Assignment: Assessing and Treating Adult and Geriatric Clients with Mood Disorders
Advances in genetics and epigenetics have changed the traditional understanding of mood disorders, resulting in new evidence-based practices. In your role as a psychiatric mental health nurse practitioner, it is essential for you to continually educate yourself on new findings and best practices in the field. For this Assignment, you consider best practices for assessing and treating adult and geriatric clients presenting with mood disorders.
Learning Objectives
Students will:
• Assess client factors and history to develop personalized plans of antidepressant therapy for adult and geriatric clients
• Analyze factors that influence pharmacokinetic and pharmacodynamic processes in adult and geriatric clients requiring antidepressant therapy
• Evaluate efficacy of treatment plans
• Analyze ethical and legal implications related to prescribing antidepressant therapy to adult and geriatric clients
To prepare for this Assignment:
• Review this week’s Learning Resources. Consider how to assess and treat adult and geriatric clients requiring antidepressant therapy.
The Assignment
Examine Case Study: An Elderly Hispanic Man with Major Depressive Disorder. You will be asked to make three decisions concerning the medication to prescribe to this client. Be sure to consider factors that might impact the client’s pharmacokinetic and pharmacodynamic processes.
• At each decision point stop to complete the following:
o Decision #1
Which decision did you select?
Why did you select this decision? Support your response with evidence and references to the Learning Resources.
What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
Explain any difference between what you expected to achieve with Decision #1 and the results of the decision. Why were they different?
o Decision #2
Why did you select this decision? Support your response with evidence and references to the Learning Resources.
What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
Explain any difference between what you expected to achieve with Decision #2 and the results of the decision. Why were they different?
o Decision #3
Why did you select this decision? Support your response with evidence and references to the Learning Resources.
What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
Explain any difference between what you expected to achieve with Decision #3 and the results of the decision. Why were they different?
• Also include how ethical considerations might impact your treatment plan and communication with clients.
Note: Support your rationale with a minimum of three academic resources. While you may use the course text to support your rationale, it will not count toward the resource requirement.
Adult/Geriatric Depression
Hispanic Male With MDD
BACKGROUND INFORMATION
The client is a 32-year-old Hispanic American male who came to the United States when he was in high school with his father. His mother died back in Mexico when he was in school. He presents today to the PMHNPs office for an initial appointment for complaints of depression. The client was referred by his PCP after “routine” medical work-up to rule out an organic basis for his depression. He has no other health issues with the exception of some occasional back pain and “stiff” shoulders which he attributes to his current work as a laborer in a warehouse.
SUBJECTIVE
During today’s clinical interview, client reports that he always felt like an outsider as he was “teased” a lot for being “black” in high school. States that he had few friends, and basically kept to himself. He describes his home life as “good.” Stating “Dad did what he could for us, there were 8 of us.” He also reports a remarkably diminished interest in engaging in usual activities, states that he has gained 15 pounds in the last 2 months. He is also troubled with insomnia which began about 6 months ago, but have been progressively getting worse. He does report poor concentration which he reports is getting in “trouble” at work.
MENTAL STATUS EXAM
The client is alert, oriented to person, place, time, and event. He is casually dressed. Speech is clear, but soft. He does not readily make eye contact, but when he does, it is only for a few moments. He is endorsing feelings of depression. Affect is somewhat constricted but improves as the clinical interview progresses. He denies visual or auditory hallucinations, no overt delusional or paranoid thought processes readily apparent. Judgment and insight appear grossly intact. He is currently denying suicidal or homicidal ideation. The PMHNP administers the “Montgomery- Asberg Depression Rating Scale (MADRS)” and obtained a score of 51 (indicating severe depression).
RESOURCES
§ Montgomery, S. A., & Asberg, M. (1979). A new depression scale designed to be sensitive to change. British Journal of Psychiatry, 134, 382-389.
Decision Point One
Select what the PMHNP should do:
Begin Zoloft 25 mg orally daily Click to see options it will take you to decision point two and three
Begin Effexor XR 37.5 mg orally daily Click to see options it will take you to decision point two and three
Begin Phenelzine 15 mg orally TID Click to see options it will take you to decision point two and three.
All references require creditable sources, nothing less than 5 years. References require doi or http. Please add conclusion. Please use the same format on order # 312 Each decision 1, 2, and 3 requires:
Which decision did you select?
Why did you select this decision? Support your response with evidence and references to the Learning Resources.
What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
Explain any difference between what you expected to achieve with Decision #1 and the results of the decision. Why were they different?
