30.Wk3Res

Jane,

I posted both cases on this page. Write me a response to each. Same as usual 2 paragraphs 2 sources. Thanks!

Respond to at least two of your colleagues who were assigned to a different case than you. For example, if you were assigned to Case Study 1, respond to one colleague assigned to Case Study 2 and one colleague assigned to Case Study 3. Explain how you might apply knowledge gained from your colleagues’ case studies to you own practice in clinical settings.

If your colleagues’ posts influenced your understanding of these concepts, be sure to share how and why. Include additional insights you gained.

If you think your colleagues might have misunderstood these concepts, offer your alternative perspective and be sure to provide an explanation for them. Include resources to support your perspective.

Case 29 (KeeTor)

Question 1: Have you had any suicidal ideation or thoughts of self-harm since in the last four weeks?

Rational: Suicidal Ideation and thoughts of self-harm should be discussed at every appointment. Patients with treatment-resistant depression are 30% more likely to attempt suicide.

Question 2: Was there any event that happened before your relapse into depression five years that you can identify as a trigger or contributing factor? Do you have a strong support system in your family/friends?

Rational: Feelings of hopelessness, or worthlessness are sometimes the result of an event or string of events and may result in a deeper depression. A strong support system is crucial in the recovery of depression.

Question 3: Have you ever tried CBT, Acceptance and Commitment therapy, or psychoanalytic therapy?

Rationale: Psychotherapy is an avenue that should be explored for this patient if it has not already. This is an additional pathway for the patient to participate in therapeutic interactions that could be beneficial in decreasing the patient’s depression by providing new coping skills and insight.

 

Questions for People in Patients Life

Patients Wife: What is your husband's home life like? What are his biggest stressors? Have there been any triggering life events that could have contributed to the depression? Is he medication compliant?

Rationale: The patient’s partner may be the most important person to speak with due to her being the closest contact. She would have the greatest insight to the patient’s behaviors, what the home life is like, if there are any unknown stressors and would be the greatest in assisting the patient with utilizing therapies and coping skills in his everyday life. She could also provide insight into whether the patient is medication compliant or not.

Patients Children: What is your perspective on your father’s mental health? Are you aware of any triggering life event when the relapse into depression began five years ago? Is he involved in your and his grandchildren’s lives? Would you be open to family therapy if necessary?

Rationale: The children may be privy to information that the wife is not. In order to get a full picture of the patient’s life, it is important to speak with those closest to them. Assessing the relationships of the patient can also provide insight into the patient’s condition

Close Friends: Is your friend still involved in social events and gatherings? Has the relationship with your friend changed over the last five years? Has the patient given away or attempting to give away their possessions that you are aware of?

Rationale: If the patient has any close friends, they may be the ones that patient has confided in and may have additional insight that the family does not. They may also be aware of behaviors that the family is not, such as withdrawing from social events or even trying to give away personal possessions which is an indicator of suicidal thoughts.

 

Diagnostic Tests

TSH- there has been a noted relationship between hypothyroidism and depression for many years. Checking a patient’s thyroid can help to rule this out or highlight the need for treatment. An elevated TSH can present as a slowing of mental and physical functioning, lethargy, apathy, crying spells, sleep disturbances, and even suicidal ideation (Dayan & Panicker, 2013).

CBC- In otherwise healthy adults there has been a noted correlation between depression and anemia. The practitioner should be looking for an overall view of the patient’s health, a CBC is a good window into this. If anemia is present, it can present as fatigue, anorexia, and depression (Vulser, Wiernik, Hoertel, Thomas, Pannier, Czernichow,  Lemogne, 2016).

ALT- Persistently elevated ALT has been associated with developing depression symptoms either minor or major. Monitoring liver function and preventing any liver damage can prevent symptoms such as weakness, anorexia, depression, and fatigue (Zelber-Sagi, Toker, Armon, Melamed, Berliner, Shapira, Halpern, Santo, Shibolet, 2013).

B12- Vitamin B-12 as well as other B vitamins are involved in the production of certain brain chemicals which affect brain function and mood. This can result in confusion, insomnia, or even mood disorders. Low levels of B-12 and B-6 as well as folate have a strong correlation with depression (Daniel K. Hall-Flavin, 2018).

Differential Diagnoses

Treatment-Resistant Depression: The most likely diagnosis. TRD is a persistent disease that fails to respond to adequate treatment. This patient has trialed many therapies that have shown little to no change in the patient's depression. Treatment-Resistant Depression presents with many unique challenges, when initial treatment has been trialed for at least 8 weeks without effect, the APA recommends dose augmentation, titration, or switching. When a medication is deemed to be ineffective, it is usually suggested to select an agent with a different mechanism of action. However, it is important to keep in mind patient compliance with medication and that a therapeutic blood level was reached for that medication before premature discontinuation and therapy change. Treatment-Resistant Depression presents with a loss of interest in previously enjoyed activities, appetite/sleep disturbances, decreased energy, and low self-esteem (Al-Harbi, 2012).

