CaseStudy22:Depression:DrugNutrientInteraction

SamBallard
KNH413
3.15.2016

1. Whatisdepression?

Depressionisacommonandseriousmooddisorderthataffectshowyoufeel,think,and
handledailyactivities.Symptomscanincludevariationsinsleeping,eating,andworking.
Depressionisdiagnosedwhenthesesymptomsprogressforatleasttwoweeks.Thereare
manydifferenttypesofdepressionsuchaspersistentdepressivedisorder,perinatal
depression,psychoticdepression,seasonalaffectivedisorder,andbipolardisorder(National
InstituteofMentalHealth,2016).

2. Dr.ByrdhasdecidedtotreatMs.GeitlwithZoloft,aselectiveserotoninreuptakeinhibitor
(SSRI).Arethereanypertinentnutritionalconsiderationswhenusingthismedication?

Likewithanymedication,itisnotrecommendedthatusersconsumealcoholwhiletaking
Zoloft.CommonlyobservedadversereactionstoZoloftincludenausea,increasedsweating,
andlackofappetite.Theseadversereactionsmakeitimportantthatusersareconsuming
enoughcalorieseventhoughtheyhavealackofappetiteornausea.Increasedsweating
couldalsorequireincreasedfluidneeds.Themanufactureralsowarnsthatindividuals
takingZoloftshouldtelltheirphysicianimmediatelyiftheybeginexhibitingsymptomsofa
conditioncalledSerotoninSyndrome(agitation,hallucination,coma,orotherchangesin
mentalstatuscoordinationproblemsormuscletwitchingracingheartbeat,highorlow
bloodpressuresweatingorfevernausea,vomiting,ordiarrheaandmuscletightness),if
theyexhibitsymptomsofasevereallergicreaction,iftheyhaveincreasedorunusual
bleeding,oriftheyexperiencesymptomsofhyponatremia(headache,weakness,
confusion).Nausea,vomiting,anddiarrheawouldindicateanincreasedneedforfluids,
changesinmentalstatuscouldaffectanindividualsabilitytomonitortheirnutritionstatus,
andhyponatremiashouldbepromptlydiagnosedandtreatedtoavoidfurthercomplications.
(Pfizer,2015).

3. Howdoserotoninreuptakeinhibitors(SSRIs)work?

Serotoninreuptakeinhibitorsblockthereabsorptionoftheneurotransmitterserotonininthe
brain.Neurotransmittersarenaturallyoccurringchemicalmessengersinthebrainusedto
communicatebetweenbraincells.SSRIsareabletoboostmoodbecausechangingthe
balanceofserotonininthebrainhelpsbraincellstosendandreceivechemicalmessages
moreefficiently(MayoClinic,2013).

4. Duringthediethistory,youaskMs.GeitlifsheusesanyOTCvitamins,minerals,orherbal
supplements.ShetellsyouhermothersuggestedshetryHypericumperforatum(St.Johns
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wort)becauseinGermanyitisprescribedtotreatdepression.Ms.Geitldidashermother
suggested,asitisavailablewithoutprescriptionintheUnitedStates.WhatisSt.Johns
wort?

St.Johnswort(Hypericumperforatum) ,alsoknownasgoatweedorKlamathweed,isawild
plantthathasbeenusedforcenturiesforhealthpurposes,particularlyinEuropeformental
healthdisordersanddepression.ThisplanthasyellowflowersanditsnamereferstoJohn
theBaptistbecauseitbloomsinlateJunearoundthetimeofthefeastofSt.Johnthe
Baptist(NationalCenterforComplementaryandIntegrativeHealth,2012).St.Johnswort
hasbeenseentobeeffectiveintreatingmildtomoderatedepressionasitworkssimilarto
antidepressantmedications(MayoClinic,2016).

5. HowisSt.JohnswortusedintheUnitedStates?

St.JohnswortissoldintheUnitedStatesasanherbalsupplementandhasnotbeen
approvedasanoverthecounterorprescriptionmedicationfordepressionbytheFoodand
DrugAdministration(NationalCenterforComplementaryandIntegrativeHealth,2016).Itis
usedformanyofthesamereasonsitisusedinEurope,mainlyasanantidepressant.
Becauseitsuseisnottightlyregulated,consumersshouldonlypurchaseSt.Johnswort
fromareputablesourceassupplementsmaycontaintoxicsubstances.Itisalsoextremely
importantthatindividualsconsultwiththeirphysicianbeforetakingSt.Johnsworttoensure
itwontinterferewithothermedicationstheyaretaking.

