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Case Study 2: Drug-Nutrient Interaction (Depression)
1. What is depression?
Depression is a clinical disorder that results in someone to feel sad, at loss,
angry, or frustrated. These symptoms affect the person’s daily life for an extended
period of time. There are many reasons why depression can come about and some
symptoms include distorted views on the self, fatigue, feelings of worthlessness,
becoming isolated, and thoughts of suicide (Zieve, & Merrill, 2012).
2. Dr. Byrd has decided to treat Ms. Geitl with Zoloft, a selective serotonin reuptake
inhibitor (SSRI). Are there any pertinent nutritional considerations when using
this medication?
When taking Zoloft it is important for Ms. Geitl to avoid alcohol. It should
also be taken in caution when intaking certain herbs. One of the herbs includes St.
John’s wort, but if the physician allows it, the herb can be taken with the drug
(Applied Health, 2007). Taking in extra vitamin D can help lessen the side effects
of the depression.
3. How do selective serotonin reuptake inhibitors (SSRIs) work?
The SSRIs help ease depression by changing neurotransmitters that
communicated between brain cells. This type of drugs blocks the reabsorption of
serotonin. Helping balance serotonin can increase the mood of someone taking the
drug making depressive symptoms less severe (MayoClinic, 2010).
4. During the diet history, you ask Ms. Geitl if she uses any OTC vitamins, minerals,
or herbal supplements. She tells you her mother suggested she try Hypericum
perforatum (St. John’s wort) because in Germany it is prescribed to treat
depression. Ms. Geitle did as her mother suggested, as it is available without
prescription in the U.S. What is St. John’s wort?
St. John’s wort is a yellow flower plant that is used for medicine. There
are many uses for it now, which are explained in the next question. Some
medications can be affected by taking this plant with them, so the physician to
ensure it will be safe to use for the patient should accept this herbal medication. It
is used medicinally to treat depression, anxiety, and/or sleep disorders. (National
Institute of Health, 2011).
5. How is St. John’s wort in the US?
The flowering tops of St. John’s wort is used to prepare teas, tablets, and
capsules for medicinal use (http://nccam.nih.gov/health/stjohnswort/). In the U.S
there is a public interest in St. John’s wort as a treatment for depression. However
it is not a prescribed medication (http://nccam.nih.gov/health/stjohnswort/sjwand-depression.htm). The U.S Food and Drug Administration do not approve it
for the treatment of depression.
6. How does St. John’s wort work as an antidepressant?
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How the compounds of St. John’s wort works as an antidepressant is not
fully understood. Some studies show that St. John’s wort works on serotonin and
dopamine http://www.anxietydepressionhealth.org/st-johns-wort-hypercium.htm).
Other studies suggest the St. John’s wort might prevent nerve cells in the brain
from reabsorbing the chemical messenger serotonin. Other theories are that St.
John’s wort works by reducing the levels of protein involved in the body’s
immune system functioning (http://nccam.nih.gov/health/stjohnswort/sjw- anddepression.htm).
7. Does St. John’s wort have any side effects?
St. John’s wort side effects (http://nccam.nih.gov/health/stjohnswort/sjw-anddepression.htm) : 
o Dry mouth
o Dizziness
o Diarrhea
o Nausea
o Increased sensitivity to light
o Fatigue
o Anxiety
o Headache
o Confusion
8. How is St. John’s wort regulated in the U.S?
St. John’s wort is unregulated in the U.S. Instead it is classified as a dietary
supplement, which are unregulated (http://www.anxietydepressionhealth.org/st-johnswort-hypercium.htm).
9. How is St. John’s wort used in Europe?
St. John’s wort is only available by prescription in parts of Europe. It is promoted
to treat depression, anxiety, and sleep disorders. In Germany, doctors often proscribe
St. John’s wort more often than prozac, a popular anti-depressant. St. John’s wort is
also used to treat bronchial inflammation, bed-wetting, stomachproblems,
hemorrhoids, hypothyroidism, insomnia, migranes, kidney disorders, and malaria
(http://www.cancer.org/Treatment/TreatmentsandSideEffects/ComplementaryandAlte
rnativeMe dicine/HerbsVitaminsandMinerals/st-johns-wort).
10. Why do you think people are interested in alternative medicine and herbal
treatments?
Drugs are a controversial topic in the United States because the effects vary
so much depending on the person, the drug, and the problem that the person has.
