Peter a 40 yr old gentleman, had become depressed following some cash pressures which had set his livelihood and home under threat.

He have been to check out his GP who got asked Peter to finished the self reporting Patient Wellness Questionnaire (PHQ9) to assist diagnosis and determine the amount of depression. Peter scored 16 upon this tool, which is definitely indicative of a moderately extreme depressive episode.

The GP recommended Peter should have a couple of weeks off work, make a scheduled appointment to see me for some psychological support and in addition prescribed the antidepressant drug Fluoxetine.

Peter did not attend the appointment given to him to attend my clinic, did not take anytime off job and did not utilize the prescription for medicine. Peter later explained he had been rather shocked by his GP’s diagnosis as he experienced that depression was an indicator of weakness and hadn’t considered himself to become a weak guy. Therefore he decided he’d try to sort himself out with no other intervention.

Unfortunately Peter was struggling to deal with items himself and his unhappiness worsened. When he attended the GP practice some 2 months afterwards at the insistence of his wife, he was severely depressed and had a PHQ9 score of 25.

The GP right away booked him right into a space in my clinic and once testmyprep again urged Peter to begin taking the Fluoxetine.

I saw Peter the next day and again assessed him to possess a severe depression. I wanted to commence a cognitive behavioural therapy method of manage the depression and again suggested the antidepressant could be beneficial to lift his disposition. I explored his uncertainty around acquiring the medication and described the potential unwanted effects which might occur. Peter required the medicine and after weekly found that his symptoms were needs to lift. He experienced some gastro intestinal unwanted effects, specifically, nausea which lasted for approximately 6 weeks but was manageable. I noticed Peter on 4 further occasions when we done some behavioural activation job, which is known to succeed for depression, (NICE, 2009) and his mood started out to lift further. His PHQ9 rating dropped from 25 to 9, which is certainly indicative of mild depression.

At the 6tth session, some 12 weeks after, Peter informed me he previously stopped taking the Fluoxetine since it was triggering some sexual dysfunction which was affecting his ability to achieve orgasm. Peter found this very hard to discuss but explained that he and his wife fond this very frustrating therefore therefore had made a decision to stop the medication.

I tried to explore this with Peter and encouraged that another antidepressant could be prescribed which may not have this particular side-effect. I likewise explained that his decision to avoid the antidepressant could also increase his chances of relapse. Peter was reluctant to check out these issues further and even though he made another appointment to observe me, he didn’t go to that appointment and failed to respond to any further communication.


On reflection, it would appear that Peter had several issues relating to his diagnosis of depression. Peter evidently had negative views about depression and what it designed for him as a person, regrettably it is the case for many persons as there is a great deal of stigma associated with depression.

He did not have enough info on taking the medication from his GP and although I felt I experienced covered the medial side effect profile at length, it was obvious that Peter had problems talking about sexual dysfunction side effects with me. He found this spot particularly embarrassing to disclose.

I also feel that I did not wholly follow the 7 principles of prescribing completely enough as I did not make Peter alert to the necessity to continue taking the medication for at least 6 months following remission to be able to prevent relapse. I did so not discuss this at first with Peter as I was conscious this could be facts overload for him at the start of treatment when our main concerns were symptom decrease. I was likely to discuss this aspect as part of my discharge planning session but Peter opted out of treatment ahead of this going on. With hindsight it could have been good for introduce this idea earlier.

These 3 points damaged Peter’s ability to adhere to his medication regime therefore therefore I will explore the problem of adherence within the assignment mounted on this research study.


This assignment will consider the problem of medication concordance associated with depression and the use of antidepressant medication as this was clearly an issue which became obvious within the research study. The assignment will explore what’s meant by concordance in relation to the case study, factors affecting it and strategies which may be used to inspire concordance for the treatment of depression.

Depression is recognised among the major causes of ill overall health worldwide and in Britain it really is the most common purpose listed on incapacity gain claims (World Health Company (WHO) 2001). Despite this statistic, depression and also other mental health problems continues to have a great deal of stigma attached to it. Gray et al, (2008) supports this watch and argues depressive disorder has been stigmatised because of widespread ignorance about the causes of the illness which has led it to be often perceived as an indicator of personal weakness. Therefore, people experiencing depression often neglect to seek help because they think ashamed or embarrassed to reveal their symptoms or do not know there are treatments available which might help.

The National Institute for Clinical Excellence, (NICE, 2004) recommended approaches to improve the profile of mental overall health by recommending means of improving the reputation and treatment of common mental health problems, such as for example depression by the application of self support, Cognitive behavioural therapy and antidepressant medication.

The function of the mental overall health nurse prescriber also has the potential to enhance the treatment of average to serious depression in primary care by combining the application of psychological treatments with medication management, (Badger, 2006). The amount of depression can be determined by use of the individual Overall health Questionnaire, (PHQ9) which says that a rating above ten signifies a probable moderate to severe depressive instance, if the reporter has had these symptoms for longer than a two week period, (Anderson et al, 2008).

Several research articles have highlighted that simply a proportion of antidepressants are taken as approved and discontinuation after one month is common. The statistics because of this vary between 30 to 68% according to this article. Fox, (1999), Warrington et al, (2000) and Olfson et al, (2006) confirmed that 42% of folks prescribed antidepressants stop spending them at one month.

Prior to 2005, what compliance and adherence have been used to describe patients taking medication relative to instructions but because the NICE guidance …….. the word concordance has been employed as this implies a negotiated agreement between your prescriber and the individual about the taking of medication. Despite this assistance, Hunot et al, (2007) argues concordance may not be any longer than compliance, unless the patient believes they have the same partnership with the prescriber.


Between a third and a half of medicines1 that are recommended for long-term conditions aren’t used as

recommended. This symbolizes a overall health loss for individuals and an economical loss for society.

Non-adherence shouldn’t be considered the patient’s trouble. Rather, it usually results from a failure

to fully recognize the prescription with the patient to begin with and to support the patient once the

medicine offers been dispensed.

Non-adherence falls into two overlapping types: intentional (the patient decides not to follow the

treatment suggestions) and unintentional (the patient really wants to follow the treatment

recommendations but has practical problems).

To understand non-adherence we have to consider perceptual elements (beliefs and preferences) that

influence motivation to get started on and continue treatment together with practical factors.

This requires:

_ an wide open, no-blame approach that encourages patients to discuss any doubts or worries about


_ a patient-centred methodology that encourages informed adherence

_ identification of perceptual and functional barriers to adherence during prescribing and

during regular review.

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Case study of a guy with severe depression


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