Instructions
After you posted your complex case presentation (see attached document).
1. Actively respond to and guide the conversation as your colleagues post responses to your presentation.
2. Respond to each post (colleague) with at least 1 paragraph and give at least 1 reference per respond.
Response 1
Hi, Ariel. Your presentation is informative and clearly explains the symptoms related to your patient's primary diagnosis. I will focus my response to your 3rd question about the possible risks of a patient not adhering to a medication regimen as prescribed. According to Velligan et al. (2017), patient nonadherence to medication is associated with a rise in the utilization of emergency psychiatric services, SI and self-harm behaviors, increased aggression, and poor social, emotional, and occupational functioning. The authors explain that the person’s quality of life is reduced when their symptoms are not treated adequately because of choosing not to adhere to their medication regimen.
Not all nonadherence is intentional. Velligan et al. (2017) explain that unintentional nonadherence can occur when a person's mental illness impairs their ability to take their medication on time or to take it at all. A person’s cognitive abilities, severe depressive symptoms, or psychotic symptoms can keep a person from adhering to medications. The authors also point out that practical reasons, such as access to healthcare and lack of social support, can also affect a person's ability to adhere to their med regimen.
Interventions for nonadherence should be patient-oriented and targeted toward their reason(s) for not taking their medications as prescribed. In an article by Malik et al. (2020), the authors explain the importance of psychoeducation in patient medication adherence. Discussing barriers to adherence and engaging with the patient to form a solid therapeutic alliance are also critical factors. Clinicians must keep these factors in mind when intervening with a patient who is not following their med regimen.
References
Malik, M., Kumari, S., & Manalai, P. (2020). Treatment nonadherence: An epidemic hidden in plain sight. Psychiatric Times, 37(3).
Velligan, D. I., Sajatovic, M., Hatch, A., Kramata, P., & Docherty, J. P. (2017). Why do psychiatric patients stop antipsychotic medication? A systematic review of reasons for nonadherence to medication in patients with serious mental illness. Patient preference and adherence, 11, 449–468.
Response 2
Hello Ariel,
Thank you for sharing this presentation with us.
Depression is associated with a high burden of disease. Fortunately, there are many treatments, including pharmacological, psychological, and neurostimulatory options that are associated with the remission of symptoms and full restoration of psychosocial function. If there is a lack of response to, or tolerability of, initial treatment, alternatives can be trialled. In other instances, acute responses may be obtained but subsequent relapses occur even on treatment. Unfortunately, a significant proportion of patients do not achieve sustained remission, despite serial treatments(McAllister-Williams et al.,2020).
Depression is the syndrome most frequently diagnosed in psychiatric practice. There is a wide acknowledgment that this syndrome is not a homogeneous entity and that further clinical characterization of the individual patient would be needed in order to personalize the management plan. However, it is common practice to base the choice of treatment in each case solely on the syndromal diagnosis. Clinical trials have found a variety of medications and psychotherapies to be “equivalent” in the treatment of the syndrome, and these interventions are therefore commonly perceived as interchangeable. The choice of treatment for depression is at present usually based on the clinician's and/or the patient's preference and on safety issues, in a trial-and-error fashion, paying little attention to the individual features of the specific case. This may be one of the reasons why the majority of patients with a diagnosis of depression do not achieve remission after the first treatment they receive, and at least 30% do not respond to two consecutive evidence-based treatments and may be classified as treatment-resistant(Maj et al.,2020).
Maj, M., Stein, D. J., Parker, G., Zimmerman, M., Fava, G. A., De Hert, M., … & Wittchen, H. U. (2020). The clinical characterization of the adult patient with depression aimed at personalization of management. World Psychiatry, 19(3), 269-293.
McAllister-Williams, R. H., Arango, C., Blier, P., Demyttenaere, K., Falkai, P., Gorwood, P., … & Rush, A. J. (2020). The identification, assessment and management of difficult-to-treat depression: an international consensus statement. Journal of Affective Disorders, 267, 264-282.
Response 3
That was a very thorough presentation, Ariel. Your patient seems as if he has some treatment-resistant depression, or he may not take his medications as directed. I have found that throughout my clinicals sometimes it's a challenge getting older adults to either take their medications or take them as intended, as they would often ‘dose themselves.’
A strategy that can be used is psychoeducation with the patient encounter can help clients learn more about their diagnoses, such as etiology, progression, prognosis, and treatment alternatives. Sarkhel et al. list the goals of psychoeducation as promoting relapse prevention, providing insight into illness, engaging in crisis management and suicide prevention, and ensuring the basic knowledge and competence of patients and families about their illness (Sarkhel et al., 2020). Another strategy for this patient can be advanced pill boxes, alarms, group social support, and follow-up appointments. Family members getting involved to help with ADLs and check in on the patient is a useful tool for medication adherence(Huang et al., 2020).
References
Response 4
Hello Ariel, thank you for your case study. It was very interesting and informative. To answer your question regarding the possible risk factors not following medication regimen. If the patient decides not to follow the medication regimen, they will continue to have the symptoms relating to MDD and not have any relief from recovering. In the event that the patient does not want to follow the regimen they should be sure to let their provider know so that they can make sure to make adjustments as needed. Depression is a relatively common clinical disorder and can be difficult to effectively treat according to findings from the Sequenced Treatment Alternatives to Relieve Depression study. Given this working terrain, patient adherence with antidepressant therapy is a critical aspect of effective clinical management (Sansone, R. A., & Sansone, L. A., 2012). Physician-specific issues including poor patient education, lack of shared decision-making, prescription of inadequate dosages of antidepressants, and lack of follow-up care are all aspects that physicians need to control to improve patient’s adherence, since they represent some of the main obstacles to adequate antidepressant treatments (Dell’Osso, B., & Albert, U. 2020).
Reference:
Dell’Osso, B., & Albert, U. (2020, October 12). How to improve adherence to antidepressant treatments in patients with major depression: A psychoeducational consensus checklist – annals of general psychiatry. BioMed Central. https://annals-general-psychiatry.biomedcentral.com/articles/10.1186/s12991-020-00306-2
Sansone, R. A., & Sansone, L. A. (2012, May). Antidepressant adherence: Are patients taking their medications? Innovations in clinical neuroscience. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3398686/
