Week 3 discussion
Discussion: The Impact of Ethnicity on Antidepressant Therapy
Major depressive disorder is one of the most prevalent disorders you will see in clinical practice. Treatment for this disorder, however, can vary greatly depending on client factors, such as ethnicity and culture. As a psychiatric mental health professional, you must understand the influence of these factors to select appropriate psychopharmacologic interventions. For this Discussion, consider how you might assess and treat the individuals in the case studies based on the provided client factors, including ethnicity and culture.
Required Readings
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 7, “Antidepressants”
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
To prepare for this Discussion:
Note: By Day 1 of this week, your Instructor will have assigned you to one of the following case studies to review for this Discussion. To access the following case studies, click on the Case Studies tab on the Stahl Online website and select the appropriate volume and case number.
Case 1: Volume 1, Case #1: The man whose antidepressants stopped working
Case 2: Volume 1, Case #7: The case of physician do not heal thyself
Case 3: Volume 1, Case #29: The depressed man who thought he was out of options
Review this week’s Learning Resources and reflect on the insights they provide.
Go to the Stahl Online website and examine the case study you were assigned.
Take the pretest for the case study.
Review the patient intake documentation, psychiatric history, patient file, medication history, etc. As you progress through each section, formulate a list of questions that you might ask the patient if he or she were in your office.
Based on the patient’s case history, consider other people in his or her life that you would need to speak to or get feedback from (i.e., family members, teachers, nursing home aides, etc.).
Consider whether any additional physical exams or diagnostic testing may be necessary for the patient.
Develop a differential diagnoses for the patient. Refer to the DSM-5 in this week’s Learning Resources for guidance.
Review the patient’s past and current medications. Refer to Stahl’s Prescriber’s Guide and consider medications you might select for this patient.
Review the posttest for the case study.
Week 3 assignment
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.
Required Readings
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
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.
Walden NURS 6630 Week 3 Sample Paper
(Impact of Ethnicity on Antidepressant Therapy)
Impact of Ethnicity on Antidepressant Therapy
Student’s Name:
Institutional Affiliation:
Impact of Ethnicity on Antidepressant Therapy
Case #7: The Case of Physicians Do Not Heal Thyself
The patient is a 60-year-old man physician who presents with chief complaint of being unstable. He states that he spend two-thirds of his previous year in a mixed dysphoric state and one-third depressed. He has a psychiatric childhood, adolescent, and adult history. The family members and maternal relatives have an account of mental health. His medical history is Crohn disease, and current medication is methylphenidate, remiacid for Crohn, and Azothiaprine.
Questions and Rationale
The patient will be asked the following questions to assess his mental state. The first question is to understand more about the patient’s background and specifically his relationship with divorced wife. This question will help to determine if the patient has a personality disorder or mental. A follow-up discussion with the former wife will be essential in highlighting her experience with the patient. The second questions on his relationship with his patients, how does he manage to attend to them.Since he stated that he spend two-thirds of his time in a mixed dysphonic state and one-third depressed. The third question is on his experiences and perceptions of the medication that is prescribed to him. This is because it is evident that, in most instances, he is unable to follow the dosage prescribed.
Physical Examination and Diagnosis
The patients need to have a comprehensive physical examination. This will include assessing all physical elements that have an impact on his mental health. This physical examination is crucial since it helps to exclude conditions that may present with similar signs and symptoms. In physical examination helps in narrowing down to specific diagnoses. Since the patient has suggested that they have mental concerns, it will be appropriate to use the bipolar spectrum diagnostics scale (Shabani, Khoshalani, Mahdavi & Ahmadzad-Asl, 2019). This tool is essential in accessing patient’s ideas and emotional concerns on the things that are happening to him. Moreover, the bipolar spectrum diagnostics scale will help to evaluate the presence of bipolar disorder in the patient. Due to the mood swings that the patient experiences, a mood disorder questionnaire will be administered to the patient (Shabani et al., 2019). This tool will offer an overview of the patient’s feelings and will be analyzed to mental depict the status of the patients.