Major Depressive Disorder: The patient must exhibit 5 or more of the following symptoms within a two-week period and results in a change of functioning. One of the symptoms must be either loss of interest/pleasure or a depressed mood. This patient presents with a depressed mood, loss of energy, diminished interest in activities of the day and pain without a known cause. The changes seen in the patient cannot be attributed to physiological effect of a substance or any other medical condition (American Psychiatric Association2013).

Persistent Depressive Disorder (Dysthymia): Consolidation of MDD and Dysthymic disorder. The patient presents with a depressed mood for most of the day, for the majority of days, noted by the patient or those close to them, and lasting at least two years. The patient presents with low energy, and feelings of hopelessness. This diagnosis should be considered due to the length of the patient’s episode as well as present symptoms (American Psychiatric Association2013).

Pharmacologic Agents

The discontinuation of the MAOI should be considered due to lack of a positive response. The patient exhibited a positive effect to Venlafaxine 225mg previously, the provider may want to consider restarting this drug therapy with an increased dose of 375mg seeing as the blood levels of the drugs therapeutic response were low. After an appropriate window of time on the new dose, the blood levels should be taken again and if still below the therapeutic window increasing the Venlafaxine again until a therapeutic level is reached. Something to be considered with Venlafaxine is to monitor the patient’s blood pressure and ensure compliance with blood pressure medications is maintained as this medication can cause a rise in blood pressure. If blood pressure cannot be controlled on this medication or a therapeutic level cannot be reached with appropriate dosing the patient could be started on Pristiq. Pristiq can be prescribed at lower doses, between 50-100mg daily. The therapeutic blood levels would need to be monitored the same as with Venlafaxine. Both drugs break down into an active form of desvenlafaxine. However, Pristiq has fewer drug to drug interactions (The Carlat Psychiatry Report, 2013).

Check Points

At each appointment the patient should be assessed for suicidal ideation and self-harm thoughts. This is an important tool in monitoring the patient’s overall safety, level of depression, and effectiveness of treatment. The patient should also be assessed for quality of life, are they getting out of bed every day, eating regularly, participating in social events, are they feeling joy or hope. Medication blood levels need to be monitored regularly. If a therapeutic level is reached, ensuring it is maintained on the lowest needed dose of the medication. Treatment regime should also be assessed, is the overall treatment resulting in a positive response. For example, the patient participated in a long treatment course of ECT which was ineffective and resulted in worsening outcomes for the patient. This is when an alternate treatment regime should be considered, such as elevating the dose of the previously effective medication into a therapeutic range.

Lessons Learned

This was a difficult case study. When a patient has such a long history with depression and has already been through so many treatment avenues, it can make finding an effective treatment regime difficult. The patient being resistant to treatment is a good lesson to take into practice because when treating older adults, they will present with a long history of trial and error treatments. Treatment should not necessarily be ignored just because it has been trialed in the past. As with this patient, there could be another dosage or aspect that would make that treatment a success for the patient.

References

Al-Harbi K. S. (2012). Treatment-resistant depression: therapeutic trends, challenges, and future

directions. Patient preference and adherence, 6, 369–388. https://doi.org/10.2147/PPA.S29716

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

Daniel K. Hall-Flavin, M. (2018, June 01). Vitamin B-12 and depression: Are they related? Retrieved September 15, 2020, from https://www.mayoclinic.org/diseases-conditions/depression/expert-answers/vitamin-b12-and-depression/faq-20058077

Dayan, C. M., & Panicker, V. (2013). Hypothyroidism and depression. European thyroid

 journal, 2(3), 168–179. https://doi.org/10.1159/000353777

The Carlat Psychiatry Report . (2013, September 03). Pristiq vs. Effexor. Retrieved September

 16, 2020, from https://pro.psychcentral.com/pristiq-vs-effexor/

Vulser, H., Wiernik, E., Hoertel, N., Thomas, F., Pannier, B., Czernichow, S., . . . Lemogne, C. (2016, May 30). Association between depression and anemia in otherwise healthy adults. Retrieved September 15, 2020, from https://onlinelibrary.wiley.com/doi/abs/10.1111/acps.12595

Zelber-Sagi S;Toker S;Armon G;Melamed S;Berliner S;Shapira I;Halpern Z;Santo E;Shibolet O;. (2013). Elevated alanine aminotransferase independently predicts new onset of depression in employees undergoing health screening examinations. Retrieved September 15, 2020, from https://pubmed.ncbi.nlm.nih.gov/23522007/

Case 7 (NathNwo)

The Case of Physician do not Heal Thyself

            This is the case of a 60-year-old man with a chief complaint of “being unstable.”  Patient estimates that he has spent about two-thirds of the time over the past year being in a mixed dysphoric state and about one third as depressed, but waxing and waning every few days, or even every few hours. As a child, the client experienced generalized and separation anxiety which continued through adolescent age, and the mother experienced recurrent episodes of unipolar or bipolar. At age 23, the patient was diagnosed with major depression  (MDD) for the first time. The patient has been on and off of psychotropic medications. The client is a physician by profession.

