Lauren Farmer
KNH 413
3/19/15
Depression: Drug-Nutrient Interaction
1. What is depression?
Depression is common, however serious disorder of the brain that alters an
individual’s mood, thinking, sleep, appetite, and overall behavior. Depression is
characterized by severe symptoms that interfere with an individual’s patterns and
habits of living. Major depression is disabling and prevents an individual from
functioning and carrying on a normal lifestyle. Some may only experience a
single episode during their life, while others may have multiple episodes.
Depression can be caused by a combination of genetic, biological, environmental,
and psychological factors. Symptoms include persistent sad, anxious, or “empty”
feelings, loss of interest in activities that were once pleasurable, fatigue, insomnia,
excessive sleeping, overeating, loss of appetite, irritability, restlessness, thoughts
of suicide, aches and pains, and feelings of hopelessness, pessimism, guilt,
worthlessness, and helplessness. It has been shown that women are more likely
than men to experience depression, approximately 70%, and the average age of
onset is 32 years old.
(What is Depression, n.d.)
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?
A common side effect of SSRIs, like Zoloft, is weight gain. This change in weight
status may be a factor of noncompliance with treatment. However, research
indicates that no specific mechanism has been identified in explaining the
observed weight gain. Individuals who are taking SSRIs should be provided with
basic nutrition education and a means of referral to a registered dietitian. The RD
should establish a baseline diet and weight history, provide drug-nutrient
information, assist patients in developing a plan to monitor weight regularly,
develop a physical activity plan, and reinforce the importance of continuing
prescribed medications.
(Nelms, 632)
3. How do serotonin reuptake inhibitors (SSRIs) work?
Serotonin reuptake inhibitors ease symptoms of most cases of moderate to severe
depression. They work by affecting naturally occurring chemical messengers
(neurotransmitters), which are used to communicate with brain cells. SSRIs block
the reabsorption or reuptake of the neurotransmitter serotonin in the brain.
Essentially, SSRI changes the balance of serotonin in the body, which helps brain
cells to send and receive chemical messages and boosts the individual’s mood.
SSRIs are selective because they seem to primarily affect serotonin, not other
neurotransmitters.
(Depression, 2013)
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. Geitl did
as her mother suggested, as it is available without prescription in the United States. What
is St. John’s wort?
St. John’s wort is an herbal plant, in which its flowers and leaves are used to
produce medicine. It is most commonly used for reducing mild to moderate cases
of depression and other conditions such as, anxiety, fatigue, loss of appetite, and
sleeping problems.
(St. John’s wort, 2014)
5. How is St. John’s wort used in the United States?
Considering St. John’s wort does not require a prescription in the United States, it
is one of the most commonly purchased herbal products. It can be obtained in
many forms, such as capsules, tablets, tinctures, teas, and oil-based skin lotions.
As mentioned, it is used to reduce the symptoms of mild to moderate depression,
along with premenstrual syndrome (PMS), menopause, seasonal affective disorder
(SAD), and various other disorders. However, it should not be used to treat severe
depression. Whatever the case may be, it is recommended that an individual
consult their physician before using St. John’s wort.
(St. John’s wort, 2013)
6. How does St. John’s wort work as an antidepressant?
There are several theories regarding the mechanism of action in St. John’s wort.
Some research states that a chemical in St. John’s wort called hypericin is
responsible for its antidepressant effects. Other information suggests that another
chemical called hyperforin plays a larger role in acting on mood boosting
neurotransmitters. Some studies have reported that St. John’s wort is no more
effective than a placebo. However, the majority of research shows that it does in
fact aid in reducing symptoms of depression.
(St. John’s wort, 2013)
7. Does St. John’s wort have any side effects?
Side effects of St. John’s wort include:
 Upset stomach
 Hives or other skin rashes
 Fatigue
 Restlessness
 Headache
 Dry mouth
 Dizziness or mental confusion
 Skin sensitivity to sunlight (photodermatitis)
 Can weaken many prescription medications
 Psychosis
(St. John’s wort, 2013)
8. How is St. John’s wort regulated in the United States?
In the United States, St. John’s wort can be purchased over-the-counter, without a
prescription. The FDA does not regulate herbs as tightly as prescriptions and
other over-the-counter medicines. They also can’t guarantee its strength or purity.
It is advised that health care providers are notified before consuming this
medication.
(St. John’s wort, 2013)
9. How is St. John’s wort used in Europe?
St. John’s wort is native to European countries and is widely used to treat
depression, anxiety, and sleep disorders. Individuals must obtain a prescription to
take this medication in treating depression. France has banned the use of St.
John’s wort products. The ban is based on a report that discussed the significant
interactions between St. John’s wort and some medications.
(St. John’s wort, 2014)
10. Why do you think people are interested in alternative medicine and herbal treatments?
I believe people interested in alternative medicine and herbal treatments because
these treatments are considered to be “natural”. These also cause less side effects
than medications. There is a growing interest in alternative medicines and herbal
supplements and people believe that these are natural/organic and therefore won't
contain processed chemicals. However, side effects can occur in any type of
medicine or supplement. In any case, an individual should consult a physician
before adding alternative medications or supplements into their regimen.
11. Because Ms. Geitl is ambulatory, you are able to measure her height and weight. 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.
Height: 5’11” = 71 inches x 2.54 = 180.34 cm
Weight: 160lbs / 2.2 = 72.72 kg
12. Is Ms. Geitl’s recent weight loss anything to be worried about?
It was reported that she has lost 5 pounds within the last three months. Even
though it may not seem significant, she should be monitored for future weight
changes. Her weight loss is most likely due to symptoms of depression including
lack of appetite and poor diet. Nutrition intervention may be recommended to
improve her eating habits and to ensure that they don’t get worse. Her recent
weight loss is of concern due to her diagnoses of depression.
