NURS 6521 Discussion Decision Making When Treating Psychological Disorders

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NURS 6521 Discussion Decision Making When Treating Psychological Disorders

NURS 6521 Discussion Decision Making When Treating Psychological Disorders

Main Post Doud, S.

I selected the interactive media piece related to depression in the geriatric patient. The decision steps were to begin Zoloft 25mg daily, then to add Wellbutrin IR 150mg in the morning due to complaints of erectile dysfunction, then to change the Wellbutrin from IR to XL.

The Zoloft can have an impact on sexual dysfunction, but the student guidance clarified that the “jittery” feeling the patient reported could be caused by either Zoloft or Wellbutrin, but that with SSRIs that feeling tends to be temporary. This provides guidance on considering which medications to make adjustments to. I appreciated the additional guidance in the interactive media exercise that highlighted the point to not add a medication to treat the side effects of a different medication—in reference to the suggestion of adding Ativan as a decision. Pathophysiology effects of SSRIs can be nausea, agitation, insomnia and sexual dysfunction and may be mitigated by changing the dose or medication in the same category or another category (Rosenthal & Burchum, 2017). In the case study, Wellbutrin was added for additional efficacy of depression management in addition to treating complaints of sexual dysfunction. Zoloft blocks the reuptake of 5-HT and cause CNS stimulation and have minimal effects on seizure threshold and ECG. Food increases the distribution of Zoloft with its high binding to plasma proteins and metabolized through the liver. Risk for hyponatremia and GI bleeding should be considered depending on a geriatric patient’s comorbidities.

Alternative treatment may include electroconvulsive therapy as it has been found to be effective in some geriatric patients with depression and should be considered when pharmacology is not appropriate or effective (Geduldig & Kellner, 2016). Pharmacological treatments continue to be researched for late-life depression management and SSRIs continue to be one of the first line treatments with additional augment medications being considered as noted in example with Wellbutrin but also newer medications such as apriprazole (Beyer & Johnson, 2018).

Masse-Sibille et al. (2018) report how more studies need to be done to better know the pathophysiological affects of depression on subgroups of geriatric patients to better know how to adjust pharmacological therapies. The better effects can be predicted the more thorough the treatment of depression can be. NURS 6521 Discussion Decision Making When Treating Psychological Disorders.

NURS 6521 Discussion Decision Making When Treating Psychological Disorders

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References

Beyer, J. L., & Johnson, K. G. (2018). Advances in pharmacotherapy of late-life depression. Current psychiatry reports, 20(5), 34.

NURS 6521 Discussion Decision Making When Treating Psychological Disorders

https://doi.org/10.1007/s11920-018-0899-6

Geduldig Emma, T., & Kellner, C. H. (2016). Electroconvulsive therapy in the elderly: New findings in geriatric depression. Current Psychiatry Reports, 18(4). http://dx.doi.org.ezp.waldenulibrary.org/10.1007/s11920-016-0674-5

Masse-Sibille, C., Djamila, B., Julie, G., Emmanuel, H., Pierre, V., & Gilles, C. (2018). Predictors of response and remission to antidepressants in geriatric depression: a systematic review. Journal of geriatric psychiatry and neurology, 31(6), 283-302. https://doi-org.ezp.waldenulibrary.org/10.1177/0891988718807099

Rosenthal, L. & Burchum, J. (2017). Lehne’s Pharmacotherapeutics for Advanced Practice Providers – E-Book. [VitalSource Bookshelf 9.3.0]. Retrieved from vbk://9780323447799

RE: Depression-Geriatric patient

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Hi ,

I enjoyed reading your post. I, also, chose the interactive media piece related to depression in the geriatric patient. Depression is the most common psychiatric disorder and affects fifteen million adults in the United States per year (Rosenthal and Burchum, 2021). I, also, chose to treat the patient with Zoloft and Wellbutrin IR, and then switching the Wellbutrin IR to ER. In treating the elderly with depression, I feel that non-drug therapies, such as cognitive behavioral therapy, taken alongside antidepressants can help improve the symptoms of depression. Cognitive behavioral therapy (CBT) composed of cognitive reframing and behavioral activation can help with depression. According to Gallagher-Thompson, Eagle, and Dunn (2017), the model of CBT links thoughts, behaviors, feelings, and health symptoms and works to change thoughts and behaviors in older adults. In turn, emotions will began to change. In order for this model of CBT to be beneficial the patient has to have the cognitive capacity, have sufficient memory function, and have cognitive processing skills (Gallagher-Thompston et. al, 2017). I believe that this would be beneficial to the patient in the interactive media piece. NURS 6521 Discussion Decision Making When Treating Psychological Disorders

References:

Gallagher-Thompson, D., Cassidy-Eagle, E., and Dunn, L. (2017). Cognitive behavioral therapy

for treatment of late-life depression. Today’s Geriatric Medicine, 10(1).

