Geriatric Depression Therapy
Among the elderly, depression has been associated with several negative impacts to both the patient and his or her family members. It is the role of the healthcare workers to familiarize themselves with depression’s causative variables to be able to identify patients who may require screening with instruments like Montgomery- Asberg Depression Rating Scale (Vuorilehto, Melartin, Riihimäki, & Isometsä, 2016). A clear understanding of the depression symptoms among the elderly forms the first basis for the development of appropriate interventions and the best choice of drugs to include in a patient’s care plan. The choice of a drug depends on its effectiveness and safety profile. Nonetheless, when the first choice seems to fail, an alternative drug within the same class might be combined with the first drug, or the medication can be entirely replaced. At this point, the nurse might consider a psychotherapeutic approach (Cowen, 2017; Stahl, 2013). Depression is diagnosed differently since the condition exists on varied scales. Thus, inasmuch as pharmacotherapy and psychotherapy are the main interventions used to manage the condition, electroconvulsive intervention might be considered in severe cases of depression. In the current paper, the case scenario provided is of a 31-year-old Hispanic man who was diagnosed with a severe depressive state, as per his scores on the Montgomery-Asberg Depression Rating Scale, which was 51. All the options of drug regiments that can be utilized in managing the patient’s symptoms of depression will be revealed in the present discussion. As a result, the analysis of this case will offer a comprehensive understanding of the therapeutic management of depression among geriatrics.
Decision Point One
Selected Decision
Begin Zoloft 25 mg OD
Reason for Selection
The first line choice of drug for the treatment of depression is usually Zoloft, which belongs to the broad class of
SSRIs. The Hispanic male patient was diagnosed with severe depression as per the scale that was used. Hence, the best choice of drug, in this case, based on the provided options, is Zoloft. The drug has proven to be the most effective and safest compared to other SSRIs (Polatin, Bevers, & Gatchel, 2017: Stahl, 2014b). On the other hand, the PMHNP can only recommend phenelzine if Zoloft, among other drugs, has proven to be ineffective, but not as a first line choice of treatment. Further, Effexor XL is usually associated with several side effects and should only be used as a last resort.
Expected Results
Most studies show that the effects of Zoloft start showing after continuous use for at least 14 days. By the end of week two, the drug should have been able to improve the patients sleeping patterns and concentration. Generally, most of the patient’s symptoms will be relieved after two weeks of using the drug (Coplan, 2015). Additionally, the patient should be able to interact appropriately with other people by this time with a reduced recollection of past mistreatments showing.
Geriatric Depression Therapy
Differences between Expected Results and Actual Results
The patient came back to the hospital after two weeks with a 25% reduction of the depression symptoms just as expected by the PMHNP. However, the patient reported erectile dysfunction, which is one of the side effects of Zoloft. This effect was however not anticipated by the PMHNP since erectile dysfunction is usually very rare as compared to other side effects of Zoloft (Cipriani et al., 2016).
Decision Point Two
Selected Decision
Add augmenting agent such as Wellbutrin IR 150 mg in the morning
Reasons for the Selection
After two weeks, the patient responded appropriately to Zoloft with a 25% reduction in depression symptoms. However, he also reported signs of erectile dysfunction, which needs to be addressed if the patient continues using the drug. In this case, the best intervention would be to include Wellbutrin, which is an effective augmenting agent that helps in the management of Zoloft induced erectile dysfunction. The two-drug combination therapy has been used over the years to prevent drug-induced erectile dysfunction in young and elderly men (Linde, Kriston, & Rucker, 2015). The other drugs provided for this case study cannot be used as they do not have the required pharmacological activity to manage erectile dysfunction. In this scenario, Wellbutrin will be administered slowly at first, while slowly withdrawing Zoloft, to be able to correct the erectile dysfunction as the depression symptoms of the patients are managed as well. Consequently, low doses of Zoloft are ineffective, hence cannot be recommended by the nurse. Continuous use of the drug might also worsen the erectile dysfunction among other side effects; hence, it is best to withdraw the use of Zoloft.
Expected Results
Augmentation of Zoloft with Wellbutrin is expected to reduce the erectile dysfunction side effects. The depression symptoms of the patient are also expected to reduce even further from the results of the first two weeks. A combination therapy comprising of Wellbutrin and Zoloft has shown great synergism in the past, with one drug boosting the effect of the other, hence having maximum benefit in the management of depression (Linde, Kriston, & Rucker, 2015). At the end of the treatment period, the patient should negligible depression symptoms with resolved erectile dysfunction.
