Danielle.Degroot.Case Study Pp

COMPLEMENTARY THERAPY: USE

OF OMEGA 3’S IN DEPRESSION

By: Danielle DeGroot

Dietetic Intern

PREVALENCE CDC reports:

~1 in 10 adults report depression in the U.S.

Groups more likely to meet criteria for major depression: 45-64 years Female African Americans, Hispanics, non-Hispanic persons of other or

multiple races Persons with less than a high school education Previously married Unable to work/unemployed Without health insurance coverage

Similar criteria fit “other depression” category with the exception of: 18-24 year olds were more likely to report “other depression”

Current medical treatment: Antidepressants, antipsychotics

http://www.cdc.gov/Features/dsDepression/

http://www.cdc.gov/Features/dsDepression/

PREVALENCE

http://www.cdc.gov/Features/dsDepression/

CASE STUDY: AM• AM is a 22 year old Caucasian female.• Inpatient in the Adolescent Psychiatric Unit Readmitted because of increasing

symptoms of depression, some SI, and severe difficulty functioning.

Admit Date: 4/11/2011Chart reviewed due to positive findings on

nursing admission screen – patient triggered for history of eating disorder. Hospital course and events leading to admission reviewed per notes. Noted patient has been followed by EDU RD with most recent visit in December of 2010.

CURRENT PROBLEM LIST• Current Dx:

1. Obsessive-compulsive disorder (300.3)2. Depressive disorder, not elsewhere classified (311)3. Anxiety state, unspecified (300.00)

• PMH includes: depressive disorder, anxiety state, eating disorder, primary insomnia, Chiari malformation type 1, attention deficit disorder

Currently presents with: 7% loss of body weight in 2 months Poor appetite

Anthropometrics:– IBW: 125 lbs; %IBW:74%; BMI:15.79

PERTINENT LABORATORY VALUESLaboratory Test Normal Values Patient Values

Blood Pressure 120/80 102/64

Albumin 3.5-5.0 g/dL 4.5*

WBC 4.0-10.0 7.6

RBC 4.00-5.20 4.25

HGB 12.0-16.0 12.8

HCT 36-46 38.4

PLT 150-399 280

GLUCOSE Fasting: 60-109 mg/dLNonfasting: 60-200 mg/dL

91

NA 137-147 138

K 3.4-5.3 3.5

*May be falsely normal

LABORATORY TESTS CONTINUEDLaboratory Test Normal Values Patient Values

CL 99-108 103

CO2 22-29 mmol/dL 29

BUN 8-21 mg/dL 10

CREAT 0.5-1.1 mg/dL 0.6

CA 8.7-10.7 mg/dL 9.7

PROT 6.0-8.2 g/dL 7.3

TBILI 0.2-1.3 mg/dL 0.6

AST 5-55 units/L 17

ALT 3-50 units/L 13

GGT 0-51 IU/L 14

Reference ranges from EPIC

MEDICAL TESTS Mental Status Examination

Verbal, cooperativeNormal rate and tone of speechDepressed moodAffect constrictedThought logical with no evidence for

hallucinations/delusions/homicidal ideation Judgment/insight fair.Alert/oriented x 3Memory grossly intact Intelligence in superior range

DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS Axis I: Clinical disorders; other conditions

that may be the focus of clinical attention. Major depression, recurrent, severe

Axis II: Personality disorders, mental retardation. none

Axis III: General medical conditions Insomnia

Axis IV: Psychosocial and environmental problems Moderate

Axis V: Global assessment of function (GAF: a scale from 1 – 100) Past week – 30. Best in past year – 50.

CURRENT PERTINENT MEDICATIONS• Adderrall/Adderall XR:

• ADHD, CNS Stimulant, Appetite Suppressant• Zolpidem (Ambien):

• Sleep Aid• Quetiapine (Seroquel):

• Antipsychotic • Lorazepam (Ativan):

• Antianxiety • Fluvoxamine (Luvox):

• OCD or Social Anxiety Disorder, Depression• Hydroxyzine (Atrax):

• Antianxiety • Alprazolam (Xanax/Xanax XR):

• Antianxiety, antipanic

PSYCHOTROPIC POLYPHARMACY Increased risk of:

Drug-drug interactions“Uncertain gains for quality of care

and clinical outcomes.”

Limited supporting evidenceMany patients continue to

experience symptoms

Mojtabai R, Olfson M. National Trends in Psychotropic Medication Polypharmacy in Office-Based Psychiatry. Arch Gen Psychiatry. 2010;67(1):26-36.

DIET ORDER HISTORY Adolescent Stress Diet

General Caffeine Free

Is this appropriate for A.M.?Patient with poor PO intake; general diet

appropriate to encourage intakes Caffeine interacts with several

psychotherapeutic drugs

PATHOPHYSIOLOGY

PATHOPHYSIOLOGY CONTINUED

Schmidt, M. Brain Building Nutrition: The Healing Power of FNB and Oils. Frog; LTD. 2001.

Omega-3 Supports Healthy Immune Response. Nordic Naturals 2006.

