Evidence Based Practice Paper #2

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Elvin Patterson
5 years ago
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1 1 Evidence Based Practice Paper #2 1.) Introduction to hypothetical patient in one paragraph case study KT is a 22 F coming into the clinic today for consultation of St Johns Wort for frequent sadness episodes. Pt is new to this small rural clinic in Montana, moving here two months ago from a neighboring town. She states her last visit to the doctors was a little over a year ago for annual PE and did not note anything abnormal. PMHx: denies PMH except sadness that has been on going since the age of 16, she states that since her recent move the feelings of sadness have worsened. Pt denies ever being diagnosed with depression or any other psychiatric disorder by an MD or NP in the past. She also denies ever seeking counselling, support groups, or being on antidepressants. When asked to elaborate about worsening sadness she states at times it has been hard to get up to care for the children and feels like she is eating less. Gravida: 2, Para: 2, Abortus: 0 Currently breastfeeding Social Hx: Recent move was for husbands job and she didn t really want to move. Pt is a stay at home mother of two children ages 2 and four months old. Her husband works 12 hour shifts most days and she does not have any support when he arrives home because he is too tired. Where they were living prior, her mother would take the kids at least 3x a week to allow her to do the shopping and get some housework done. Since moving she has not met anyone, staying home with the kids indoors all day I don t have any friends around like I use to. Although tired and sad she does feel like she is caring for her children well. KT denies suicidal ideations Medication: Progestin only birth control pill minipill. PT unsure of medication name and dose

2 2 PE: benign assessment except HAM D score: 10, denies suicidal ideations VS: 125/84, P 72, RR 18, 02 sat 100% on RA Height 5 8, Weight 145 lbs After discussing options KT only wants to try and take St Johns Wort, wanting to be natural not want to take any prescription medications other than birth control. 2.) Development of clinical question Should recommendations on an herbal medication such as St John s Wort be given to a patient when evidence in the literature is present but contradicting? 3.) Identification of intervention to be considered With a patient presenting with a seven year history of sadness symptoms, as a clinician I would like further evaluation. Since KT is new to our clinic I would start out with a thorough history and physical focusing on a detailed psychiatric evaluation. A few tools I may want to use would be a depression screening questionnaire such as Beck Depression Inventory or the Hamilton Rating Scale for Depression (HAM D). The HAM D is commonly used it consists of a list of 21 items, each having a range score, and usually takes the patient around minutes to complete. I would also want to refer her to psychologist for evaluation, to make sure there is no other underlying psychiatric diagnosis, as well as make recommendations on course of care. I would want to provide KT with a list of support groups for mothers with young children.this would be a good way for her to meet people within her community in the same age bracket and with similar life circumstances. I would also want to do a lot of education: getting outside, going for walks, going to the park and self care. Most importantly before leaving the office it is important to establish if she becomes suicidal or has suicidal ideations to come back immediately or call 911.

3 3 4.) Exploration of the most current and valid evidence St John s Wort (Hypericum perforatum) has been around for over 2000 years in use of folk medicine particularly in use of chasing away the devil (Gupta, 2003). Upon reviewing recent literature there have been a handful of clinical trials evaluating St John s Wort against placebos, tricyclics, and selective serotonin reuptake inhibitors. A few double blinded clinical trials suggests that for the treatment for mild to moderate depression St John s Wort is more effective than the placebo (Gupta, 2003). Another article, Safety of St Johns Wort, believes this herb to be effective treatment working similarly on neurotransmitter activity just as other psychiatric drugs. Another longitudinal study observed 440 individuals with mild to moderate depression for a full year on both safety and effectiveness (Brattstrom, 2009). After a year of treatment in this study, there were no changes to labs or EKG nor was their change to the individuals BMI. Although there were 504 side effect symptoms documented, only 30 were attributed St John s Wort use and symptoms were mild, mostly gi related and skin issues. Most common side effects found through research with St John s Wort include nausea, constipation, diarrhea, rashes, fatigue headache, restlessness, sweating, and photosensitivity.observing for effectiveness, the study used several tools including the HAM D scale that found a steady decline over the time on therapy. The research also makes note that it may take 4 weeks for clinical effects to be noticed and a full 6 month course taken consistently to prevent relapse of depression. One thought to also consider when choosing St Johns Wort as a therapy is many of the studies discussed the induction of cytochrome P450 causing decreased blood levels of many commonly used medications including birth control pills. Another consideration, particularly for KT, is the passing of St Johns Wort through her breast milk to the baby. One small study of 30 breastfeeding women suggested there was few adverse reactions noted with the infant however due to lack of research the study does still recommend first line antidepressants rather than use of St John s Wort. 5.) Evaluation of evidence

