Assignment: Psycopharmacologic Approaches to Treatment

Assignment: Psycopharmacologic Approaches to Treatment

Assignment: Psycopharmacologic Approaches to Treatment

Case 1: The Man Whose Anti-Depressants Stopped Working

            In the above case, the client is a 63-year old who shows signs of depression and anxiety. In order to successfully diagnose the condition, a psychiatrist nurse would need to ask certain questions depending on the tool they will intend to adopt. In the present case, and given the history of the patient, one would ask the following questions:

1. How can you describe your sleep pattern for the last two weeks?
2. Have you entertained suicidal ideations of late?
3. Have you lost interest in anything that was initially enjoyable to you?

Asking these questions is important because of several reasons. The first reason is that they help a nurse to determine whether the common symptoms of depression are present in a patient. Moreover, these questions, specifically the third one, would help the nurse determine the level of impact that the symptoms have on the patient’s capacity to function. Lastly, they help a psychiatric mental health nurse practitioner determine how the symptoms affect a patient’s ability to maintain relationships with other people.

Social Screening

            Screening a patient for depression may also entail asking for opinions from third parties. Given that the patient is married, the very first person to ask about the presence of certain depressive symptoms will be his wife. Studies have suggested that the involvement of family members in the holistic management of depression has improved the process (Zhang & Wudong, 2013). Hence, the nurse will ask the wife to reveal the functioning of the family- Do you think that your family has been functioning normally in the last 3 months?  Also, studies have produced considerable evidence in support of the notion that impaired family functioning may lead to depression. Thus, by asking this question, the nurse practitioner will look to establish whether family functioning could have contributed to the patient’s condition.

In addition to the wife, the nurse will also question the patient’s children. These children can play an integral role in diagnostic process. The reason for using their subjective assessment to determine the existence of depression is founded on the fact that they may have noticed changes in their father’s behavior. Thus, in order to discover the existence of these changes, the nurse practitioner needs to ask them, “Is your father able to concentrate when holding conversations?” Asking this question enables a nurse to gauge the concentration levels of the patient with a view of determining whether the patient has difficulties in sustaining thoughts during conversations with his children.

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Physical Exams and Diagnostic Tests

            The diagnosis of depression takes many forms. The multidimensional approach to depression intends to eliminate another medical cause for the condition. Research works have indicated that physical examination plays a fundamental role in this diagnostic process (Ghaemi, 2013). For the present patient, and given his age, a nurse will order for physical examination on his neurological and endocrine systems. Specifically, the nurse will order for hypothyroidism and hyperthyroidism tests. Moreover, the patient will undergo central nervous system tumors tests and scans for head traumas.

In addition, further confirmatory tests may become necessary to differentially diagnose the condition. A diagnosis of depression may not be complete without a psychiatric evaluation of the patient. During this period, the patient will reveal their behavior patterns, feelings, thoughts, and symptoms. To successfully conduct the process, the mental health practitioner may ask the patient to fill in a questionnaire if they do not have the confidence to answer the questions in a face-to-face setting. Also, the mental health professional may enlist the services of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria (Ghaemi, 2013). The DMS-5 allows the practitioner to confirm if the patient meets the criteria for depression diagnosis. These physical examinations and diagnostic tests are important as they will help the nurse practitioner to rule out other causes of the condition. In addition, they will allow the nurse to eliminate or even determine the presence of co-morbidity with other mental health conditions.

Differential Diagnosis of the Patient

            The differential diagnosis of the patient’s condition will entail a broad range of conditions given his symptoms. However, the following three conditions are more likely to present with the condition: anxiety disorder, obstructive sleep apnea, and adjustment disorder with depressive mood due to marital problems. Out of the above conditions, anxiety disorder has the highest probability of presenting. During the preceding depressive episodes, anxiety was a constant as a symptom.

Assignment: Psycopharmacologic Approaches to Treatment

Pharmacologic Agents for the Patient

            The usage of certain pharmacological agents has proven essential in the management of major depressive disorders. In the present case, the psychopharmacological therapy that the nurse can formulate for the patient includes a selective serotonin reuptake inhibitor (sertraline) or a serotonin-norepinephrine reuptake inhibitor (venlafaxine). If the therapy consists of Sertraline, then the patient should be given an initial dose of 50 mg orally once per day (Stahl, 2014). This will be followed by a maintenance dose of between 50-200 mg depending on the maximum effective and safe dose for the patient. However, if the pharmacotherapy comprises venlafaxine, the patient will be started on Effexor XR at 75 mg once daily (Stahl, 2014). Upon monitoring, the dosage could be increased by 75 mg up to 225 mg maximum, contingent upon the patient’s reaction to the same. The mechanisms of action of the two and how they quickly achieve their peak plasma concentration levels make them prime candidates for the therapy.