DEPRESSION AND ADIPOSE ESSENTIAL POLYUNSATURATED FATTY ACIDS (2002)

Reported n-3 PUFA can suppress pathophysiological features of depression (inflammation and immune reactivity markers)Human studies indicate that dietary

supplementation with EPA and DHA supress IL-1, IL-2, IL-6 and TNF-a production by monocytes

Increasing long-term DHA intakes indicates decrease in depression

Mamalakis, G., Tornaritis, M., & Kafatos, A. (2002). Depression and adipose essential polyunsaturated fatty acids [Abstract]. Prostaglandins, Leukotrienes, and Essential Fatty Acids, 67(5) 311-318.

OMEGA-3 POLYUNSATURATED FATTY ACIDS AND DEPRESSION: A REVIEW OF EVIDENCE (2009) N-3 PUFA deficiency linked to (all associated with

depression): Altered neurotransmission Decreased glucose metabolism Increased production of pro-inflammatory

cytokines Reduced levels of brain-derived neurotrophic

factor (BDNF) Neuronal atrophy

Liperoti, R., Landi, F., Fusco, O., Bernabei, R., & Onder, G. (2009). Omega-3 polyunsaturated fatty acids and

depression: A review of the evidence. Current Pharmaceutical Design, 15(36), 4165-4172.

EVALUATION OF DOCOSAHEXAENOIC ACID DEFICIENCY AS A PREVENTABLE RISK FACTOR FOR RECURRENT AFFECTIVE DISORDERS (2009)

Cross-sectional survey: 21,835 adult/elderly subjects from NorwaySignificantly [(OR = 0.71 (95% CI = 0.52 –

0.97)] less likely to have depressive symptoms

1000-1500 mg/d in a 2:1 EPA:DHA ratio optimal for tx of affective disorders.

McNamara, R. K. (2009). Evaluation of docosahexaenoic acid deficiency as a preventable risk factor for recurrent affective disorders: Current status, future directions, and dietary recommendations [Abstract]. Prostaglandins, Leukotrienes, and Essential Fatty Acids, 81(2) 223-231.

NUTRITIONAL CARE RECOMMENDATIONS Omega 3 supplementation

Regular intake of 1g to 2g EPA/day + DHA n-3 improves irritability

Improved depression scores in many studies found with supplementation of 1g: higher levels may not show greater improvement

6-8 oz fish/week (750-1000mg EFA/day)Vitamin E

Care manual

POSSIBLE NUTRITION EDUCATION NEEDS/RECOMMENDATIONS

Importance of a balanced diet in relation to overall mental health and well being. Recommend aiming 2 servings of high n-3 containing

fish at least 2x/wk Recommend increasing fruits and vegetables rich in

vitamins, minerals, antioxidants

Benefits of supplementing with Omega-3 fatty acids/Vitamin E as it relates to patient condition. Recommend at least 1-2g/day Contraindications: Decreased hepatic fx, fish/soy

allergy, pts with implantable defibrillators (inc risk of ventricular fibrillation/tachycardia), on blood thinners (i.e., Coumadin).

Proper vitamin/mineral intake Supplement with Vitamin E

(Care Manual info)

REFERENCES 1. Centers for Disease Control and Prevention. CDC

Features: Depression. Page last reviewed: March 31, 2011. Available at: http://www.cdc.gov/Features/dsDepression/.

2. EPIC Computer Charting. 3. Trzepacz, PT; Baker RW (1993). The Psychiatric Mental

Status Examination. Oxford, U.K.: Oxford University Press. p. 202. 

4. Nutrition Care Manual. American Dietetic Association. 2011. Available at: www.nutritioncaremanual.org.

5.  DSM-IV-TR Multiaxial Classification System. Des Moines Area Community College. Available at: http://www.dmacc.edu/Instructors/tkwilson2/Diagnosis.pdf.

6. Pronsky ZM, Crowe JP. Food Medication Interactions 16th Edition. Birchrunville, PA. 2010.

7. Mojtabai R, Olfson M. National Trends in Psychotropic Medication Polypharmacy in Office-Based Psychiatry. Arch Gen Psychiatry. 2010;67(1):26-36.

REFERENCES CONTINUED 8. Mahan LK, stump SE. Krause’s food & Nutrition

Therapy. Saunders Elsevier, St. Louis, Missouri; 2008. 9. Omega-3 Supports Healthy Immune Response. Nordic

Naturals 2006. 10. Mamalakis, G., Tornaritis, M., & Kafatos, A. (2002).

Depression and adipose essential polyunsaturated fatty acids [Abstract]. Prostaglandins, Leukotrienes, and Essential Fatty Acids, 67(5) 311-318.

11. Liperoti, R., Landi, F., Fusco, O., Bernabei, R., & Onder, G. (2009). Omega-3 polyunsaturated fatty acids and depression: A review of the evidence. Current Pharmaceutical Design, 15(36), 4165-4172.

12. McNamara, R. K. (2009). Evaluation of docosahexaenoic acid deficiency as a preventable risk factor for recurrent affective disorders: Current status, future directions, and dietary recommendations [Abstract]. Prostaglandins, Leukotrienes, and Essential Fatty Acids, 81(2) 223-231.