Differences between Expected Results and Actual Results
The patient came back to the hospital later, after the introduction of Wellbutrin, with positive results. His erectile dysfunction had been resolved. He also claimed that he felt better, with significantly reduced symptoms of depression. This was precisely what was expected after the intervention. The patient, however, complained of a feeling of nervousness and jittery in some cases (Arroll et al., 2016). This was not strange as they are the main side effect of most antidepressants. In this case, both Zoloft and Wellbutrin could have been the reason behind these side effects. The synergistic effect on the dose of both drugs could have been a factor that led to these symptoms.
Discussion Point Three
Selected Decision
Change Wellbutrin to XL 150 mg orally daily in AM
Reasons for the Selection
During follow up assessment, the patient only reported signs of jittery, as the side effect of the combination therapy. Both the antidepressants can cause this side effect. However, the side effect most likely came as a result of Wellbutrin’s mode of release, given that the drug is formulated as an immediate release. Hence, the most appropriate intervention, in this case, is to change the formulation of Wellbutrin to extended release, instead of slow release, to track down the main cause of the jittery feeling displayed by the patient. The slow release formulation has also proven to be effective in managing depression symptoms (Linde, Kriston, & Rucker, 2015). Ativan should be avoided, as the introduction of a new pharmacological agent as a result of the side effects of another drug is greatly discouraged. Moreover, withdrawal of Zoloft is also not necessary as the drug is not the reason behind the displayed side effects.
Expected Results
If the feeling of jittery was as a result of the Wellbutrin’s immediate release formulation, then the formulation change to extended-release should be able to resolve the problem. The depressions symptoms will be reduced even further as both drugs are maintained. The patient’s confidence will be improved once the jitteriness has been resolved, which is one of the main goals of the intervention. Additionally, other symptoms of depression are expected to be entirely resolved by the end of the prescribed duration.
Differences between Expected Results and Actual Results
The treatment outcome of the patient was consistent with the nurse’s expected results. Just like the intervention made by the PMHNP nurse, most side effects are usually managed by altering the formulation of the drug first, rather than changing the drug regimen. Introduction of another drug, or replacing the existing one, could result in other side effects which will also become a problem (Linde, Kriston, & Rucker, 2015).
Impact of Ethical Consideration on Treatment Plan
From an ethical perspective, the management of depression using the most appropriate antidepressants surpasses the administration of other drugs. It is the moral obligation of the PMHNP nurse to provide the patient with adequate information on the drugs used in terms of both the benefits and side effects. Consequently, before picking on a specific drug to use, the nurse is obliged to utilize the patient’s past medical history and comprehensively evaluate the prompt diagnosis. The nurse must also inform the patient about the reasons behind the use of different pharmacological agents (Lee, 2013). On the other hand, the nurse needs to be aware of the hopes of the patient, what motivates them and their most significant concerns, to create a root basis for psychotherapeutic interventions in addition to pharmacological especially in the management of specific depression symptoms. Consequently, concerning evidence-based practice, drugs with high suicidal risks should be eliminated from the patients care plan.
Conclusion
Depression can cause substantial impacts on the patient’s social and economic status, in addition to that of their family. Hence, the management of this condition should be taken very seriously with proper diagnostic assessment methods to be able to come up with the most appropriate intervention. Additionally, the choice of drugs for such cases are usually based on several factors and might even require altering in the course of treatment depending on the treatment outcome. Other pharmacological agents in addition to psychotherapy might also be used in the management of depression.
References
Cowen, P. J. (January 01, 2017). Backing into the future: pharmacological approaches to the management of resistant depression. Psychological Medicine, 47, 15, 2569-2577.
Vuorilehto, M. S., Melartin, T. K., Riihimäki, K., & Isometsä, E. T. (September 15, 2016). Pharmacological and psychosocial treatment of depression in primary care: Low intensity and poor adherence and continuity. Journal of Affective Disorders, 202, 145-152.
Polatin, P., Bevers, K., & Gatchel, R. J. (June 14, 2017). Pharmacological treatment of depression in geriatric chronic pain patients: a biopsychosocial approach integrating functional restoration. Expert Review of Clinical Pharmacology, 1-7.
Coplan, J. D. (January 01, 2015). Treating comorbid anxiety and depression: Psychosocial and pharmacological approaches. World Journal of Psychiatry, 5, 4, 366.
Lee, Hpdabpp. (2013). Psychological Treatment of Older Adults: A Holistic Model. Springer Publishing Company.
Cipriani, A., Zhou, X., Del, G. C., Hetrick, S. E., Qin, B., Whittington, C., Coghill, D., … Xie, P. (August 01, 2016). Comparative efficacy and tolerability of antidepressants for major depressive disorder in children and adolescents: a network meta-analysis. The Lancet, 388, 10047, 881-890.