Differential Diagnosis
Based on the patient’s previous and current medical status, the following diagnosis for the following disorders will be conducted: Cyclothymic, unspecified depressive disorder, and bipolar 11 depression. The cyclothymic disease is a condition that is difficult to diagnose due to the different signs and symptoms (Amare, 2018). A patient is usually hard to diagnosis, although episodes of hypomanic systems characterize it. Signs and symptoms such as racing thoughts, pressured speech, decreased need for sleep, depression for more than two weeks, and engagement in risky behaviors suggest that the patient may be suffering from unspecified depressive disorder(Amare,2018). Moreover, a reduced need for sleep, feeling of unworthiness, over-talkative, irritability, shifts in energy, racing thoughts may indicate that the patient has bipolar two depression (Grande, Berk, Birmaher & Vieta,2016).
Patient’s Most Likely Condition
Based on the diagnosis, the patient is most likely to be suffering from cyclothymic disorder disease. This is because his conditions have been hard to diagnosis, although the patient has been experiencing episodic mental health issues since he was a child, it was not diagnosed until he was 23 years. Moreover, the family has an extensive history of mental disorders.
Pharmacologic Agents
Cyclothymic disorder is treated using medications such as ant seizure, anti-depressants, and mood stabilizers medication. In the treatment of this condition, pharmacologic agents such as valproate, lamotrigine, and lithium are recommended. They are found to have significant results as compared to other medications (Alda, 2015). Moreover, these agents can be altered to ensure that the patient can heal completely. The patient is also suffering from Chron disease; thus, the dosage of lithium can be increased gradually to avert conditions such as diarrhea. The dosage can be started low and adjusted to reach the therapeutic levels. The dosage for the patients can be started as low as 300 mg and increased gradually to 1.0mEq/L. In case, the patient is unable to cope with lithium, valproate lamotrigine are recommended. These dosages can also be increased steadily, to be effective. The pharmacokinetics and pharmacodynamics process of drug therapy for this patient is affected due to the aging factor. There is reduced metabolic, distribution, and excretion process. Therefore, these agents will be more applicable, and their dosage should be increased gradually to prevent diarrhea, which might have severe consequences on the pharmacodynamics. Evidence-based practice highlights lithium as the most effective antidepressant in the treatment of the cyclothymic disorder (Alda, 2015).
How Ethnicity Affect Drug Therapy
The ethnicity of a patient is a risk factor in the drug therapy of a patient. Some drugs are likely to do well among some ethnic groups and fail to be effective in others. The anti-depressant that is recommended for the patient is lithium. This drug may be required to be changed to either lamotrigine or lithium is the patient is of African American descent. The risk of lithium among African Americans is contributed by the high levels of red blood cells to plasma ratio (Arnold et al., 2015). Although it is rearly used, African American patients can sustain a low dosage of lithium.
Check Points
In week 12, the patient had stopped taking methylphenidate, and started lamotrigine at a higher dose than what is recommended. This is health risk behavior, and the patient is required to remain within the stipulated dosage. Alternatively, he could have continued with the lithium dosage that was recommended previously. The moods of the patient had stabilized, although there was a decrease in libido and sexual dysfunction. From the start, the patient should have kept a record of his pathological changes. However, for patients with mental disorders, it is hard to keep such records. Thus the need to be helped to keep records, and this will ensure that they keep track of their mood changes.
Lessons Learned
Completing this task has shaped my understanding of dealing with a patient with a mental disorder who is also a medical practitioner. Due to their knowledge in medicine, the patient is not likely to follow drug therapy that is prescribed to them. Moreover, when attending to such a patient, it is essential to have clear health practitioners’ patient roles. This will ensure that they can respect the medication, and if they are not cooperative, it is advised to have a debrief. However, it is crucial to educate them on the importance of following drug therapy. Mental disorders require a comprehensive approach to address and may occasionally review of the medication.
References
Alda, M. (2015). Lithium in the treatment of bipolar disorder: pharmacology and pharmacogenetics. Molecular psychiatry, 20(6), 661.Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5125816/
Amare, A. T. (2018). Genetic predictors of response to pharmacotherapy in patients with mood disorders: steps on the path to personalized psychiatry (Doctoral dissertation).