Example of paper, please do not use as it will be plagiarism
Major depressive disorder (MDD) is a common but serious disorder. It causes sever
symptoms that affect how a person feels, thinks and handles daily activities, such as sleeping,
eating or working. To be diagnosed with MDD, the symptoms must be present for at least two
weeks (National Institute of Mental Health, n.d.) (NIMH). MDD is a common but serious mood
disorder that requires treatment (National Institute of Aging, n.d.) (NIA). According to NIA,
MDD is a common problem among older adults, but not a normal part of aging (NIA, n.d.).
Antidepressant medications treat depression and help improve the way the brain uses certain
chemicals that control mood or stress (NIMH, n.d.). There may be a need to try different
medications before finding one that improves the symptoms and has manageable side effects
(NIMH, n.d.). This paper is going to examine a case study of a 32 y/o Hispanic male with sever
depression and the treatments available.
Decision One: Begin Zoloft 25mg PO daily. Begin Effexor XR 37.5 PO daily. Begin
Phenelzine 15 mg PO TID.
My decision: As the PMHNP treating this client, I will start the client with Zoloft 25mg PO
daily.
Why I selected this drug: Studies have shown that sertraline (Zoloft), a second-generation
SSRI, to be efficacious the other medications in the study and better tolerated than the other
antidepressants (Patrick, Combs and Gavagan, 2009). In the study fifty-nine percent of
participants responded to sertraline, vs a 52% response rate for fluoxetine (Prozac) (number
needed to treat [NNT=14). This second-generation SSRI, antidepressant is frequently
recommended as a first-line antidepressant treatment options due to relative tolerability of side
effects compared to tricyclics antidepressants (TCA’s) and Monoamine oxidase inhibitors
(MAOIs) and the overall safety of the drug (Patrick, et al., 2009). The drug generally, lacks the
common adverse reactions (anticholinergic, sedative effects) of the tricyclics
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Adult and geriatric depression treatment
antidepressants and cause fewer problems when taken in overdose (O’Connor, Whitlock and
Gaynes, 2019). The goal of treatment for the client, is to reduce depressive symptoms and
eventually prevent recurrence of the depression (Teter, 2017).
When the client returns to the clinic in four weeks, reports a decrease in symptoms, however,
patient reports concern over the new onset of erectile dysfunction. This side effect is common of
antidepressants. Studies have shown that 35% to 50% of people experience some type of sexual
dysfunction that can have a significant impact on the person’s quality of life (Higgins, Nash,
Lynch, 2010).
I did not choose Effexor XR, another SSRI because of the potential to misuse or abuse the
drug. Research has shown that because it has become one the most popular antidepressants on
the market, it is easy to obtain (Schifano and Chiappni, 2018). Because it is easy to obtain it
lends itself to being easily abused (Schifano, et al., 2018). Although Effexor is known to be
non-addictive, a person can develop a psychological (Schifano, et al., 2018). This addiction can
result when a person has co-occuring anxiety or other mood disorders (Schifano, et al., 2018).
Effexor also has serious side effects when taking other prescriptions or over-the-counter
medications, for example taking it with aspirin may cause bleeding and bruising (Magalhaes,
Alves, LLerena, Falcao, 2015). In addition, Effexor may raise blood pressure, cause muscle
cramps or weakness, shaking or tremors (Magalhaes, et al.,2015).
I did not choose Phenelzine (Nardil), because this drug may interact with some pain
medications, medications for migraines, amphetamines and antibiotics (NAMI, n.d.). Also, there
an increased risk of serotonin syndrome when the drug is used with other medications that
increase serotonin (NAMI n.d.). Phenelzine is a monoamine oxidase inhibitor (MAOI), so the
clients taking on Nardil therapy will have to avoid foods rich in thymine, food that has been
fermented, different cheeses and food with excessive amounts of caffeine and chocolate
(Fiedorowicaz and Swartz, 2004).
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Adult and geriatric depression therapy
Decision two: Client returns to the client in four weeks and ahs informed the PMHNP that he
stopped taking the drug because his inability to perform sexually and his self-esteem has
worsened.
My decision: At this point I have decided to change to Wellbutrin IR (immediate release) 150mg
in the morning. Switching from antidepressant to another is frequently indicated due to an
inadequate treatment response or in the case of this client unacceptable adverse effects (Keks,
Hope, Keogh, 2016). When switching antidepressants, the most conservative strategy, with the
lowest risk of drug interactions, would be to gradually taper the does of the first antidepressant
to minimize withdrawal symptoms, then start a washout period equivalent to five half-lives of
the drug, which equates to about five days for most SSRI’s (Keks, et al., 2016). Unacceptable
adverse effects from antidepressants, such as sexual dysfunction and weight gain may necessitate
a change of therapy.
