxine XR for
15 months there was no relief of the symptoms which can be a
result of the patient had become resistant and as his age
progresses to 63 yrs-old also the changes in brain structure and
neurotrophic factors. Due to recurrent, and recurrences of
depression which possibly indicate disease progression
potentially manifested as shorter and shorter periods of wellness
between subsequent episodes, which has resulted to poor inter
episode recovery and ultimately, treatment resistance thus the
need to introduce tricyclic antidepressants (TCAs) and
monoamine oxidase inhibitors (MAOIs) which are regarded as
second-line and third-line due to their tolerability and safety
profile. Tricyclic antidepressants have antagonist action at
5HT2A and 5HT2C which could contribute to their therapeutic
profile. Monoamine oxidase inhibitors (MAOIs) are enzymes
that break down serotonin, norepinephrine, and dopamine. By
preventing these enzymes from working MAOI medications
allow neurotransmitters to remain the synaptic gap longer thus
giving more opportunity to activate the post-synaptic neuron’s
receptor and create greater stimulation of the post-synaptic
recipient neuron. Increasing serotonin, norepinephrine and
dopamine levels tend to have an antidepressant effect. There is
no contraindication to use as a treatment for depression due to
the patient ethnicity although TCAs can cause anticholinergic
effects (dry eyes, constipation, and urinary hesitancy) and be
lethal if overdosed. MAOIs can lead to a hypertensive crisis if
combined with tyramine-rich foods such as cheese and many
medications, including common primary care drugs such as
decongestants and cough syrups (Stahl’s, 2013).

6. As a clinician, when prescribing treatment for
depression patients may have to try several different
medications before finding one that works well. Even within a
group of similar antidepressant medications, some people do
better with one than with others. The decision about when it is
time to try new medications is best made when the patient,
clinician and psychotherapist work together as a team. For this
patient, I believe the combination of psychotherapy and
medication would have been beneficial and probably he would
have been able to get to a point where he could gradually
decrease or discontinue the use of antidepressants. He would
have learned how to maintain well-being by using skills learned
in psychotherapy. However, for those individuals whose
depression returns when they stop using the medication, long-
term use of antidepressants may be necessary.
Reference
Diagnostic and Statistical Manual of Mental Disorders (DSM-
5)(n.d.a.). Retrieved on March 11th, 2020 from
https://www.ncbi.nlm.nih.gov/books/NBK519712/table/ch3.t5/
Gulf Bend Center (n.d.a.). Depression: Depression & related
conditions basic information. Retrieved on March 11th, 2020
from https://www.gulfbend.org/poc/center_index.php?cn=5
Ng, C. W. M., How, C. H., & Ng, Y. P. (2017). Managing
depression in primary care.
Singapore Med J.
58(8), 459-466,doi.org/10.11622%2Fsmedj.2017080
Samuels, M. H. (2018). Subclinical hypothyroidism and
depression: Is there a link?
The Journal of Clinical Endocrinology & Metabolism
. 103(5), 2061-2064, doi.org/10.1210/jc.2018-00276

7. Stahl, S. M. (2013).
Stahl’s essential psychopharmacology: Neuroscientific basis
and practical application,
(4th ed.). Cambridge University Press.
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