Arnold, J. G., Salcedo, S., Ketter, T. A., Calabrese, J. R., Rabideau, D. J., Nierenberg, A. A., … & Sylvia, L. G. (2015). An exploratory study of responses to low-dose lithium in African Americans and Hispanics. Journal of affective disorders, 178, 224-228. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4397978/
Grande, I., Berk, M., Birmaher, B., & Vieta, E. (2016). Bipolar disorder. The Lancet, 387(10027), 1561-1572. Retrieved from https://www.sciencedirect.com/science/article/pii/S014067361500241X
Shabani, A., Khoshalani, M. M., Mahdavi, S., & Ahmadzad-Asl, M. (2019). Screening bipolar disorders in a general hospital: Psychometric findings for the Persian version of mood disorder questionnaire and bipolar spectrum diagnostic scale. Medical journal of the Islamic Republic of Iran, 33, 48. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6708087/
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.
Walden NURS 6630 Week 3 Sample Paper
(Assessing and Treating Adult and Geriatric Clients With Mood Disorders)
Mood Disorders
Student’s Name:
Institutional Affiliation:
Mood Disorders
In a mental health class, mood disorder is a term that is used by health providers to describe all types of bipolar and depression disorders broadly. A mood disorder can affect people of all ages that is adults, teens, and children. A major depressive disorder is a mood disorder that usually interferes with a person’s daily life. It is characterized by a lack of interest in outside stimuli or a persistent feeling of sadness. Mood disorders represent the most common psychiatric morbidity in older adults, which includes bipolar and unipolar with varying levels of severity. Mood disorders are usually intense and harder to manage as compared to normal feelings of sadness. Several factors can lead to mood disorders, including life events. This paper discusses three decisions that can be included in the treatment plan of an elderly Hispanic man with major depressive disorder.
Decision One
The first decision that I selected, in this case, is to administer the patient with Effexor XR 37.5 orally daily. The reason for selecting this decision is because it has been approved for use in adults in the treatment of major depressive disorders, social anxiety disorder, generalized anxiety disorder, and panic disorder. Effexor XR is a medication that belongs to a class of drugs that is referred to as serotonin-norepinephrine reuptake inhibitors.it was important to start the dosage at 37.5 mg per day to give the patient time to adjust to it and monitor if there is any form of side effect that the patient will experience. Effexor XR works by increasing and regulating the levels of serotonin and norepinephrine, which are neurotransmitters in the brain. According to Clevenger, Malhotra, Dang, Vanle, & IsHak, 2018) serotonin is a hormone that helps in controlling several processes within the brain. Some of these processes include sleep, aggression, perceptions, mood, and emotions. Norepinephrine, on the other hand, is a hormone that tends to affect parts of the brain that relates to response and attention. Another reason for making this decision is because Effexor XR is usually taken once daily, and therefore it is crucial in this case considering the condition to help prevent the occurrence of medication errors. I also selected this decision because Effexor XR is extensively metabolized and well absorbed in the liver (Barhate, & Husain, 2016). According to past studies, approximately 92% of a single oral dose of this medicine is absorbed. When selecting the decision, I also considered the half-life of the drug, which is five hours, and therefore it was less likely to have a clinical effect on the patient. Although there were other options, I did not choose them because I considered them as being less suitable in this case. The reason I did not select Zoloft 25mg orally daily as my first option is because Zoloft is a selective serotonin reuptake inhibitor, unlike Effexor XR, which is a reuptake inhibitor for both norepinephrine and serotonin. Another reason for not selecting Zoloft is because of its effects in the liver. Zoloft also cause allergic reactions to some patients (Citrome, 2016). Also, I did not select the decision of beginning with phenelzine 15mg orally TID because the medication is mostly used in persons who have not responded to treatment with other drugs, which is not the case for the Hispanic patient (Chiuccariello et al.,2016).
By making this decision, I was hoping to improve the mood and the client’s energy level, which would in turn help in restoring his interests in daily living since he reported to have a remarkably diminished interest in engaging in usual activities. I was also hoping to reduce any form of unwanted thoughts, fear, and anxiety that the client could be having and improve his concentration since he reports to have poor concentration, which was impacting his work life negatively. I was also hoping to reduce the side effects that the patient could probably experience since Effexor XR have fewer side effects as compared to other antidepressants.
There was no difference between what I expected to achieve and the actual results of the decision because the client had improved as expected and had not experienced any severe side effects after using the medicine.