6. HowdoesSt.Johnswortworkasanantidepressant?

ItisthoughtthattwochemicalsinSt.Johnswort,hypericinandhyperforin,regulatemood
byactingonchemicalmessengersinthenervoussystem(RxList.com,2016).Hyperforin
hasbeenseentobetheactiveingredientinSt.Johnswort.Inadditiontoregulatingmood,
hyperforinwasfoundtoactivateaparticularreceptorintheliverthatinducestheproduction
ofanenzymeusedforthemetabolismofmedications.Thiseffectcausesmorerapid
breakdownofmanyprescriptionmedicationsandcaninterferewiththeireffectiveness
(Vollmer&Rosenson,2004).ThisiswhyitissuggestedthatindividualsnotconsumeSt.
Johnswortiftheyaretakingothermedications.

7. DoesSt.Johnsworthaveanysideeffects?

St.Johnswortcaninterferewithmanymedicationsandtheirintendedeffects.Medications
suchasantidepressants,birthcontrolpills,cyclosporine(anantirejectiondrug),digoxin(a
heartmedication),drugsusedtocontrolHIVinfection,cancertreatingdrugs,seizurecontrol
drugs,andanticoagulantsareatriskforinterference.Itmayalsocausesensitivityto
sunlight,anxiety,drymouth,dizziness,gastrointestinalsymptoms,fatigue,headache,or
sexualdysfunction.TakingSt.Johnswortincombinationwithcertainantidepressantsmay
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leadtoincreasedserotoninrelatedsideeffects,whichmaybelifethreatening(National
CenterforComplementaryandIntegrativeHealth,2012).

8. HowisSt.JohnswortregulatedintheUnitedStates?

BecausecurrentevidencethatSt.Johnswortiseffectivefordepressionisnotconclusive,
theFoodandDrugAdministrationoftheUnitedStateshasnotapproveditsuseasan
overthecounterorprescriptionmedicinefordepression(NationalCenterfor
ComplementaryandIntegrativeHealth,2016).St.Johnswortissoldasanherbal
supplementsotherearenoregulatedmanufacturingstandardsinplace.Theycouldbe
contaminatedwithtoxicmetalsorotherdrugs.Thesetypesofherbalsupplementsshouldbe
purchasedfromreliablesourcestominimizecontamination(Drugs.com,2015).

9. HowisSt.JohnswortusedinEurope?

St.JohnswortiscommonlyprescribedinEuropetotreatmanyconditionsanddisorders.It
wasfirstusedmedicinallyinEurope,specificallyinancientGreece.Sincethen,ithasbeen
usedtotreatmentaldisordersandnervepain.Ithasalsobeenusedasasedative,forthe
treatmentofmalaria,andasabalmforwounds,burns,andinsectbites.St.Johnswortis
usedtodayasatraditionalremedyfordepression,anxiety,andsleepdisorders.Theflowers
ofSt.Johnswortareusedtoprepareteas,tablets,andcapsulescontainingconcentrated
extracts,aswellasliquidextractsandtopicalointments(NationalCenterforComplementary
andIntegrativeHealth,2012).

10. Whydoyouthinkpeopleareinterestedinalternativemedicineandherbaltreatments?

Ithinkthatpeopleareinterestedinalternativemedicineandherbaltreatmentsbecauseof
theiraffordability,accessibility,andnaturalhealingpowers.Alternativemedicineand
herbaltreatmentsdontcomewiththesamecostsasprescriptiondrugsandtheycanoften
bepickedupatthelocaldrugstorewithouttheneedforaprescription.Peoplearenow
moreresistanttoconsumingnumerousvarietiesofdrugsandhavingexpensivetestsand
treatmentsdoneeverytimetheyareill.Alternativemedicineandherbaltreatmentsprovide
consumerswithnaturalalternativesthattheyfeelarelessdamagingtotheirbodiesoverall.
Medicaltechnologyhascomeanextremelylongwayandcanoftentreatconditionsthat
wereonceuntreatable,butalotofpeoplebelievethatthereisanoverrelianceonthistype
ofmedicalinterventionandtheyarelookingforalternativewaystotreatthemselves.