Three Questions to ask the Client with Rationale

            Describe what you mean by “being unstable,” and “waxing and waning” every few days or even every few hours, and what you do to get better?

It is important to allow the client to explain as much as he can, exactly how he feels that makes him describe himself unstable, waxing, and waning. Symptoms of depression, hypomanic, or bipolar, including anxiety, rage, impulsivity, poor sleep, and sadness may suggest a comorbid manifestation of psychiatric illness. It is important to know what the client does as a coping skill, and what helps him in times of crises.

            I see you have a list of medications you have been taking, which medications have helped you the most, and which ones helped you the least or not all?

It is important to get the initial list of the client's medication right because it is critical to the client’s treatment. Medications the client perceives as not being helpful or has adverse reactions can be substituted/changed. Medication reconciliation will help prevent adverse drug interactions.

            What other forms of therapy have you tried other than these medications? Would you like to consult a psychotherapist also?

Psychiatric disorders including borderline personality disorders are treated with a combination of drug therapy and psychotherapy (Nelson and Schulz, 2012).

Client’s Associates/Secondary Sources of Information

            Interviewing close family members such as a spouse, children, or parents, if available, can give more insight or corroborate what the patient is saying. They can give information on observed mixed symptoms that represents a change from the client's usual behavior (American Psychiatric Association. , 2013). Also, the client’s colleagues at work and close friends whom the patient trusts can provide useful information that can help in the diagnosis and planning of the client’s therapy.

Physical Examination and Diagnostic Tests

A basic head-to-toe physical examination of the client is necessary to have a holistic view of the patient’s physical condition. Vital signs, gait, breathing pattern, allergies, pain, dietary preferences, if any,  appetite, previous/recent falls, trauma, history of seizure, and past surgeries, drugs and substance use/abuse, suicidal risks/attempts, and home environment, including living conditions (parents, siblings, children, spouse), sources of stressors (work, relationships) and any medical condition that may mimic psychiatric illness (Varcarolis & Halter, 2010). Information derived from questions on these variables will help to rule out physical causes of symptoms and plan the client's therapy.

In addition, the client's mental status examination (MSE) will focus on appearance, behavior, speech, mood, thought process, perception, cognition, suicidal/homicidal ideations. The MSE will provide objective data for the plan of care (Varcarolis & Halter, 2010).

Diagnostic Tests

            Laboratory tests will focus on thyroid problems. The thyroid-stimulating hormone (THS) level has to be determined. Hypothyroidism may have the clinical appearance of depression, while hyperthyroidism may appear to be a manic phase of bipolar disorder (Varcarolis & Halter, 2010). Liver function, complete blood count (CBC), Complete metabolic panel (CMP), urinalysis and urine drug test, drug levels, such as Lithium and Depakote (valproic acid) are necessary laboratory test results to be obtained.

Three Differential Diagnostics

            Symptoms of psychiatric disorders overlap making it difficult to pronounce a diagnosis without adequate evaluation of the client's medical history and psychotic trajectory. For example, the major depressive disorder may not be associated with a single type of underlying pathological process, but with a range of different causal pathways, each involving complex interactions of various biological, psychological, and social factors (Maung, 2016).  The three preliminary diagnoses for this patient are based on available information from the patient and review of medical records/history.

· Bipolar 11 disorder, recurrent episode, hypomanic, depressed, moderate

· Major Depressive disorder, recurrent episode, moderate, with mixed features

· Borderline Personality Disorder

            According to Vieta and Suppes (2008), bipolar 11 is underdiagnosed and often mistaken for depression or personality disorders. It is important to note the interlocking relationships in the symptoms of bipolar, depression, and personality disorders being manifested by this client. Underdiagnosis will amount to missing the necessary and adequate therapy for this client.

            The client appears depressed but at the same time exhibits symptoms characteristics of hypomanic and borderline personality disorder patients. The mood swings which the client described as unstable, waxing and waning episodes appear to be within the realm of bipolar disorder. The decreased need for sleep, the complaint of suicidal ideation, the sense of self-esteem that makes him feel he is intelligent and accomplished as a physician, and which makes him prescribe medication for himself, and thinks other physicians don’t know what they are doing or understand his situation make the above three diagnoses seem appropriate for this client.