Decision Two
The second decision that I selected was to increase Effexor XR to 75 mg orally daily. The reason I selected this decision was because the patient had shown signs of improvement after using the drug. Therefore there was no cause of alarm to change the medication and start using another one; instead, it was better to increase the dosage. According to past research, it is vital to begin by administering a small amount of dosage when using antidepressants and increase the dosage later after the patient is used to the medication and after establishing that there are no major side effects of using the medication (Stahl, 2014b). Another reason for selecting this decision is to avoid changing the medication since it could affect the health outcome of the patient negatively. A gradual change of medication can cause resistance form the patient. A gradual reduction of Effexor is recommended rather than abrupt cessation. I also selected this decision because increasing the amount of dosage would, in turn, help increase the amount of natural substances, serotonin, and norepinephrine in the brain of the patient (Barhate, & Husain, 2016).
By making this decision, I was hoping to manage the depression symptoms further and improve the health outcome of the patient. I was hoping to do away with the feelings of depression that the patient was endorsing and also help him to carry on with his daily activities smoothly and gain interest in usual activities. There was no difference between what I expected to achieve with decision two and the results of the decision because the patient had started improving as expected. The patient had stopped getting troubled with insomnia, had begun to gain interest in engaging in usual activities, and his level of concentration was also improving.
Decision Three
The third decision that I selected was to increase Effexor XR from 75 mg to 112.5 mg orally. The reason for choosing this decision was because the medication had proved to be effective in the management of the client’s symptoms. By making this decision, I was hoping to help manage the symptoms fully and restore the client’s optimal health. I was hoping to clear all the symptoms of depression. There was no difference between what I expected to achieve with decision three and the actual results. The patient’s Montgomery- Asberg Depression Rating Scale had improved since, by the end of this decision, his score was ten, which indicated mild depression and was close to normal or no symptoms for depression.
Ethical Considerations
One of the ethical considerations that might impact the treatment plan and communication with clients is ensuring that the principle of autonomy is respected. A health provider is expected to respect the decisions made by patients concerning their own lives and health. Ensuring that the treatment plan does not pose any form of harm to the patient is another ethical consideration that could impact the treatment plan since some medications tend to have severe side effects on a patient. Causing harm to a patient is against the principle of beneficence, which requires a health provider to do what is best for a client. The patient should be administered with the right medication at the right time to prevent any type of medical error from occurring (Carpenter, & Gonzalez, Retsch-Bogart, Sleath, & Wilfond, 2017).
Conclusion
Mood disorders are usually intense and harder to manage as compared to normal feelings of sadness. A health provider needs to weigh the benefit of using different medications before administering it to a patient. Effexor XR is one of the medications that can help in managing the symptoms of severe depression effectively.
References
Barhate, S., & Husain, M. (2016). Comparative in vitro dissolution testing of hydrophilic controlled-release venlafaxine matrix tablets and Effexor XR using QbD. Dissolution Technologies, 23(3), 40-44.
Citrome, L. (2016). Vortioxetine for major depressive disorder: an indirect comparison with duloxetine, escitalopram, levomilnacipran, sertraline, venlafaxine, and vilazodone, using number needed to treat, number needed to harm, and likelihood to be helped or harmed. Journal of affective disorders, 196, 225-233.
Carpenter, D., & Gonzalez, D., Retsch-Bogart, G., Sleath, B., & Wilfond, B. (2017).
Methodological and Ethical Issues in Pediatric Medication Safety Research
Pediatrics. 140 (3) e20170195; DOI: 10.1542/peds.2017-0195.
Chiuccariello, L., Cooke, R. G., Miler, L., Levitan, R. D., Baker, G. B., Kish, S. J., … & Meyer, J. H. (2016). Monoamine oxidase-A occupancy by moclobemide and phenelzine: implications for the development of monoamine oxidase inhibitors. International Journal of Neuropsychopharmacology, 19(1).
Clevenger, S. S., Malhotra, D., Dang, J., Vanle, B., & IsHak, W. W. (2018). The role of selective
serotonin reuptake inhibitors in preventing relapse of major depressive disorder. Therapeutic advances in psychopharmacology, 8(1), 49–58. DOI:10.1177/2045125317737264.
Stahl, S. M. (2014b). The prescriber’s guide (5th ed.). New York, NY: Cambridge University Press.
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