Katie Davis KNH 413. Ms. Matuszak. Case Study 3 - Depression: Drug-Nutrient Interaction

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1 Katie Davis KNH 413 Ms. Matuszak Case Study 3 - Depression: Drug-Nutrient Interaction 1. What is depression? Depression is a common, but serious disorder of the brain involving altered functioning in areas associated with mood, thinking, sleep, appetite, and behavior. There are several forms of depression including major depressive order, dysthymic disorder, bipolar disorder, and minor disorder which includes psychotic depression, postpartum depression, and seasonal affective disorder. Depression can be caused by a combination of genetic, biological, environmental, and psychological factors and includes symptoms such as persistent sad, anxious, or empty feelings, loss of interest in activities once pleasurable, fatigue, insomnia, excessive sleeping, overeating, loss of appetite, irritability, restlessness, thoughts of suicide, aches and pains, and feelings of hopelessness, pessimism, guilt, worthlessness, and helplessness ( Depression ). 2. Dr. Byrd has decided to treat Ms. Geitl with Zoloft, a selective serotonin reuptake inhibitor (SSRI). Are there any pertinent nutritional considerations when using this medication? It is important to consider that a common side effect of SSRIs like Zoloft is weight gain, which may be a factor in noncompliance with treatment. Unfortunately, there is no known specific mechanism identified to explain the observed weight gain. Registered Dietitians who work with patients on these medications should establish a baseline diet and weight history, provide drug-nutrient information, assist patients to develop and plan to monitor weight regularly, develop a physical plan to monitor weight regularly, develop a physical activity plan for each patient, and reinforce the importance of continuing prescribed medications. 3. How do serotonin reuptake inhibitors (SSRIs) work? SSRIs block the reabsorption of the neurotransmitter serotonin in the brain changing the balance of serotonin, which seems to help brain cells send and receive chemical messages ultimately boosting mood. SSRIs are selective because they primarily effect serotonin and not other neurotransmitters ( Selective serotonin reuptake inhibitors (SSRIs) ).

2 4. What is St. John s wort? St. John s wort is a plant that frown in the wild. Its flowers and leaves are used to make medicine. It is most commonly used for depression and conditions that are associated with depression such as anxiety, fatigue, loss of appetite, and sleeping problems. St. John s wort can also be used to treat other conditions such as heart problems, cancer, ADHD, skin conditions, and much more. There are several concerns about its safety and effectiveness that consumers should be aware of ( St. John s wort and Depression ). 5. How is St. John s wort used in the United States? In the United States, the Food and Drug Administration has not approved its used as an over-the-counter or prescription medicine for depression ( St. John s wort and Depression ). 6. How does St. John s wort work as an antidepressant? There are several theories on St. John s wort s mechanism of action. Some research states that a chemical in St. John s wort called hypericin was responsible for its antidepressant effects. Other information suggests that another chemical called hyperforin plays a larger role in acting on mood boosting neurotransmitters ( St. John s wort ). 7. Does St. John s wort have any side effects? Minor side effects include upset stomach and sensitivity to sunlight or increase feelings of anxiety in some people. Combining St. John s wort with antidepressant medications can lead to serotonin syndrome, which is characterized by a potentially life-threatening increase in serotonin levels, or other symptoms such as tremors, diarrhea, confusion, muscle stiffness, drop in body temperature, and even death. Psychosis is a possible side effect particularly in individuals at risk for mental health disorders. St. John s wort can weaken many prescription medications. 8. How is St. John s wort regulated in the United States? St. John s wort can be purchased over-the-counter in the United States because the U.S. Food and Drug Administration does not strictly regulate herbs and supplements ( St. John s wort (Hypericum perforatum) ). However, it is not prescribed for treatment of

3 depression. Also, the U.S. is in the process of including drug-herb interaction warnings on St. John s wort products ( St. John s wort ). 9. How is St. John s wort used in Europe? In Europe, St. John s wort is often prescribed my medical professionals for use in treatment of depression. 10. Why do you think people are interested in alternative medicine and herbal treatments? I think people are interested in alternative medicine and herbal treatments because these treatments have a stigma of being more natural or causing less side effects. People may not want to take a synthetic drug with potential short-term or long-term side effects. Consumers pay not realize that many alternative medical treatments and herbal treatments may also have negative effects. 11. She is 5 1 tall and weight 160 pounds. Convert her height and weight to metric units. (61 in.) x (.0254) = 1.55 m (160 lbs.) / (2.2) = kg 12. Is Ms. Geitl s recent weight loss anything to be worried about? Ms. Geitl s weight loss is of concern due to the fact that the loss likely resulted from her symptoms of depression including lack of appetite and poor diet. She needs nutrition intervention in order to make changes in her diet. Loss of appetite is a one symptom of depression and; therefore, should not be ignored ( Depression ). 13. Because Ms. Geitl is alert and cooperative, you ask her to complete a Patient- Generated Subjective Global Assessment of Nutritional Status. How would you score her? Sections Box 1 1 Box 2 3 Box 3 1 Box 4 1 Weight loss section (Table 1) 2 Disease section (Table 2) 0 Metabolic section (Table 3) 0 Score

