This is a discussion board, a page or two long and references to more than 5 years old

We will focus our discussion this week on depression and chronic suicidality. For this discussion board, review the case study, “A 37-year-old Depressed Man with Poor Response and Suicidal Ideation,” and  answer the following questions: 

1. What would you do first? (Must provide a detailed rationale for your treatment choice PLUS a rationale for not choosing the other options). 

a. Refer the patient for electroconvulsive therapy (ECT).

b. Switch the patient to another first-line antidepressant.

c. Switch the patient to a tricyclic antidepressant.

d. Switch the patient to a monoamine oxidase inhibitor (MAOI).

e. Refer the patient to a multidisciplinary program that includes medication management and psychotherapy.

f. Admit the patient to an inpatient unit immediately. 

2. After you make adjustments to his medication regimen, he experiences a partial response, but continues to complain of depressive symptoms including anergia, poor motivation, poor concentration, and insomnia. What would you do to address the residual symptoms? 

3. How will you assess for suicide risk and protective factors? Be VERY specific. Will you use specific screening or diagnostic tools? Are their specific questions you will ask? How will determine level of risk? 

4. If you determine the suicide risk to be high (extreme), what would you do? In other words, what would be your treatment approach?  

A 37-year-old Depressed Man with Poor Response and Suicidal Ideation

  • The patient is a 37-year-old married man who has suffered from depression for at least 2 years
  • He has not undergone psychotherapy but has had multiple antidepressant trials over the last 2 years; he has had intermittent improvement but has never achieved remissionMost recently, he has been treated with bupropion XL 300 mg/day (24-hour formulation) for 12 weeks, with limited response
    • Previous medication trials have included paroxetine, citalopram, and sertraline 
  • The patient’s primary symptoms are depressed mood every day, insomnia (both initiation and maintenance of sleep), anhedonia, poor motivation, poor concentration, and feelings of hopelessness/helplessness
  • He also admits to almost constant suicidal ideation; however, he has never made a plan to hurt or kill himself and denies any intent to do so
  • Additionally, the patient suffers from chronic back and knee pain
    • He has taken celecoxib 200 mg/day for several months
    • He recently began taking gabapentin  100 mg 3 times daily