13. Because Ms. Geitl is alert and cooperative, you ask her to complete a Patient-Generated
Subjective Global Assessment (PG-SGA) of Nutritional Status. How would you score
her?
Sections
Box 1
Box 2
Box 3
Box 4
Weight loss section
Disease section
Metabolic section
Physical section
Score
1
2
1
2
1
0
0
0
Total 7
SGA Rating: B = moderately (or suspected of being) malnourished
14. Using Appendix I, how would you triage nutritional intervention?
Having a score of 4-8, which Ms. Geitl scored a 7, indicates that she required
intervention by a dietitian, in conjunction with a nurse or physician as indicated
by symptoms survey.
15. What methods are available to estimate Ms. Geitl’s energy needs?
 Mifflin-St. Jeor
 Harris Benedict
 Quick Estimate
16. Calculate Ms. Geitl’s basal energy needs using one of the methods listed in Question 15.
Harris Benedict:
655 + (9.56 x wt (kg)) + (1.85 x ht (cm)) – (4.68 x age (yrs))
655 + (9.56 x 72.72kg) + (1.85 x 180.34cm) – (4.68 x 20yrs)
655 + 695.20 + 333.63 – 93.60
= 1,590.23 kcal/day
17. What is Ms. Geitl’s estimated energy expenditure?
1,590.23 kcal x 1.6 PAL = 2,544.37 kcal
2,500 – 2,600 kcal/day
*Chose PAL of 1.6 because its seated work with some movement, which I believe
indicates her amount of daily activity.
18. Evaluate her diet history and her 24-hour recall. Is she meeting her energy needs?
Food
Calories
2 cups black coffee
0
½ cup low-fat frozen yogurt
90
3” square lasagna, half
150
1 cup steamed broccoli
50
1 breadstick
80
Diet cola
0
Air-popped popcorn with Pam and salt
80
Diet cola
Total:
0
450
Total:
0
80
90
30
60
0
60
150
0
470
1 cup black coffee
1 slice whole wheat toast
2 cups chicken noodle soup
2 saltine crackers
½ cup strawberry gelatin
Diet cola
2 peach halves
1 cup low-fat cottage cheese
1 cup black coffee
According to Ms. Geitl’s diet history and 24-hour recall, she is not meeting her
energy needs.
*Energy intakes were calculated using the Exchange Groups as a reference.
19. What would you advise?
First off, I would advise nutrition intervention for Ms. Geitl. She needs to be
educated on what a healthy and full meal plan/diet looks like and consists of. We
would work together in determining foods that she likes and has an appetite for. It
is important for her to consume foods that are nutrient and calorie dense, in order
to get her up to her recommended energy needs. Another priority is treating her
depression. It can be seem like her symptoms are causing a severe calorie
restriction for Ms. Geitl. If her depression doesn’t get treated, the same cycles of
eating habits will continue and will only worsen her health status. Educating her
to take dietary changes slowly and possibly incorporate one new food per day.
She should also try to limit her intake of diet cola and try to incorporate other
beverages such as milk, juice, and water.
20. List each factor from your nutritional assessment and then determine an expected
outcome from each.
Assessment Factor
Expected Outcome
Increase caloric intake
Nutrition education will aid in her knowledge of
hoe to increase her daily kcal intake. She will
know how to pick nutrient and calorie dense
foods and how to construct a healthy meal plan.
Increase appetite
Her appetite will increase as treatment for her
depression continues on a successful path. She
will regain a desire to eat and make foods that she
likes.
Maintain weight
With treatment of depression and her knowledge
of calorie dense foods, she will be able to
maintain a proper weight for her needs.
21. What is your immediate concern regarding this patient’s use of St. John’s wort?
An immediate concern regarding Ms. Geitl’s use of St. John’s wort is the fact that
she has been prescribed Zoloft, which is an antidepressant. Taking a combination
of these medications can dangerously increase serotonin levels. This can cause
serious side effects such as heart complications, shivering, and anxiety. Another
factor to consider is that she may experience drug interactions with her oral
contraceptive, which would make the medication less effective.
(St. John’s wort, 2014)
22. Review the initial nutrition note written for this patient. Is this progress note
appropriate? Is it complete? Any errors? Any omissions?
Using a SOAP note is appropriate but an ADIME would’ve been more clear and
complete. The note doesn’t include her patient and family history. There are
multiple omissions, included note of her depression and symptoms which are
leading to her poor appetite, caloric intake, and energy level. It would’ve been
important to note that she is originally from Germany and attending school in the
United States, which can indicate a difference in culture and diet. There were no
PES statements included in the note. These statements are useful in furthering
treatment.
References
Depression. (2013). Mayo Clinic. Retrieved March 17, 2015, from
http://www.mayoclinic.org/diseases-conditions/depression/in-depth/ssris/art-20044825.
Nelms, M., Sucher, K.P., Lacey, K., & Roth, S.L. (2011). Nutrition Therapy & Pathophysiology.
(2nd ed.). Belmont, CA: Brooks/Cole Cengage Learning.
St. John’s wort. (2013). University of Maryland Medical Center. Retrieved March 17, 2015,
from http://umm.edu/health/medical/altmed/herb/st-johns-wort.
St. John’s wort. (2014). MedlinePlus. Retrieved March 17, 2015, from
http://www.nlm.nih.gov/medlineplus/druginfo/natural/329.html.
What is Depression? (n.d.). National Institute of Mental Health. Retrieved March 17, 2015, from
http://www.nimh.nih.gov/health/topics/depression/index.shtml.