Question

You work in a large hospital system that does regular chart reviews of your caseload, which is now happening more frequently in preparation for an upcoming Joint Commission review (where your chart could be chosen by the reviewers). Like many large health care systems, there is a push towards utilizing evidence based treatments where available along with requirements for documentation of ongoing assessment throughout the treatment process (the Joint Commission always looks for this!).

Your evaluation determines that Gabriella meets criteria for Major Depressive Disorder, Moderate – which is based on a structured diagnostic interview as well as additional assessments including the Beck Depression Inventory and the MMPI-2 (where you used the validity scales to ensure that she is not over or under reporting symptoms). The next step is to choose a treatment for Gabriella.   

Referring to reading related to evidence-based treatments / treatment guidelines AND descriptions of treatment approaches, please answer the following:

1. What treatment orientation would you be least likely to choose for Gabriella? What is involved in this treatment approach (be specific!)? Considering information from both readings (which includes research!), why are you least likely to choose this approach?

2. What treatment orientation would you be most likely to choose for Gabriella? What is involved in this treatment approach (be specific!)? Considering information from both readings (which includes research!), why are you most likely to choose this approach? What assessment(s) would you use throughout treatment? Why did you choose this assessment?

Referring to the readings related to the recovery model:

3. How can you incorporate the recovery orientation into your treatment? What components could be important to keep in mind with Gabriella (and why do you think this is?)? What additional assessment measures could assist you in integrating this approach (and what do they assess?)?

Answer 1

1).

Mood disorders: The characteristic symptoms of mood disorder are frequent changes in mood and affect (way of expression of mood). If only low moods are expressed, it is known as depressive disorders or if both the hyper and hypo activities are involved, it is known as bipolar disorder.

The signs of depression are more due to the decreased secretion of serotonin and other monoamine neurotransmitters like noradrenaline and dopamine (all of them are excitatory neurotransmitters).

Therapeutic management: Most of the people suffering from major depressive disorder respond to the treatment. Some of the common therapeutic interventions for all mood disorders include the following.

i). Anti-depressant drugs (Eg: amitryptiline)

ii). Mood stabilizers (Eg: valproic acid)

iii). Psychotherapy

iv). ECT (electroconvulsive therapy)

Lithium carbonate (anti manic) is used in the treatment of bipolar disorder. Time to time monitoring of patient response and the side effects is must because of lower therapeutic window of certain drugs used in the treatment of psychological disorders (Eg: lithium toxicity).

Thus, the following categories of drugs are used in the treatment of depression:

Monoamine oxidase inhibitors (Eg: selegiline, phenelzine) inhibit the metabolism of monoamines (adrenaline, noradrenaline, dopamine, and serotonin) by the “monoamine oxidase” enzyme. This increases their availability at the nerve terminals and thus, increase the transmission.

Tricyclic antidepressants block the reuptake of norepinephrine and serotonin from the synapse, and thus, increase their transmission. Eg: Imipramine, desipramine.

Selective serotonin reuptake inhibitors (SSRIs) selectively inhibit the reuptake of serotonin and promote the neurotransmission of serotonin. Eg: Fluoxetine.