I did not see the need to which to Paxil 20mg at this point. Because of the clients’ concern for
sexual dysfunction, studies have shown Paxil to have the highest frequency for sexual side
effects at 70.7% compared to Wellbutrin, Zoloft and Prozac (Higgins, et al., 2010).
Outcome: Client returns in four weeks his depressive symptoms have decreased and his erectile
dysfunction has abated. However, the client reports feeling “jittery” and sometimes nervous. It’s
important to explain to the client that these side effects with this drug are generally mild and
often resolve over the first 1-2 weeks of treatment (Stahl, 2014b).
Decision three: Add Ativan 0.5mg orally TID/PRN for anxiety.
My decision: Is to not add the Ativan 0.5 orally TID/PRN for anxiety. Lorazepam/Ativan, a
benzodiazepine is known as a minor tranquilizer, commonly prescribed to relieve stress and
anxiety and to help people sleep (Alcohol and Drug Foundation, ADF, 2019). This drug is to be
used for a short period of time or PRN (as needed). However, this drug has a high risk for
addiction when misused or abused (ADF, 2019).
Outcome: The PMHNP treating with client, the Wellbutrin IR will be changed to Wellbutrin ER
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Adult and geriatric depression therapy
or XL (extended release) is usually taken once daily in the morning and the dose range from
150mg to 450mg. Wellbutrin IR is an immediate release is usually taken 2 or 3 times per day 4-6
hours between doses. According to Stahl, the Wellbutrin XL is more appropriate for major
depressive disorder (Stahl, 2014b).
Research provides firm evidence that antidepressant medication is associated with sexual
dysfunction in both men and women (Higgins, et al., 2010). Researchers have investigated
through a self-reported anonymous questionnaire, the sexual side effects of Wellbutrin and the
SSRI’s (Prozac, Paxil and Zoloft) among 107 out-patients. Overall, 73% of the SSRI-treated
clients reported a decrease in sexual dysfunction with Wellbutrin (Higgins, et al., 2010).
Ethical consideration that may impact the treatment plan and
communication with clients
Before a client is offered an antidepressant medication, a thorough diagnostic evaluation and
careful review of the client’s history (including past symptoms and response to treatment) are
essential (Roberts and Jain, 2011). It is important to learn what the client’s goals are, their
greatest concerns, and motivations are is essential to developing an appropriate therapeutic
strategy that may include the use of psychopharmacological agents to address specific target
symptoms (Roberts, et al., 2011). The goal is to prescribe medications only when they are clearly
indicated and when there is a strong evidence base (Roberts et al., 2011).
To conclude, antidepressants are the mainstay of treatment in reducing depressive symptoms
and has been demonstrated in both short and long-term use (NAMI n. d.). The decision to which
antidepressant should be used is based on factors that include history of prior response, adverse
effects, concurrent medications and cost (NAMI n.d.). Its important the PMHNP has a supportive
relationship with the client to help improve treatment compliance. Its important to educate the
clients on the disorder and the medications to help the client remain complaint (Roberts, et al.,
n.d.).
– Free Essay Sample
Adult Clients with Mood Disorders
Student’s Name
Institutional Affiliation
Course
Professor’s Name
Date
Adult Clients with Mood Disorders
Introduction
Major Depressive Disorder (MDD) is a common mental disorder that triggers a loss of interest in daily activities causing significant impairment. The symptoms of MDD affect the mood, the thought process, and response to daily activities. For instance, mood disorder affects daily activities, including sleep, appetite, and daily chores. According to the National Institute of Mental Health, a person is diagnosed with MDD if the symptoms are persistent for two weeks (Oliveira et al., 2018). The institute also states that the disorder can cause significant impairment in life, which requires immediate treatment. Although the condition is common among adults or the elderly, it is not part of aging. PMHNP prescribe antidepressant medications to alter the mood, reduce stress, and improve brain functioning. Clinicians also administer various medications before settling on an effective drug. The following paper examines a case study of a 32-year old Hispanic male with severe depression.
Decision #1
Prescribe Zoloft 25mg orally daily, begin Effexor XR 37.5 PO daily, and begin Phenelzine 15mg PO TID.
My Decision: The first decision is to prescribe Zoloft 25mg orally daily.