Not all of the information on drugs is known, so some people are unsure about
whether they should be taken or not. On the other hand, herbal medications are
more a natural remedy that people want to try. Herbs have been used for a long
time and often produce health benefits (MedlinePlus, 2012).
11. Because Ms. Geitl is ambulatory, you are able to measure her height and weight.
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She is 5’11” tall and weighs 160 pounds. You also determine that she is of
medium frame. Because Ms. Geitl is from Germany, she is used to reporting her
weight in kilograms and her height in centimeters. Convert her height and weight
to metric numbers.
Weight: 160 lb /2.2 = 72.72 kg
Height: 60+11 = 71 inches x 2.54 = 180.34 cm= 1.8 meters
BMI: 72.72/(1.8)^2 = 22.44
12. Is Ms. Geitl’s recent weight loss anything to be worried about?
Ms. Geitl’s recent weight loss of 5 lbs is not a severe worry currently. It is
related to her poor appetite, which is occurring because of her depression.
However, if she continues to lose weight, due to her poor appetite, then other
nutritional problems/deficiencies are likely to occur.
13. Because Ms. Geitl is alert and cooperative, you ask her to complete a PatientGenerated Subjective Global Assessment of Nutritional Status. What is her score
(Ottery, 2005)?
Sections
Box 1
Box 2
Box 3
Box 4
Weight Loss section (table 1)
Disease section (table 2)
Metabolic section (table 3)
Physical section (table 4)
Score
1
1
1
3
0
0
1
0
Total 7
14. Using Appendix 1, how would you triage nutritional intervention?
I would say, based on Ms. Geitl’s PG-SGA point score that her triage point
score is 2-3. This means the Ms. Geitl needs patient and family education by
dietitian, nurse, or other clinician with pharmacologic intervention as indicated by
symptom survey and lab values as appropriate. If her weight loss continues she
may have a triage score of 4-8. This score requires intervention by dietitian, in
conjunction with nurse or physician as indicated by symptoms.
15. What methods are available to estimate Ms. Geitl’s energy needs?
The methods available to estimate Ms. Geitl’s energy needs are the
Harris-Benedict equation, Mifflin-St Jeor Formula, World Health Organization
Equation, and the Quick Estimate Equation.
16. Calculate Ms. Geitl’s basal energy needs using one of the methods you listed
above. (pg. 60)
Basal energy needs using Mifflin-St. Jeor:
10xwt+6.25xht–5xage–161 
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10x72.73+6.25x180.34–5x20–161
727.3 + 1127.125 – 100 – 161= 1,593.43 kcal 1500-1600 kcals a day
17. What is Ms. Geitl’s estimated energy expenditure? Estimated energy expenditure:
 354–6.91xage+PAx(9.36xweight+726xheight)
 354–6.91x20+1.12x(9.36x72.73+726x1.8034) = 2, 287.5 kcal
 Protein needs: 
o 2,287.5 x .15 = 343.125/ 4 = 85.78 grams
 Fat needs:
o 2,287.5 x .07 = 160.125/ 9 = 17.79 grams
 Carbohydrate needs:
o 2,287.5 x .60 = 1372.5/ 4 = 343.13 grams
18. Evaluate her diet history and her 24-hour recall. Is she meeting her energy needs?
Ms. Geitl is not meeting her energy needs. Using Fitday.com each of Ms.
Geitl’s foods within her diet history and 24-hour recall were evaluated to
determine the amount of calories is actually consuming on a daily basis. Her diet
history shows that she consumes about 493 calories a day. Her 24-hour recall was
similar to her diet history, being that she consumed about 468 calories. The
amount of calories she needs in a day is significantly higher, being about 1,593.43
kcal. Ms. Geitl’s diet history shows she consumed approximately 19.4 grams of
fat, 66.7 grams of carbohydrate, and 18.8 grams of protein. Her 24-hour recall
showed she consumed about 9.2 grams of fat, 54.2 grams of carbohydrates, and
41.5 grams of protein. The amount of fate Ms. Geitl needs is about 18 grams. The
amount of protein she needs is about 86 grams. The amount of carbohydrates she
needs is approximately 344 grams. Based on her diet history and 24-hour recall,
Ms. Geitl needs to increase her calorie, fat, protein, and carbohydrate
consumption to correct her weight loss.