However, whereas the patient responded well to Sertraline, the mechanism of actions of the two drugs above would make Effexor XR to be more effective. Whereas the two drugs target the inhibition of the re-absorption of serotonin, Effexor XR additionally targets the reabsorption of norepinephrine (Stahl, 2013). Both norepinephrine and serotonin play fundamental roles in the transmission of feel-good messages between cells in the brain. Thus, inhibiting the reuptake of norepinephrine and serotonin makes Effexor XR preferable based on mechanism of action alone.

Effect of Ethnicity on Effector XR

            Studies have shown that the dosage of Effector XR may be manipulated according to the ethnicity of a patient. The enzyme CYP2D6 catalyzes the conversion of venlafaxine to its active metabolite O-desmethylvenlafaxine (ODV). The enzyme above has a functional variant known as CYP2D6*1 and nonfunctional variants called CYP2D6*4 and CYP2D6*4 that are prevalent in Caucasian ethnicities (Dean, 2015). Hence, given that the patient is of this ethnicity, he is a poor metabolizer of the drug. According to a study by the Pharmacogenetics Working Group of the Royal Dutch Association for the Advancement of Pharmacy (KNMP), the necessary data for the calculation of dose adjustment for poor metabolizers was insufficient. However, the FDA asserted that there are no varied dosing regimens for either poor or extensive metabolizers (Dean, 2015), which implies that the dosage for the present patient could be adjusted to 150% of the normal dose.

Lessons Learned

            The analysis of this case has revealed fundamental lessons to the nurse. The case has shown that major depressive disorders are recurrent in nature. Moreover, the periods between subsequent episodes shorten as the recurrences occur. Thus, one needs to be keen as they manage patients with the condition. Secondly, the case study has revealed that if the treatment regimen is not properly done, then a patient runs the risk of becoming resistant to anti-depressants. This implies that at a certain period, it will become impossible to treat such a patient. Therefore, the nurse will make sure that they prescribe maintenance doses for patients at the third recurrence even with remission. This will ensure that the probability of a relapse reduces significantly for the nurse’s patients.

Assignment: Psycopharmacologic Approaches to Treatment

Case #7 The Case Of Physician Do Not Heal Thyself

Case #7 The Case of Physician Do Not Heal Thyself presents a case of a 60-year old patient who shows symptoms of complex mood disorder. Moreover, the patient is difficult to handle and uses his medical background to treat himself. Thus, in order to successfully diagnose and manage the condition, the section will examine certain important aspects in the management of such a unique case.

Three Questions

• Have you ever had a period in your life whereby you felt that you were different and consequently felt that you were irritable and shouted at other individuals or started fights and arguments?
• Has a health professional ever said to you that you are suffering from a complex mood disorder or bipolar?
• Has any of your relations ever suffered from any form of complex mood disorder e.g. bipolar?

The rationale for asking these questions involves getting a subjective perspective from the patient. As a starting point, the questions are important as they allow the present nurse practitioner to familiarize herself with the background of the patient before she can conduct a full analysis. In addition, question three may help the nurse identify the genetic makeup of the patient considering that he was not responsive to most of the antipsychotics that he had been given.

People in the Patient’s Life

According to the patient’s social history, he does not have a lot of people that could offer information regarding his status. The closest people that are mentioned are his three divorced wives. However, these are not in his life anymore. Thus, the only people that can be interviewed are his co-workers and friends. His colleagues will thus be asked: “What is his productivity and what does he say about it?” On the other hand, his friends will be requested to answer the question: “How can you describe the interpersonal relationship that he has with you?” These questions are pertinent since they seek to discover if the patient has demonstrated some of the symptoms of complex mood disorder to persons in his social life (Culpepper, 2014). Indeed, the two questions will help reveal the mood of the patient around the people that are in his life.

Physical Examinations and Diagnostic Tests

            A physical examination cannot confirm or discard the presence of complex mood disorder. However, such an examination may succeed in establishing the presence of a medical condition that may cause the existence of the condition’s symptoms. In the present case, the nurse may do a physical examination to establish the presence of either hyperthyroidism or hypothyroidism as they also cause the depressive symptoms that the patient has presented.

In addition to the physicals above, other diagnostic tests may be necessary. Whereas no laboratory test may be required to confirm the presence of the condition, they are important for excluding alternative etiologies for the symptoms shown by the patient (Mann. McGrath, & Roose, 2013). Important in this respect is a urine toxicology and a comprehensive blood count. The former will be utilized to confirm the usage of drugs by the patient whilst the latter test will exclude anemia or infection as the causes of the depressive episodes (Culpepper, 2014).  Moreover, an MRI will be important in excluding an organic etiology for the mood disorder.

Differential Diagnosis

The patient has shown numerous symptoms that make the diagnosis of the disease difficult. The symptoms of the patient indicate the presence of a complex mood disorder. A majority of the said symptoms are shared by other mood disorders. Personality disorders usually mimic or occur concomitantly with complex mood disorders (Culpepper, 2014). The client has demonstrated depressive symptoms that a patient with complex mood disorder is susceptible to having. Also, given the information from the family history in the case study, the patient should be examined for major depressive symptoms. However, the decision to go with complex mood disorder is informed by the presence of irritability and mania episodes that do not reach the thresholds of either hyper- or hypo-mania according to the DSM IV or even ICD 10 tools.