11. BecauseMs.Geitlisambulatory,youareabletomeasureherheightandweight.Sheis
511tallandweighs160pounds.Youalsodeterminethatsheisofmediumframe.Because
Ms.GeitlisfromGermany,sheisusedtoreportingherweightinkilogramsandherheightin
centimeters.Convertherheightandweighttometricnumbers.

160lbs/2.2kg=72.7kg

5inx12in=60in+11in=71inx2.54cm=180.34cm

12. IsMs.Geitlsrecentweightlossanythingtobeworriedabout?

Ms.Geitlhasreportedexperiencinga5lb.weightlossinthepast3months.Herrecent
weightlossisnotanythingtobeworriedabout.Ms.Geitlsidealbodyweight(IBW)is
calculatedasbeing155lbs.usingtheHamwimethod[100+(5x11over5)=155lbs.].
Hercurrentweight,asreportedinheradmissionchart,is160lbs..Ms.Geitlisstill5lbs.
overheridealbodyweight,whichiswhyher5lb.weightlossoverthespanofthepast3
monthsisnotanythingtobeworriedabout.

13. BecauseMs.Geitlisalertandcooperative,youaskhertocompleteaPatientGenerated
SubjectiveGlobalAssessment(PGSGA)ofNutritionalStatus.Howwouldyouscoreher?
(SeeAppendixI.)

Sections

Score

Box1

Box2

Box3

Box4

Weightlosssection(Table1)

Diseasesection(Table2)

Metabolicsection(Table3)

Physicalsection(Table4)

0
Total

SGARating
Selectone:
A=wellnourished

B=moderately(or
suspectedofbeing)
malnourished

C=severelymalnourished

14. UsingAppendixI,howwouldyoutriagenutritionalintervention?

Whenaddingthescoresfromboxes14,Ms.Geitlhasatotalscoreof6.Thenutritional
triagerecommendationsforscoresof48arethattheindividualrequiresinterventionbya
4

dietitian,inconjunctionwithanurseorphysicianasindicatedbythesymptomssurveyin
box3.Whileseeingadietitian,Ms.Geitlwouldalsoneedtobeseeingapsychologistto
addressherdepressionandtocorrectherunderlyingmentalhealthissuessothather
dietaryissuescanalsoberesolved.Herlackofappetitewouldlikelyimprovesimultaneously
withhermood.Untilthishappens,morenutrientandcaloricallydensefoodanddrinkscould
berecommendedsothatMs.Geitlwouldgetmorewhilestillconsumingless.Onceher
appetitereturns,adietitianwouldbeabletofocusmoreonthequalityofMs.Geitlsdiet
ratherthanthequantity.

15. WhatmethodsareavailabletoestimateMs.Geitlsenergyneeds?

Indirectcalorimetryinaclinicalsettingwouldbethemostaccuratemethodofestimating
energyneeds,butthismethodisoftenexpensiveandtimeconsuming.Therearemany
predictiveequationsavailableforestimatingMs.Geitlsenergyrequirements.Twoofthe
mostpopularequationsinclude:

HarrisBenedictEquation:[655+(9.56xwt(kg))+(1.85xht(cm))(4.68xage(yrs))]xPAL
MifflinSt.JeorEquation:[10xwt(kg)+6.25xht(cm)5xage(yrs)161]xPAL

16. CalculateMs.GeitlsbasalenergyneedsusingoneofthemethodsyoulistedinQuestion
15.

MifflinSt.JeorEquation:[10xwt(kg)+6.25xht(cm)5xage(yrs)161]
[(10x72.7kg)+(6.25x180.34cm)(5x20yrs)161]
[727+1,127.125100161]=1,593.125kcal/day1,5001,600kcal/day

Ms.Geitlsbasalenergyneedswerecalculatedtobeabout1,5001,600kcal/day.When
multipliedbyanactivityfactor,herenergyneedsincreasetoabout2,5002,600kcal/day.