Arroll, B., Chin, W., Martis, W., Goodyear-Smith, F., Mount, V., Kingsford, D., Humm, S., … MacGillivray, S. (January 01, 2016). Antidepressants for treatment of depression in primary care: a systematic review and meta-analysis. Journal of Primary Health Care, 8, 4, 325.
Linde, K., Kriston, L., & Rucker, G. (January 01, 2015). Efficacy and Acceptability of Pharmacological Treatments for Depressive Disorders in Primary Care: Systematic Review and Network Meta-Analysis. Annals of Family Medicine, 13, 1, 69-79.
Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (4th ed.). New York, NY: Cambridge University Press.
Stahl, S. M. (2014b). The prescriber’s guide (5th ed.). New York, NY: Cambridge University Press.
Depression amongst the elderly has been demonstrated to possess certain levels of negative impact on families, groups and patients. Thus, it becomes imperative for healthcare workers to become familiar with the causative variables of the condition, which will aid them to recognize patients that may require screening with instruments such as the Montgomery- Asberg Depression Rating Scale (Montgomery & Asberg, 1979) and the Geriatric Depression Scale (American Psychiatric Association, 2013). The determination of the existence of depressive symptoms in a patient will herald the beginning of the development and administration of medication regimen paramount to fortifying the other aspects of a multidisciplinary intervention. The usage of a certain drug becomes dependent on the reactivity profile of a drug as well as its safety. However, should such a formulation fail to give the desired results, then a different approach, which may include additional medicines, and psychotherapy, could become candidates for the intervention (Flint & Rifat, 2013). Depression exists on varied scales and as such, the condition is diagnosed differently. Whereas medical formulations and psychotherapeutic treatments can manage some levels of the condition, electroconvulsive intervention will be utilized in its most severe form. In the present paper, a 31-year-old Hispanic man has been diagnosed with a severe form of depression as his scale on the Montgomery-Asberg Depression Rating Scale indicated 51-severe depression. Also, the various treatment options that can be prescribed to the patient are revealed. This allows the present assessment to be compared to the decisions undertaken so as to facilitate a comprehensive understanding of the depression therapy for geriatrics.
Decision Point One
Selected Decision
Begin Zoloft 25 mg orally daily
Reason for Selection
When it comes to SSRIs and the treatment of depression, Zoloft is very efficient and the first line drug for the management of depression. The Hispanic patient demonstrated symptoms of severe depression from the diagnostic results. Thus, based on the existing antidepressants list, Zoloft is the best option because of its safety and efficacy (Stahl, 2014b). The PMHNP cannot recommend phenelzine since it can only be used after Zoloft and other drugs have proven ineffective. On the other hand, Effexor XL is characterized by numerous side effects, thus it is not generally recommended.
Expected Results
According to experiments, Zoloft’s effects will normally start after 14 days of utilizing the medication. One of the early impacts of the drug includes improved sleep patterns, which the patient should indicate by week two. Further, Liu and his colleagues (2015) also state that Zoloft should boost concentration within two weeks. Also, greater motivation is expected of the patient within the same period. Lastly, it is anticipated that the patient will relate well to people and his feelings of past mistreatments should start to reduce.
Differences between Expected Results and Actual Results
After our weeks, the patient visited the clinic again and indicated a 25% reduction of his symptoms, which was expected by the PMNHP. The client also was afflicted by one of the side-effects of the condition in erectile dysfunction (Gaboda et al., 2014). Whereas there is always a room for some of Zoloft’s side-effects to impact a patient, erectile dysfunction was not expected by the PMNHP due to its uncommon nature.
Decision Point 2
Selected Decision
Add augmenting agent such as Wellbutrin IR 150 mg in morning
Reason for selection
When the client was given Zoloft, there were two impacts from the drug. One of the impacts was the reduction of the depressive symptoms by 25% and the other was a side effect known as erectile dysfunction. Thus, whereas Zoloft is addressing its primary purpose, there is need to address the erectile dysfunction as well. To this end, Wellbutrin is the most ideal medication as it possesses such capabilities. According to Flint and Rifat (2013), Wellbutrin works well with other antidepressants such as Zoloft to reduce erectile dysfunction. The other medicine in the repertoire cannot be used as it does not have this capability. Even then, the Wellbutrin will be introduced slowly as the Zoloft is withdrawn so as to correct the erectile dysfunction while ensuring that the symptoms of depression are still being addressed. Also, the nurse could not decrease Zoloft dose as this would impact the depressive symptoms negatively or maintain its dose as then the side effect will continue.
