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Week 3 Assignment: Assessing and Treating Adult and Geriatric Clients With Mood Disorders

Week 3 Assignment: Assessing and Treating Adult and Geriatric Clients With Mood Disorders

Week 3 Assignment: Assessing and Treating Adult and Geriatric Clients With Mood Disorders, NURS6630

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.

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Required Readings – Week 3 Assignment: Assessing and Treating Adult and Geriatric Clients With Mood Disorders

Note: All Stahl resources can be accessed through the Walden Library using this link. This link will take you to a log-in page for the Walden Library. Once you log into the library, the Stahl website will appear.

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

Note: To access the following chapters, click on the Essential Psychopharmacology, 4th ed tab on the Stahl Online website and select the appropriate chapter. Be sure to read all sections on the left navigation bar for each chapter.

Chapter 6, “Mood Disorders”

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

Note: To access the following medications, click on the The Prescriber’s Guide, 5th ed tab on the Stahl Online website and select the appropriate medication.

Review the following medications:

  • amitriptyline
  • bupropion
  • citalopram
  • clomipramine
  • desipramine
  • desvenlafaxine
  • doxepin
  • duloxetine
  • escitalopram
  • fluoxetine
  • fluvoxamine
  • imipramine
  • ketamine
  • mirtazapine
  • nortriptyline
  • paroxetine
  • selegiline
  • sertraline
  • trazodone
  • venlafaxine
  • vilazodone
  • vortioxetine

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

Note: Retrieved from Walden Library databases.

Montgomery, S. A., & Asberg, M. (1979). A new depression scale designed to be sensitive to change. British Journal of Psychiatry, 134, 382-389. Retrieved from https://www.researchgate.net/profile/Marie_Asberg/publication/22697065_A_New_Depression_Scale_Designed_to_be_Sensitive_to_Change/links/09e41513f85c708fee000000.pdf

Required Media

Laureate Education. (2016g). Case study: An elderly Hispanic man with major depressive disorder [Interactive media file]. Baltimore, MD: Author.

Note: This case study will serve as the foundation for this week’s Assignment.

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:

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?

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?

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.

Case Study

The client is a 32-year-old Hispanic American male who emigrated from Mexico to the United States with his father during his high school years. The mom was reported deceased in Mexico. The patient presented with a chief the complaint of depression and mentioned extreme decrease interest in activities he previously enjoyed. He reported 15 pounds’ weight gain in two months, insomnia for the past six months, poor concentration and getting in “trouble” at work.

Client revealed that he felt like an “outsider,” “teased a lot for being black” in high school. He said that he kept to himself but has few friends. He reported that there were eight children and home life was “good,” and his dad provided as much as he can. Mental health exam (MSE) shows that the client was alert and oriented x3. He was a good historian. The client speech is soft and clear. He rarely makes eyes contact. He reported depression and has a noticeable restrained affect, with an occasional smile. He denies visual or auditory hallucination, and his thought process is intact. The client’s awareness is age appropriate and associated with proper judgment and understanding. He denies current suicidal ideation. The diagnostic test of Montgomery- Asberg Depression Rating Scale (MADRS) was administered to the client. The score was 51, which indicates severe depression.

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
  • Begin Effexor XR 37.5 mg orally daily
  • Begin Phenelzine 15 mg orally TID

Decision Point One answer that I selected

Begin Effexor XR 37.5 mg orally daily

AFTER TAKEN EFFEXOR XR 37.5MG BELOW IS THE RESULTS OF DECISION POINT ONE

  • Client returns to clinic in four weeks
  • Client reports that there is no change in depressive symptoms at all

Decision Point Two

Select what the PMHNP should do next:

Increase dose to 75 mg of Effexor XR orally daily

Change to Cymbalta 30 mg orally daily Augment with an atypical antipsychotic

Decision Point Two

Increase dose to 75 mg of Effexor XR orally daily

RESULTS OF DECISION POINT TWO

  • Client returns to clinic in four weeks
  • Client reports an improvement in depressive symptoms
  • Montgomery- Asberg Depression Rating Scale (MADRS) decreased from 51 to 38 (25% reduction)

Decision Point Three

Select what the PMHNP should do next:

Increase dose to 112.5 mg orally daily

Continue same dose of medication

Augment with Wellbutrin XL 150 mg orally daily

Decision Point Three

Increase dose to 112.5 mg orally daily

Guidance to Student

At this point, the PMHNP would have two choices to discuss with the client- the current dose of drug can be maintained if the client is feeling better and is not offering any complaints of side effects. The dose can also be increased at this point, but the PMHNP must counsel client regarding the possibility of side effects. The use of an augmenting agent is not appropriate at this time as we have not reached a maximum dose with Effexor (in fact, 75 mg is still a relatively small dose), displaying primarily SSRI properties only (recall that at lower doses, Effexor exerts a greater effect on serotonergic receptors than norepinephrine at low doses).

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