Why I Selected the Drug: The reasons for selecting Zoloft is due to the available evidence that the drug is effective in treating mood disorders. The second-generation SSRI has minimal side effects among adults. Clinicians recommend the drug as a first-line medication in the treatment of depression and mood disorders (Stahl, 2013). It has relatively severe side effects compared to other antidepressants such as tricyclics antidepressants and Monoamine oxidase inhibitors. The drug is highly recommended since it lacks sedative effects and has high safety levels compared to tricyclics. Zoloft 25mg is one of the recommended doses while beginning treatment. The reason is that a high dose can cause significant side effects (Stahl, 2013). However, the goal of the treatment is to reduce depressive symptoms and prevent reoccurrence of the mood disorder.
The decision to select Zoloft was after rejecting other potential drugs such as Effexor XR. I did not select the drug due to the high potential to abuse the drug. Effexor XR is one of the standard and most available drugs in the market (Strawn et al., 2017). Due to ease of access, the drug is easily abused. Although it is non-addictive, it can cause a reoccurrence of anxiety or mood disorders (Strawn et al., 2017). Additionally, Effexor XR has poor interaction with other drugs such as aspirin. It can cause bruising and bleeding, high blood pressure, and muscle tremors.
I did not prefer Phenelzine since it interferes with other pain killer drugs and antibiotics. It can also cause serotonin syndrome when the drug is used alongside other mental disorder drugs (Strawn et al., 2017). Phenelzine also requires patients to take precautions such as avoid fermented food or foods rich in thymine since it is a monoamine oxidase inhibitor. Patients should also avoid cheese, chocolate, or caffeine.
Expectations: The expectations while prescribing the medication is that the depressive symptoms would subside. For example, I expected that the patient would resume daily duties, including normal eating habits, sleep, and interest in diverse activities.
Outcome: When the patient returns to the clinic, he reports a decrease in the symptoms, but indicates that he recently experienced erectile dysfunction. Sexual dysfunction is a common side effect among adult patients taking antidepressants (Stahl, 2013). The dysfunction can significantly affect the quality of life of an individual.
The patient should return to the clinic after four weeks for further assessment to determine whether to continue with the drug or not.
The outcome shows there is a variance between expectations and results. For example, it was not expected that the patient could have erectile dysfunction. The differences in similarities are due to the side effects of the drug.
Decision #2
The patient returns the clinic after four weeks. He reports that although the depressive symptoms had abated, his erectile dysfunction prompted him to stop taking the medication. His self-esteem has also deteriorated over the four weeks.
My Decision: Due to the side effects, one of the best alternatives is Wellbutrin IR 150mg orally in the morning. The change is necessary since the previous antidepressants triggered adverse effects on the health of the patient. The adverse effects, such as erectile dysfunction, are also not acceptable, thus necessitating the need to change the drug (Jaworska & Rybakowski, 2019). One of the best strategies while switching from one drug to another is to reduce the withdrawal effects. For instance, a washout period of five days is sufficient.
The decision to switch the drug did not prefer medications such as Paxil 20mg. The reason is that Paxil 20mg also triggers sexual dysfunction.
Outcome: The patient returns to the clinic after four weeks of taking the new medication. The patient reports a decrease in erectile dysfunction. The patient, however, reports side effects such as feeling jittery or nervousness. It is essential to explain to the patient that the side effects of Wellbutrin IR 150mg resolve within 1-2 weeks (Castrén & Kojima, 2017).
The expectation was that the change of the drug would reduce erectile dysfunction. The outcome indicated that the selection of the drug was accurate. However, the results were different since the patient experienced anxiety. Anxiety is one of the side effects that occur during the treatment, and it will require another medication to relieve the symptoms.
Decision #3
The third decision was to add Ativan 0.5mg orally TID/PRN. The purpose of prescribing and extra medication is to reduce the level of anxiety. A reduction in anxiety will consequently improve the quality of sleep (Castrén & Kojima, 2017).
My Decision: My decision after consultation with the patient is to continue with the prescription of Wellbutrin IR. The reason is that the patient reported that the depressive symptoms had improved significantly. For example, the patient describes progress, including enhanced quality of sleep, interest in daily activities, and improved appetite. The patient also reports that erectile dysfunction which occurred upon the prescription of Zoloft 25mg has not abated (Castrén & Kojima, 2017). However, the patient indicates their only concern is high anxiety levels.