Expected Results
One of the most expected results of the augmentation of Zoloft using Wellbutrin is the reduction of the erectile dysfunction. Also, since the patient is already feeling better in terms of depression, the symptoms should reduce even further. Wellbutrin and Zoloft will produce a greater effect on depression symptoms since they will work in combination due to increased dosage of the pertinent agent from the two antidepressants (Flint & Rifat, 2013). At the end, the patient is expected to feel better in both fronts as a result of Wellbutrin augmentation.
Differences between Expected Results and Actual Results
When the patient visited the nurse after the introduction of Wellburtin, he stated that his erectile dysfunction had ended and that his depressive symptoms had significantly reduced. This was consistent with the expectations after the introduction of the augmenting agent. However, the patient also reported feeling jittery and nervous in some cases, which are some of the side effects of antidepressants (Gaboda et al., 2014). According to the above authors, both Zoloft and Wellbutrin can lead to these two outcomes. Specifically, the dosage of the two drugs could have a role to play in the existence of these side effects.
Discussion Point Three
Selected Decision
Change Wellbutrin to XL 150 mg orally daily in AM
Reason for Selection
When the patient came back for assessment, jitteriness was the only side effect that he was feeling. According to Stahl (2013), the existence of such a side effect is normal given the circumstances. They go further and attribute it to the mode of release of Wellburtin, which is in the form of immediate release. Thus, attempting to alter the administration of Wellbutrin from immediate release to extended release could form the basis of tackling the jittery feeling shown by the patient. In addition to eliminating the jitteriness, the extended release formulation is effective in combating depression. Ativan cannot be introduced as pharmaceutically, it is unadvisable to introduce a different drug to combat the side effects of another medication. In fact, the advice would be to try and modify Wellbutrin first. Also, the discontinuation of Zoloft is not advisable as it did not cause the side effects.
Expected Results
Should the jitteriness be caused by the immediate release formulation of Wellburtin, then administering it in extended release formulation is expected to cure the side effect. Also, the reduction of depressive symptoms will continue at a more significant rate according to Liu and his colleagues (2015). Cessation of jitteriness will have fundamental effects on the confidence of the patient vis-à-vis the intervention. Also, it is expected that almost all the symptoms of the condition will be curtailed by this point.
Differences between Expected Results and Actual Results
The decision undertaken appears to be consistent with expectations. Thus, from decision three, there are no differences between expected results and actual results. According to Laureate Education (2016), a nurse is expected to alter the formulation of a drug if they want to manage a side effect without resorting to a different one. This was done by the PMNHP nurse, which prevented the introduction of other side effects from different drugs.
Impact of Ethical Consideration on Treatment Plan
Ethically, the treatment of depression using antidepressants transcends the administration of drugs. The PMHNP nurse bears a moral obligation to reveal the entire information related to a drug including the true benefits and risks to a patient before an intervention can be adopted. However, even before an intervention can be formulated, the nurse is required to conduct a comprehensive diagnostic evaluation as well as thoroughly review their past history (Flint, 2012). Identifying the hopes of the patient, their greatest concerns, as well as motivations are paramount to establishing a psychotherapeutic stratagem that may include the usage of psychopharmacological agents to address particular symptoms. Based on evidence-based practice, the drugs that may cause suicidal ideations will be eliminated from the treatment plan as the patient does not interact with other individuals, making those drugs risky.
Conclusion
Therefore, depression has substantial impacts on the familial, economic and social set-ups of a patient. The management of the condition thus needs to be thorough and thorough diagnostic assessment is necessary in the determination of an apt intervention. Also, the prescriptions made to such patients are impacted by certain variables across the choosing, changing and altering processes. Similarly, other medication and psychotherapeutic interventions may be adopted to address depressive symptoms in a patient.
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
Flint, A. J. (2012). Choosing appropriate antidepressant therapy in the elderly. Drugs & Aging, 13(4), 269-280.
Flint, A. J., & Rifat, S. L. (2013). The effect of sequential antidepressant treatment on geriatric depression. Journal of Affective Disorders, 36(3), 95-105.
Gaboda, D., Lucas, J., Siegel, M., Kalay, E., & Crystal, S. (2014). No longer undertreated? Depression diagnosis and antidepressant therapy in elderly long‐stay nursing home residents, 1999 to 2007. Journal of the American Geriatrics Society, 59(4), 673-680.
Laureate Education. (2016g). Case study: An elderly Hispanic man with major depressive disorder [Interactive media file]. Baltimore, MD: Author.
Montgomery, S. A., & Asberg, M. (1979). A new depression scale designed to be sensitive to change. British Journal of Psychiatry, 134, 382-389.
Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (4th ed.). New York, NY: Cambridge University Press.
Stahl, S. M. (2014b). The prescriber’s guide (5th ed.). New York, NY: Cambridge University Press.