4 Physical Section (Table 4) 0 Total 8 SGA Rating = A = well nourished B = moderately (or suspected of being) malnourished C = severely malnourished 14. Using Appendix I, how would you triage nutritional intervention? Ms. Geitl s triage nutrition intervention is that she requires intervention by a dietitian, in conjugation with a nurse or physician. 15. What methods are available to estimate Ms. Geitl s energy needs? Miffle-St. Joer Harris Benedict Quick estimate 16. Calculate Ms. Geitl s basal energy needs using one of the methods you listed in 15. = (9.56 x wt) + (1.85 x ht) - (4.68 x age) = (9.56 x kg) + (1.85 x 155 cm) - (4.68 = 20) = kcal REE = 1550 kcal 17. What is Ms. Geitl s estimated energy expenditure? ( kcal) x 1.7 = kcal = 2620 kcal 18. Evaluate her diet history and her 24-hour recall. Is she meeting her energy needs? Based on her usual dietary intake, Ms. Geitl s energy intake it 584 kcal. Based on her 24- hour recall, Ms. Geitl s energy intake is 527 kcal. Energy intakes were calculated using the USDA s SuperTracker Food Tracker feature. 19. What would you advise? I would advise Ms. Geitl to determine foods that she like and has an appetite for. She needs to consume foods that are nutrient- and calorie-dense when she has an appetite. I may also advise increased physical activity when she feels like it. This may increase her energy, appetite, and mood.

5 20. List each factor from your nutritional assessment and then determine an expected outcome from each. Assessment Factor Appetite has been poor Usual intake of 584 kcal per day 24-hour recall intake of 527 kcal No food allergies No previous MNT Expected Outcome May be difficult for Pt to find foods in order to increase calorie intake. May need nutrient- and calorie-dense foods. Pt will continue to lose weight. Pt will continue to lose weight. Less restrictions on food when making plan to increase kcal or nutrient- or calorie- density of food. Need to be aware that Pt understanding and knowledge of nutrition may be limited in the present. Herself and roommates purchase food Pt needs to make roommates aware of her situation. Having roommates will be good accountability for increasing calorie intake if aware of the her No vit/min intake Regular diet order situation. Pt may develop vitamin or mineral deficiencies especially due to low calorie intake. Pt will need guidance in selecting and finding foods that will be good for her appetite and also be nutrient- and calorie-dense. What is your immediate concern regarding this patient s use of St. John s wort? My main concern with the fact that she is considering St. John s wort is that she was prescribed the antidepressant Zoloft. Taking St. John s wort with this medication can increase serotonin to dangerous levels causing dangerous side effects such as heart problems, shivering, and anxiety ( St. John s wort ). Review the initial nutrition note written for this patient. Is this progress note appropriate? Is it complete? Any errors? Any omissions?

6 Needed to include that the 5 pound weight loss occurred within the past 3 months. Needs to address supplementation recommendations. Needed to indicate referral to house psychologist for counseling. It may be advisable to wait to do nutrition education until after Pt meeting with counselor. SOAP note is appropriate; however, ADIME note may have been more clear or effective. References Depression. (n.d.). NIH National Institute of Mental Health. Retrieved from Food Tracker. (2014). USDA SuperTracker. Retrieved from Mahan, L.K., Escott-Stump, S., and Raymond, J.L. (2012). Krause s Food & The Nutrition Care Process, Thirteenth Edition. St. Louis, MO: Elsevier Saunders. Nelms, M., Sucher, K. P., Lacey, K., and Roth, S. L. (2011). Nutrition Therapy & Pathophysiology, Second Edition. Belmont, CA: Brooks/Cole Cengage Learning. Selective serotonin reuptake inhibitors (SSRIs). (2013). Mayo Clinic. Retrieved from St. John s wort. (2012). MedlinePlus. Retrieved from St. John s wort and Depression. (n.d.). NIH National Center for Complementary and Alternative Medicine (NCCAM). Retrieved from St. John s wort (Hypericum perforatum). (2013). Mayo Clinic. Retrieved from