Expectations: The expectations are that in the next four weeks, the patient will improve in various ways. One of the ways is a reduction in anxiety levels leading to quality sleeping time. The reason is that Lorazepam/Ativan is a minor tranquilizer used to relieve stress and anxiety (Khouzam, 2016). The medication is approved for use among adults to improve their quality of sleep (Khouzam, 2016). However. Due to the high risk of addiction or abuse, Lorazepam/Ativan should not be used for a long period. The patient should only take the medication when necessary to avoid addiction or dependence.
If the patient does not show considerable improvement, there is a need to change the drugs or increase the dose depending on the outcome (Khouzam, 2016). However, the decision will be made based on the assessment of the patient after four weeks.
Outcome: The outcome shows that depressive symptoms reduced significantly. The patient reported that the anxiety levels had abated and that he was now enjoying quality sleep. According to the patient’s report, it is evident that the various drugs are effective. Evidence-based practice shows that Wellbutrin is appropriate for major depressive disorders. Stahl insists that it is important for a PMHNP to consider the outcomes to determine whether to continue with the prescription or change the drug (Khouzam, 2016). The reason is that various dynamics, such as age or gender, may affect the impact of the drug on a patient. For example, while Zoloft causes suicidal thoughts to young people, to the patient in the case study, it triggered sexual dysfunction.
The outcome and expectations had major similarities. The expectation was that the depressive symptoms would decrease considerably, which is what happened. For example, the patient started enjoying quality sleep.
Ethical Considerations
Ethical considerations are necessary to ensure clinicians provide quality care to patients, reduce the risk of poor patient outcomes, and avoid lawsuits. In the current case study, before prescribing antidepressants, a comprehensive diagnostic test and evaluation of a patient’s history are required (Stahl, 2013). Clinicians are required to prescribe medication only when it is necessary and when there is strong evidence that the depressive symptoms require medication. It is also essential to start the Zoloft dose with 25mg compared to starting with 50mg (Oliveira et al., 2018). The purpose of starting with a small dose is to reduce the risk of suicidal thoughts or other side effects such as erectile dysfunction.
Another ethical consideration is to determine the patient’s motivations, concerns, and goals. The patient’s preferences are essential in developing a personalized and appropriate therapeutic strategy. For example, personal preferences may lead to the use of psychopharmacological agents. The patient in the case study is an adult, so they should enjoy confidential and privacy rights (Oliveira et al., 2018). Confidentiality is necessary to avoid sharing information about the illness of the patient. Clinicians are also obliged to warn patients about the possible side effects. The warning will ensure patients are ready for the medication (Strawn et al., 2017). Clinicians are also required to prescribe medication approved by the FDA or drugs with reliable evidence of treating mood disorders among adult patients.
Conclusion
The cases of patients with mood disorders require critical attention to prevent adverse effects. One of the adverse effects of MDD is the loss of interest in daily activities. Patients with MDD thus require immediate treatment with reliable drugs. The various reliable drugs are administered in the three decisions made in the case study of a 32-year old Hispanic male with severe depression. All three decisions focused on administering antidepressants, which are the mainstay of treatment. Antidepressants are reliable in the treatment of mood disorders among patients of different ages. PMHNP decides the medication to use on patients based on their age, medical history, and side effects. PMHNP should develop a supportive relationship for all depressed patients to improve compliance with the treatment plan. Clinicians should also educate the client on the need to comply with the treatment until full recovery. Compliance helps in assessing the changes in a patient and determining the best medication to improve the outcomes.
References
Castrén, E., & Kojima, M. (2017). Brain-derived neurotrophic factor in mood disorders and antidepressant treatments. Neurobiology of Disease, 97, 119-126.
Jaworska, P., & Rybakowski, J. K. (2019). Childhood trauma in mood disorders: neurobiological mechanisms and implications for treatment. Pharmacological Reports, 71(1), 112-120.
Khouzam, H. R. (2016). Psychopharmacology of chronic pain: a focus on antidepressants and atypical antipsychotics. Postgraduate Medicine, 128(3), 323-330.
Oliveira, A. S., Martinez-de-Oliveira, J., Donders, G. G., Palmeira-de-Oliveira, R., & Palmeira-de-Oliveira, A. (2018). Anti-Candida activity of antidepressants sertraline and fluoxetine: effect upon pre-formed biofilms. Medical Microbiology and Immunology, 207(3-4), 195-200.
Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (4th ed.). New York, NY: Cambridge University Press.
Strawn, J. R., Dobson, E. T., & Giles, L. L. (2017). Primary pediatric care psychopharmacology: focus on medications for ADHD, depression, and anxiety. Current Problems in Pediatric and Adolescent Health Care, 47(1), 3-14.