Rosenthal, L.D. and Burchum, J.R. (2021). Lehne’s pharmacotherapeutics for advanced practice

nurses and physician assistants (2^nd ed.). St. Louis, MO: Elsevier.

Discussion

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The psychological disorder that I selected for this discussion was generalized anxiety disorder (Laureate Education, 2019g). The first decision I made was to start the patient on Zoloft because it is a selective serotonin reuptake inhibitor (SSRI), which is safer than tricyclic antidepressants (TCA). Because the patient’s Hamilton Anxiety Rating Scale (HAM-A) yielded a score of 26, this places him at the moderate to the severe range (Hamilton, 1959). Due to his elevated score, the patient could benefit from medication with better tolerability, which was Zoloft (Rosenthal & Burchum, 2021). After four weeks, the patient returned with improved symptoms and a decreased HAM-A score of 18. I decided to increase his Zoloft from 50 mg daily to 75 mg daily because he was still within the six to 12-week window for the medication to reach the therapeutic range. He was already positively responding to the initial dose. When he returned after another four weeks, his symptoms improved, and his HAM-A score decreased to 10, which places his anxiety at the mild range. Due to his positive response, I decided to maintain him on Zoloft 75 mg daily.

When a patient takes an SSRI like Zoloft, the monoamine neurotransmitter serotonin becomes more abundant in the synaptic space due to the reuptake pump being blocked by the SSRI (Rosenthal & Burchum, 2021). The serotonin that stays in the synaptic space will continue to activate the postsynaptic serotonin receptors. The mechanism of the SSRIs can help relieve depressive and anxiety symptoms. One of SSRIs’ side effects would be serotonin syndrome that can occur up to three days after starting an SSRI. The patient may exhibit signs of altered mental status, tremors, fever, and involuntary muscle jerks (Rosenthal & Burchum, 2021). Patients that take SSRIs and take a TCA or a monoamine oxidase inhibitor would increase their risk of developing the serotonin syndrome. NURS 6521 Discussion Decision Making When Treating Psychological Disorders

Because of the risk of developing serotonin syndrome, I may be more conservative in increasing a patient’s SSRI dose. I must remember that it will take weeks for the medication to reach its therapeutic range. Like the interactive media piece, my treatment plan would include frequent monitoring of the patient, such as scheduling follow-up visits every four weeks and utilizing the HAM-A scoring system to assess the care plan’s efficacy. I would also incorporate cognitive behavior therapy since combination therapy is more effective (Rosenthal & Burchum, 2021).

Resources

Hamilton, M. (1959). Hamilton anxiety rating scale. Psyctests. doi:10.1037/t02824-0

Laureate Education (Producer). (2019g). Generalized anxiety disorder [Interactive media file]. Baltimore, MD: Author.

Rosenthal, L. D., & Burchum, J. R. (2021). Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistants (2^nd ed.) St. Louis, MO: Elsevier.

First response Doud,S RE: Discussion

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Response 1:

I appreciate your closing remark that cognitive therapy is recommended treatment for generalized anxiety disorder (GAD). While it is important to know appropriate pharmacotherapy it does not replace physical and psychosocial therapies. Slee et al. (2019) found that other options to SSRIs may not be tolerated as well but are effected. These included quetiapine, paroxetine and benzodiazapines and were noted to . (Slee et al., 2019). Benzodiazapines also carry the risk of dependence and potentially fatal interactions with alcohol and opioids that may be problematic in the patient population diagnosed with GAD (Slee et al., 2019). Rosenthal and Burchum (2017) explain that quetiapine should not be combined with drugs that could prolong the QT interval or various other drugs that may lead to toxic levels such as some antifungals and antibiotics making dosing difficult to maintain psychotic effects without adverse reaction. While quetiapine has been shown to be high in effectiveness, the issues with patients tolerating this pharmacological therapy is more problematic than in SSRI use.

References

Slee, A., Nazareth, I., Bondaronek, P., Liu, Y., Cheng, Z., & Freemantle, N. (2019). Pharmacological treatments for generalised anxiety disorder: A systematic review and network meta-analysis. The Lancet, 393(10173), 768–777. https://doi.org/10.1016/S0140-6736(18)31793-8

Rosenthal, L. & Burchum, J. (2017). Lehne’s Pharmacotherapeutics for Advanced Practice Providers – E-Book. [VitalSource Bookshelf 9.3.0]. Retrieved from vbk://9780323447799

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