Assignment: Psycopharmacologic Approaches to Treatment

Pharmacologic Agents and their Dosing for the Patient

The patient has not displayed full manic episodes and has similarly not displayed hypomanic episodes. Given his treatment history, it becomes clear that most of the drugs prescribed to him do not work. However, that could be due to the patient’s intransigence as opposed to any scientific basis, with exception of cases wherein specific scientific reasons for discontinuation of an SSRI have been mentioned. Thus, according to the present nurse, the patient should be given either a sertraline (Zoloft) an SSRI or a methylphenidate (Ritalin), a monoamine oxidase inhibitor (Stahl, 2013), which seems to be working for the patient.  The Zoloft will be given in doses starting dose from 50 mg per day. Given the sensitivity of the patient to other SSRIs, this dosage will be increased to a therapeutic range of between 50-200 mg per day. On the other hand, Stahl (2014) states that Ritalin may be given in doses of 20 mg daily. The two agents are chosen for their faster absorption rates and equally fast metabolism once in the system.

Sertraline, which is an SSRI, works by inhibiting the selective reabsorption of serotonin in the brain. Consequently, the chemical elements in the brain responsible for the condition under consideration are balanced as a result. Nevertheless, methylphenidate acts by stimulating the central nervous system.  It does this by inhibiting the reuptake of catecholamines, essentially blocking the reuptake of dopamine and norepinephrine (Stahl, 2013). As a consequence, the concentration of norepinephrine at the synaptic left increases. Thus, from this point of view, the methylphenidate psychopharmacology will be more effective.

Contraindications Based on Ethnicity

Methylphenidate acts by modulating the reabsorption of catecholamines in the brain. As such, the gene responsible for creating dopamine transporter (DART) plays a crucial role in the dosing response of the drug. A study by Froehlich et al. (2011) observed that individuals without copies of the 10 repeat (10R) alleles produced greater remission of the symptoms of the disease due to methylphenidate dose compared to those with the 10R alleles. Given that the 10R alleles are mostly present in Caucasians, Hispanics and African-Americans will experience contraindications from the drug due to its plasms level concentrations. As such, patients from those ethnicities may experience marked anxiety, agitation and tension when given methylphenidate in high doses.

Assignment: Psycopharmacologic Approaches to Treatment

Lessons Learned From This Case Study

The case study of “Physician do not heal thyself”’ has produced important lessons to the nurse. One is that healthcare professionals are in a spot of bother when their prospective client is a colleague in the industry. Such people often display a certain level of arrogance and intransigence when it comes to the prescription of drugs. As such, they need to be incorporated in the decision to formulate an intervention. Also, the case study has revealed that there are certain cases wherein SSRIs do not work but MAOs do. In this case, it becomes important to consider prescribing the MAOs but under very strict observations. Lastly, the case study has accentuated the process that one can use to differentially diagnose mood disorders coupled with personality disorders. The illumination becomes important for future practice as one will use the experience to handle such cases.

Moreover, the present nurse has gained fantastic insights into how to manage the so called difficult clients. According to the case study, the client did not respond to all the medications from his physicians, which compelled him to use his own prescription. Thus, the present nurse will consider listening to self-prescribed patients in future with a view of adopting their ideas in the management of various mental health issues.

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Assignment: Psycopharmacologic Approaches to Treatment

References

Culpepper, L. (2014). The Diagnosis and Treatment of Bipolar Disorder: Decision-Making in Primary Care. The Primary Care Companion for CNS Disorders, 16(3), PCC.13r01609. http://doi.org/10.4088/PCC.13r01609

Dean, L. (2015, July 27). Venlafaxine Therapy and CYP2D6 Genotype – Medical Genetics Summaries – NCBI Bookshelf. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK305561/

Froehlich, T. E., Epstein, J. N., Nick, T. G., Melguizo Castro, M. S., Stein, M. A., Brinkman, W. B., … Kahn, R. S. (2011). Pharmacogenetic Predictors of Methylphenidate Dose-Response in Attention-Deficit/Hyperactivity Disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 50(11), 1129–1139.e2. http://doi.org/10.1016/j.jaac.2011.08.002

Ghaemi, S. N. (2013). On depression: Drugs, diagnosis, and despair in the modern world. Baltimore: Johns Hopkins University Press.

Mann, J. J., McGrath, P. J., & Roose, S. P. (2013). Clinical handbook for the management of mood disorders. Cambridge, NY: Cambridge University Press.

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

Stahl, S. M. (2014). The prescriber’s guide (5th ed.). New York, NY: Cambridge University Press.

Wang, J., & Xudong, Z. (2013). Perceived family functioning in depressed Chinese couples: A cross-sectional study. Nursing and Health Sciences, 15, 9-14.