1,593.125x1.6=2,549kcal/day2,5002,600kcal/day

17. WhatisMs.Geitlsestimatedenergyexpenditure?

Ms.Geitlsrestingmetabolicrate(restingenergyexpenditure)andestimatedenergy
requirementwerecalculated.Herrestingmetabolicrateistheamountofcaloriesshewould
burnifshedoesnothingallday(justsitting).TheamountofenergyMs.Geitlwillexpend
eachdaywillbemorethan1,832caloriesperdaybecausethiscalculationisassumingshe
doesntgetoutofbedatall.Herestimatedenergyrequirementwascalculatedinquestion
16whenfactoringinherphysicalactivityleveltoherbasalenergyneeds.(HospitalFor
SpecialSurgery,2009).

RestingMetabolicRate:(0.0175xMETsxweight(kg))
0.0175x1.0(sitting)x72.7kg=1.27calories/minute1,832calories/day
5


EstimatedEnergyRequirement:(BasalenergyneedsxPAL=EER)
1,593.125x1.6=2,549kcal/day2,5002,600kcal/day

18. Evaluateherdiethistoryandher24hourrecall.Isshemeetingherenergyneeds?

UponevaluationofMs.GeitlsdietusingtheUSDAsonlineSupertrackerdatabase,itwas
determinedthatherusualdietaryintakerecordonlygetsherabout547kcal/dayandher
24hourrecallonlygetsherabout524kcal/day.Thesefoodrecordsdonotallowherto
meetherestimatedenergyneedsof2,5002,600kcal/dayasdeterminedinquestion16.

19. Whatwouldyouadvise?

BecauseMs.Geitlisnotusedtoconsumingsomanycaloriesperday,shewouldneedto
graduallybuilduptohergoalof2,5002,600kcal/day.Shemaywanttotrytoconsume
foodsanddrinksthataremorecaloricallydensetogetthoseextracalorieseachday.Once
herquantityoffoodshasincreased,herqualityoffoodscanbeprioritized.IfMs.Geitlhas
moreenergy,thiscouldfurtherbenefithermoodanddailyactivities.Sheshouldfirstfocus
onconsumingthosefoodsshehasthehighestpreferenceforsothatsheenjoyseating
more.Itcanbedifficulttoovercomealackofappetiteandherfavoritefoodsmayallowher
todothismoreeasily.Eatingsmallmealsmanytimesthroughoutthedaywouldalsoreduce
theburdenofconsumingmoreoverallcalories.ItmayalsobenefitMs.Geitltomakeeating
asocialactivitywithherroommatessothatsheisnotonlyaccountableforherfoodhabits,
butitisamoreenjoyableexperienceoverall.

20. Listeachfactorfromyournutritionalassessmentandthendetermineanexpectedoutcome
fromeach.

AssessmentFactor

ExpectedOutcome

Poorappetite

Oncetreatmentforherdepressionbegins,Ms.Geitls
appetiteshouldincrease.Ifitdoesnt,shemaycontinueto
loseweightoveraperiodofmonths,shewouldcontinueto
lackenergy,andshecouldbeatagreaterriskfor
malnutrition.

Depression&medications

Ms.Geitlwillreceivetreatmentforherdepressionfroma
psychologistandthroughtheuseofprescribedmedications
(Zoloft).SheshouldalsodiscontinueusingSt.Johnswort
whiletakinghermedications.IfshecontinuestouseSt.
JohnswortwhiletakingZoloft,sheisatgreatriskofdrug
interferenceandhermedicationsmayberendered
ineffective.Thiswouldfurtherpotentiatehernutritionand
6

mentalhealthissues.
5lb.wt.lossinpast3months Ms.Geitlhasreportedlosing5poundsinthepast3months.
Herdepressionhascausedhertohaveapoorappetite
wheresheisconsumingonly500600kcal/day.Ifthis
continues,shewillcontinuetoloseweight,lackdailyenergy,
andbeatriskofmalnutrition.Onceshehasreceived
treatmentforherdepression,shecanbegintoincreaseher
calories,maintainahealthyweight,andimproveheroverall
nutritionstatus.
Usualintake(547kcal)&
24hourrecall(524kcal)

Herusuallylowintakeofcaloriesandlowintakeofcaloriesin
thepast24hoursisaresultofherdepressionandis
contributingtoher5poundweightlossinthepast3months.
Althoughitisnotcurrentlyapparent,continuingthisdietary
patternwilleventuallyprogresstomalnutritionanditsrelated
issues.CalorieintakeshouldbegraduallyincreaseduntilMs.
Geitlisconsumingherestimatedenergyrequirementof
about2,5002,600kcal/day.