19. What would you advise?
Ms. Geitl is lacking in a lot of nutrients so I would suggest that she eats small,
frequent meals that are nutrient dense. After doing research on Zoloft, she should
take in more vitamin D because it can help with depressive symptoms, and she is
not getting much calcium in her diet. I would show Ms. Geitl the food plate and
explain the importance of nutrition especially if she is taking medications and
beginning to lose weight.
20. List each factor from your nutritional assessment and then determine an expected
outcome from each.
Assessment Factor
More Vitamin D
Inadequate Protein Intake
Expected Outcome
Less depressive symptons
Increase protein consumption, by
consuming more sources of protein (such
as meat or beans). Increasing protein would
happen as a result of increasing calories
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Inadequate Calorie Intake
Inadequate Carbohydrate Intake
Inadequate Fat Intake
Increase calorie consumption by increasing
food consumption, or adequately sized
meals (for breakfast, lunch or dinner).
Increasing calorie would stop her weight
loss
Increase carbohydrate consumption by
following the daily-recommended intake of
grains (examples, pasta and bread) from the
food plate. Increasing carbohydrates would
happen as a result of increasing calories
Slightly increase fat intake, but focus on
consuming mono and polyunsaturated fats.
This could be from lean meats sources like
chicken, or turkey. Increasing fat would
happen as a result of increasing calorie
consumption.
21. What is your immediate concern regarding this use of St. John’s wort?
The SSRI medication and St. John’s wort should not be taken
simultaneously, this is an immediate concern. As said earlier, it can also reduce
levels of protein in the body, which can affect the immune system’s function
(National Institute of Health, 2011).
22. Review the initial nutrition note written for this patient. Is this progress note
appropriate? Is it complete? Any errors? Any omissions?
After reviewing the nutrition note (SOAP) for this patient, I have
determined that while this note format is appropriate, it is incomplete, contains
errors, and omissions. In the subjective data part of the SOAP note, the R.D
should have included the Kcal and protein data from the diet history and 24-hour
recall in the objective data part. This is because she would have had to calculate
these numbers. The subjective data part includes data collected from the patient or
caregiver. The R.D should have just said a diet history and 24-hour recall were
taken in the subjective part. The R.D also omitted the information about the
patient’s alcohol consumption. She also omits any information about the religious
or ethnic background of the patient.
The objective data section includes all empirical information. The R.D
omitted the information about converting the patient’s height and weight to metric
units for patient understanding, gender of the patient, patient’s temperature, pulse,
blood pressure, respiration rate, the medical diagnosis, and current medical care.
The Assessment portion of the SOAP is lacking the nutrition problems and their
supporting data in the PES format. The Plan portion of the R.D’s SOAP note will
outline the interventions necessary to treat each nutrition problem. In this portion
the patient’s likes and dislikes should be included in the subjective portion of the
note. The R.D should describe how to adjust the patient’s meals accordingly by
how she will encourage her to eat. Also she should describe how she would
increase the patient’s intake of Kcal and protein.
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(Nutrition Therapy and Pathophysiology, 2nd edition, Pg 108)
References
Herbal Medicine. (2012). Retrieved from MedlinePlus website:
http://www.nlm.nih.gov/medlineplus/herbalmedicine.html
Nelms, Sucher, Lacey, & Roth. (2011). Diseases of the upper gastrointestinal tract. In
Nutrition
therapy and pathophysiology (2nd ed., pp. 60). Wadsworth, Cengage Learning.
Ottery. (2005). Scored Patient-Generated Subjective Global Assessment. Retrieved from
http://accc-cancer.org/oncology_issues/supplements/pgsga.pdf
Selective serotonin reuptake inhibitors . (2010). Retrieved from MayoClinic website:
http://www.mayoclinic.com/health/ssris/MH00066
St. John's wort. (2000). Retrieved from U.S. Food and Drug Administration website:
http://www.fda.gov/Safety/MedWatch/SafetyInformation/
SafetyAlertsforHumanMedicalProducts/ ucm173258.htm
St. John's wort. (2011). Retrieved from National Institute of Health website:
http://nccam.nih.gov/
health/stjohnswort/ataglance.htm
Zieve, & Merrill. (2012). Major Depression. Retrieved from PubMed website:
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001941/
Zoloft. (2007). Retrieved from Applied Health website: http://www.naturalnews.com/
DrugWatch_Zoloft.html