Depression in Heart Failure

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Formulating a treatment plan

Based on the available information provided in this scenario, select options to include in your treatment plan for this patient.

Select all that may apply:

Please select the correct answer from the choices below:

Continue current post transplant medications

Recommended

Change to another antidepressant medication

Not recommended.
It is premature to switch the patient to another antidepressant at this point. The current medication (buporprion) has been effective and well tolerated with minimal side effects. Patient decompensated due to poor medication adherence. Factors contributing to his poor medication adherence/self-care behaviors include: 1) developmental stressors (college graduation, unemployment, feelings of heading to a different life path from his friends); 2) loss of mental health treatment team; 3) perception of hitting the 10 year life expectancy mark gleaned from internet search; and 4) lack of family/social support.

Continue on buporprion XL 150mg

Recommended.
This would be appropriate for the patient’s treatment plan.

Continue on buporprion XL 150mg and add Tricyclics

Not recommended.
It is common that a person is most likely to respond to a particular class of psychotropic medication if someone in their biological family has had a successful trial. However, for this patient the use of tricyclics is discouraged due to the cardiac side effects. Tricyclics have considerable antimuscarinic potency, causing decreased parasympathetic activity (increased heart rate, tachycardia, orthostatic hypotension). In addition, tricyclics are highly lethal when taken over the recommended dosage. Given patient’s cardiac condition and his history of suicidal thoughts, the use of tricyclics should be used with great caution.

Counseling (identify life stressors, coping strategies)

Recommended.
The patient had a period of time (since last hospital admission) when he was attending college, had a circle of friends, had access to a mental health team at the college clinic where he received routine medication management and counseling. The patient started to decompensate since his graduation when he lost these resources. The counseling may focus on redefining life goals, coaching for effective coping skills, reconnecting with available resources and social groups.

Cognitive behavioral therapy (CBT)

Recommended.
Patient believes his life is coming to an end, based on information he read on the internet regarding average life expectancies for heart transplant patients. His perception of life expectancy could be a cognitive distortion as some heart transplant survivors’ may live up to 20 years. CBT can target this kind of cognitive distortion and help the patient reframe his beliefs and engage in health promotion behaviors.

Outpatient mental health services, next follow up in 1-2 weeks

Recommended.
This would be appropriate for the patient’s treatment plan.

Outpatient mental health services, next follow up in 2-3 months –

Not recommended.
This would be too long.


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Reference: Conley S, Redeker NS. Cognitive Behavioral Therapy for Insomnia in the Context of Cardiovascular Conditions. Current sleep medicine reports. Sep 2015;1(3):157-165.




Reference: Conley S, Redeker NS. Cognitive Behavioral Therapy for Insomnia in the Context of Cardiovascular Conditions. Current sleep medicine reports. Sep 2015;1(3):157-165.