Case Study 22 Depression: Drug-Nutrient Interaction By Kayla Zerman

What is depression?

Depression is a mental state or chronic mental disorder characterized by feelings of sadness, loneliness, despair, low self-esteem, and self-reproach; accompanying signs with depression are psychomotor retardation (or less frequently agitation), withdrawal from social contact, and vegetative states such as loss of appetite and insomnia.

Meet my client:

• Name: Ivanna Geitl• DOB: 9/17• Age: 20• Sex: Female• Education: International college student (junior year)• Occupation: Student• Hours of work: varies• Household members: Lives with roommates- Erika age

20, Veronica age 21, and Carol age 21- in excellent health. At home in Germany, she lives with her mother (age 45), father (age 50), and grandmother (age 70)

• Ethnic Background: German• Religious Affiliation: Lutheran

Chief Complaint:

“All I want to do is sleep. I haven’t been able to eat- I don’t feel hungry. I can hardly make myself go to classes. And when I go, I can’t concentrate on what the professors are saying. My roommates tell me that I’ve been really moody. I’m so lonely being here in the U.S. without my family. But I wouldn’t want them to see how poorly I’m doing in school. It’s just hopeless– I’ll never meet their expectations. Maybe it be better for everyone– me, my roommates, and my family– if I just wasn’t around.”

Patient HistoryMs. Geitl is a 20 year old female university student from Germany. She seeks medical attention at the urging of her roommates, who report that her mood has become increasingly depressed over the past two semesters. She has become withdrawn and moody– a significant change in her affect since first coming to the U.S. to attend college. She is otherwise a healthy young woman. Ms. Geitl reports a 5 pound weight loss in the past 3 months. She takes birth control pills for contraception and regulation of menses. Her mother has been treated for depression with St. John’s wort by the family physician for the past 10 years.

Dx: depression; Mother suggested she should start taking St. John’s wort as well.

What is St. John’s wort?

St John’s wort (hypericum perforatum) is a perennial herb with a yellow flower that has been used to treat nervous conditions since ancient Greek times. Today, it is a popular herbal remedy for mild depression. The plant has many chemical compounds, some of which are believed to help depression by preventing nerve cells in the brain from reabsorbing the chemical messenger serotonin, or by reducing levels of a protein involved in the body’s immune system functioning.

Side Effects of St. John’s

• Dry mouth• Dizziness • Gastrointestinal symptoms• Increased sensitivity to sunlight• Fatigue

Regulation of St. John’s wort in the United States

In the United States, St. John’s worts is classified as a dietary supplement by the U.S. Food and Drug Administration, which is a regulatory agency of the federal government. The FDA’s requirements for testing and obtaining approval to sell dietary supplements are less strict than its requirements for drugs. Unlike drugs, herbal products can be sold without requiring studies on dosage, safety, or effectiveness. This is because the strength and quality of herbal products are often unpredictable; products can differ in content not only from brand to brand, but from batch to batch.

Nutrition History

Usual Dietary Intake:Breakfast: Black Coffee (2 cups)Lunch: She doesn’t have time for lunch she saysPM Snack: Low-fat frozen yogurt- approx. ½ cup of chocolate or

strawberry Dinner: (usually with roommates– they take turns cooking

3” square Stouffer’s Lasagna – eats only ½1 cup steamed broccoli (plain only with salt and pepper1 breadstickDiet cola soft drink

HS Snack: air-popped popcorn sprayed with butter-flavored PamDiet cola soft drink

24-Hour recall Breakfast: 1 cup of Black Coffee

1 slice dry whole wheat toastLunch: 2 cups chicken and noodle soup

2 saltine crackers½ cup strawberry gelatin1-12 oz can of Diet Cola

Dinner: 2 peach halves1 cup cottage cheese (low fat)1 cup black coffee

Ms. Geitl’s Energy Needs

Harris-Benedict Equation:Women: REE (kcal)=655+9.56 wt. (kg)+1.85 ht. (cm)-4.68 (age)REE (kcal)= 655 + 9.56(72.96kg) + 1.85 (180.34cm) -4.68 (20) = 1,592 kcals (1,500-1,600 kcals per day)

TEE= 1.5 x 1,592 kcals = 2,388 kcals/day (2,300-2,400 kcals/day)

Ms. Geitl’s Therapy Plan

• Zoloft, 50 mg qd• Referral to house psychologist for counseling• Nutrition consult re: poor eating habits

Patient-Generated Subjective Global Assessment (PG-SGA)

Section Score

Box 1 2 pointsBox 2 0 pointsBox 3 0 pointsBox 4 0 pointsWeight Loss Section (Table 1) 2 pointsDisease Section (Table 2) 0 pointsMetabolic Section (Table 3) 0 pointsPhysical Section (Table 4) 0 points

Total 4 points

□ A = well nourished B= moderately (or suspected of being) malnourished

□C = severely malnourished

SGA RatingSelect one:

Ms. Geitl’s score:

Triage Nutritional Intervention based off of PG-SGA score

Additive Score of 4-8

• Requires the intervention of the dietician, working in conjunction with the nurse or physician as indicated by the symptom check-off for pharmacological management

Nutrition Intervention (con’t)

• Along with the triage nutritional intervention, I would advise Ms. Geitl to come talk to me or another dietician about working on a diet plan that allows her to eat healthy and get the extra calories and nutrients she has been lacking.

• To do this, I’d start by having Ms. Geitl increase her caloric intake each and every day so that way she isn’t just trying to increase her caloric intake all at once to the amount of calories she should be taking in each and everyday.

Monitoring and Evaluation

To monitor Ms. Geitl we will take her weight and ask for a 24-hour recall before every session we have with her to see if she is getting the right amount of calories in her diet and to see if she maintaining/gaining weight. Also, we will have her meet with a counselor to help her talk about why she is depressed and hopefully get her to become less depressed in the future.

References • "Definition: 'Depression'" Depression. MediLexicon, n.d. Web.

25 Nov. 2012. http://www.medilexicon.com/medicaldictionary.php?t=23823

• Nelms, Marcia Nahikian. Nutrition Therapy and Pathophysiology. Belmont, CA: Wadsworth, Cengage Learning, 2011. A67-A70. Print.

• Stanfield, Peggy, and Y. H. Hui. Nutrition and Diet Therapy: Self-instructional Approaches. Sudbury, MA: Jones and Bartlett, 2010. 198-99. Print.

• "St. John's Wort." TheFreeDictionary.com. Medical Dictionary, n.d. Web. 25 Nov. 2012.

<http://medical-dictionary.thefreedictionary.com/St. John%27s wort>.

Questions?