Pharmacological Agents/Doses/ Indications/Contraindications

            Patients with bipolar 11 disorder accompanied by depression can be difficult to manage. The initial treatment recommendation includes a mood stabilizer alone or in combination with an antidepressant (Altshuler et al., 2017). Lithium is a mood stabilizer. It is used to treat manic depressive psychosis(Kee et at., 2012), and it is well absorbed and excreted 98% in urine, mostly unchanged. Not much is known about the pharmacodynamics of Lithium (Kee at al., 2012). Post, R. M. (2018) It appears that lithium has positive effects on depression and suicide prevention, cognition, and reducing the incidence of dementia, according to Post (2012).

Zoloft is a Selective Serotonin reuptake inhibitor (SSRI) approved by the United States Food and Drug Administration (FDA) for the treatment of depression (Rosenthal & Burchum, 2018; Ball, Stahl, 2013). A study by Altshuler, et al. (2017) that compared medication-induced mood switch risk (primary outcome), as well as treatment response and side effects (secondary outcomes) with three acute-phase treatments for bipolar II depression, using Lithium as monotherapy and Zoloft as monotherapy. and then lithium/Zoloft combination therapy found similar switch and treatment response rates in participants with bipolar II depression. I have chosen to place this client on Lithium and Zoloft as follows:

· Lithium 900mg, orally, twice daily. The recommended maximum daily dose is 2400mg

· Zoloft 50mg, orally, once daily. The recommended maximum daily dose is 200mg.

Special considerations for Lithium

Lithium can cause leukocyte elevation. The drug has a narrow therapeutic index.

Both hypothyroidism and hyperthyroidism may occur. Renal damage is a serious adverse effect.

Nephrogenic diabetes insipidus may occur; hyponatremia can create complications.

The client should be monitored for CBC, Lithium level thyroid function renal function serum electrolytes (Rosenthal & Burchum, 2018).

Special considerations for Zoloft

· Do not combine with Zoloft Monoamine oxidase Inhibitors (MAOIs) such as Phenelzine or with Tricyclic Antidepressants (TCAs) such as Imipramine

Lessons Learned from this Case Study

            The psychiatric disorder can manifest different symptoms that overlap, making the diagnosis a difficult task, especially if the client is a difficult one who does not comply with medication and therapeutic regimen. There many classes of psychotropic medications, but they work differently and one medication that proved effective for one patient may not be appropriate for another. Psychiatric Mental Health Nurse Practitioners (PMHNPs) should understand that it takes patience, knowledge, and skill to diagnose mental health problems.

 References

Altshuler, L. L., Sugar, C. A., McElroy, S. L., Calimlim, B., Gitlin, M., Keck, P. E., Jr, Aquino-   Elias, A., Martens, B. E., Fischer, E. G., English, T. L., Roach, J., & Suppes, T. (2017). Switch rates during acute treatment for bipolar ii depression with lithium, sertraline, or the two combined: a randomized double-blind comparison. The American Journal of   Psychiatry, 174(3), 266–276. https://doi.org/10.1176/appi.ajp.2016.15040558

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders   (5th ed.).

Kee, J. L., Hayes, E.R., & McCuistion, L. E. (2012). Pharmacology: A nursing process approach. Elsevier Saunders.

Maung,  H. H. (2016). Diagnosis and causal explanation in psychiatry. Studies in History and Philosophy of Biological and Biomedical Sciences, 60, 15–24. https://doi.org/10.1016/j.shpsc.2016.09.003

Nelson,  K., Schulz,  S. (2012). Treatment advances in borderline personality disorder. Psychiatric  Annals, 42(2), 59-64. https//doi: 10.3928/00485713-20120124-06

Post R. M. (2018). The New News about Lithium: An Underutilized treatment in the United States.  Neuropsychopharmacology: Official Publication of the American College of  Neuropsychopharmacology, 43(5), 1174–1179. https://doi.org/10.1038/npp.2017.238

Rosenthal, L. D., & Burchum, J. R. (2018). Lehne’s pharmacotherapeutics for advanced practice providers. Elsevier.

Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (4th ed). Cambridge University Press

Varcarolis, E. M., & Halter, M. J. (2010). Foundations of psychiatric mental health nursing: A clinical approach (6th ed.). Saunders Elsevier

Vieta, E., & Suppes, T. (2008). Bipolar II disorder: arguments for and against a distinct diagnostic entity. Bipolar Disorders, 10(1 Pt 2), 163–178.

 https://doi.org/10.1111/j.1399-5618.2007.00561.x