4 4 After evaluating the literature on St Johns Wort dozens of small studies as well as a few large, longitudinal studies have been attempted. Overall the evidence appears to be overall positive on the herb itself, however not a substantial amount of evidence based research has been complete. While it is clear that this over the counter herb is much more cost effective than taking prescribed antipsychotic medications, what is not so clearly presented is the safety in use. One large component mentioned in very few articles is the standard regulatory medication. Standards for producing all herbs are lacking, making me concerned that a dose may vary from dose to dose and differing manufacturers. 6.) Conclusion and References Although my concerns for recommending St Johns Wort are justified, it appears from the conversation with KT that she will be taking this medication anyway. Instead of condoning the use of this commonly used herbal medication I must do a thorough job educating this patient on the correct self care for depression. Through education I hope to help her alleviate some of these depression symptoms. Specific recommendations I would make would include helping KT understand lifestyle changes that she can make to improve her quality of life. These include eating right, going for walks to the park with the children daily. I would also want to educate KT on the literature that notes common SE so that she would be prepared. KT should also be aware that research suggests birth control pills to be subtherapeutic with use of St Johns Wort and I would recommend she uses another form of birth control. It would be important to bring to her attention there is lack of evidence to suggest St Johns Wort is safe while breastfeeding. Besides education, I would be consulting with the physician I work with and put in a referral for a psychologist to work on any internal problems she may have. As mentioned above I would also refer her to a depression support group as well as a mommy group since she is new to the area. I would also emphasis to come back immediately or call 911 if she has any suicidal ideations. After discussion and education if KT does decide she will be trialing St Johns Wort I would remind her the studies suggest it may take up to 4 weeks to see an effect. I would want to follow up with her in two weeks (and prn emergencies) to follow up on the progression of her depression.

5 5 Resources Brattström A. Long term effects of St. John's wort (Hypericum perforatum) treatment: a 1 year

6 6 safety study in mild to moderate depression. Phytomedicine.2009 Apr;16(4): Deshmukh R., Franco K. Talking to your patients about St Johns Wort. (2003).Cleveland Clinic Journal of Medicine.Volume 70, Number Gupta R.K., Moller H.J. St John s Wort. European Archives of Psychiatry and Clinical Neuroscience June 2003, Volume 253, Issue 3, pp Henderson L, Yue, Q.Y., and et al. St John's wort (Hypericum perforatum): drug interactions and clinical outcomes.british Journal of Clinical Pharmacology.Volume 54, Issue 4, pages , October Lee A, Minhas R, Matsuda N, Lam M, Ito S. The safety of St. John s wort (Hypericum perforatum) during breastfeeding. J Clin Psychiatry Aug;64(8): Shelton RC, Keller MB, and et al.effectiveness of St John's wort in major depression: a randomized controlled trial. JAMA.2001 Apr 18;285(15): Solomon, D., Adams J., and et al. Economic evaluation of St. John's wort (Hypericum perforatum) for the treatment of mild to moderate depression Journal of Affective Disorders.Available online Jan 2013 Wheatley D. Safety of St John's wort. February The Lancet, V (355) 9203: 576.

depression easy to read

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