Smoking&alcoholintake

Smokingmayalsobecontributingtoherweightlossandlack
ofappetite.Alcoholhasthepotentialtobedangerousin
combinationwithhermedicationsanditcouldinterferewith
theireffectiveness.Bothoftheseactivitiesshouldbe
discontinuedtobenefitheroverallhealth,mentalhealth,and
nutritionproblems.Ifnot,herissuescouldbeexacerbated.

21. WhatisyourimmediateconcernregardingthispatientsuseofSt.Johnswort?

MyimmediateconcernregardingMs.GeitlsuseofSt.Johnswortisthatitwillinterferewith
heroralcontraceptivesandZoloftmedication.IfMs.GeitlsZoloftisinterferedwithand
renderedineffective,herdepressionwillnotbetreated,whichcouldcontinuetonegatively
affectherappetiteandnutritionstatus.Ifheroralcontraceptivesareinterferedwith,itwould
notonlyincreaseherriskofpregnancy,butherdisruptioninhormonescouldnegatively
impacthermoodandphysicalfeelings.

22. Reviewtheinitialnutritionnotewrittenforthispatient.Isthisprogressnoteappropriate?Isit
complete?Anyerrors?Anyomissions?


Thisprogressnoteisadequate,butitcouldbeimproved.Thisnotelacksinspecificity.For
example,itmentionsthatthepatienthashada5lb.weightloss,butdoesnotmakeitclear
thattheweightwaslostoveraperiodofthelast3months.
AlthoughIagreethatthispatientshouldhavescoredaBonthePGSGAscore,Idont
thinkthisscoringsystemwassocutanddryforthispatient.Thisscoringsystemwas
difficulttoutilizeusingacasestudyratherthantheactualpatientandIdonotthinkthatthe
informationweweregiveninthecasestudywasenoughtodefinitelydetermineher
nourishmentstatus.Themajorityofherdiagnosiswasaboutdepressionandalthoughshe
hashadpoorappetiteandalowintakeofdailycalories,wecannotautomaticallyassume
sheismalnourished.Herphysicalexamnotesindicatesheishealthyandheronlysignwas
aneurologicalone:lethargy.Wewouldbeabletocometoamoreeducatedconclusion
abouthernourishmentstatusifwewereprovidedlabvaluesinthiscasestudy.Ifhereating
habitsdonotimmediatelyimprovewiththetreatmentofherdepression,physicalsignsof
malnutritionwillbemoreevidentandwillcategorizeherasmoderatelymalnourished.Her
lackofphysicalandfunctionaldeficitsarewhatmakemehesitanttosaysheis
malnourished.Heractionsandmentalstatusarewhatmakemesuspectherofpossibly
becomingmalnourished.
ThisnotealsohasnomentionofMs.Geitlsdepressiondiagnosis,hercoordinatedcare
withapsychologist,orhowsheisgoingtobemonitoredandevaluatedthroughouther
recovery.

References

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HospitalForSpecialSurgery.(2009).Burningcalorieswithexercise:Calculatingestimated
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https://www.hss.edu/conditions_burningcalorieswithexercisecalculatingestimatedene
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MayoClinic.(2013).Depression(majordepressivedisorder). Retrievedfrom
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MayoClinic.(2016).St.Johnswort(hypericumperforatum). Retrievedfrom
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NationalCenterforComplementaryandIntegrativeHealth.(2012).St.Johnswort.Retrieved
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NationalCenterforComplementaryandIntegrativeHealth.(2016).St.Johnswortand
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Pfizer.(2015).Zoloft.Retrievedfromhttp://www.zoloft.com/

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