NURS 6630 How long have you been taking Zoloft and are you currently attending psychotherapy to help with grief support and experienced depression?

List three questions you might ask the patient if she were in your office. Provide a rationale for why you might ask these questions.

How long have you been taking Zoloft and are you currently attending psychotherapy to help with grief support and experienced depression?

Rationale: Providers need an understanding of when medication was initiated and adjusted. For the initial treatment of major depression, A combination of antidepressant medication and psychotherapy. Combination treatment is more effective than either treatment on its own. Each treatment form is effective and comparable to the other Psychotherapy may help people develop new coping skills as well as more adaptive ways of thinking about life problems (Rush, 2019).

Do you take your Zoloft daily and have you forgotten to take or missed taking a dose? Rationale: Clarifying missed doses of this medication may contribute to patient increased depression symptoms. MDD is frequently comorbid with physical problems and illnesses including obesity, cardiovascular disease and diabetes mellitus, substance misuse and other mental disorders, reflecting both antecedent and consequence pathways. This may affect the efficacy of treatments for MDD as well as increasing the vulnerability of patients to adverse effects and risk of harmful drug interactions (UptoDate, 2022).
Do you take any other medications or supplements? Rationale: Concern of Serotonin syndrome. Obtaining a current medication history will confirm if a patient is taking other medications elevate serotonin such as other antidepressants, certain NSAIDS, headache medications, St. John’s Wort.

Further Assessment

When was your last visit with your PCP, Rationale: One of the most common barriers to seeking health care is out-of-pocket medical cost? In particular, among older adults with chronic conditions, the burden of out-of-pocket medical cost is a major concern (Cheruvu & Chiyaka, 2019).

What is the patient’s current mood and how does the patient rate her current mood?

Who is and where is your PCP located? As a provider you will want to retrieve medical records from current PCP and need to send release to appropriate correspondence.

MDD is frequently associated with physical problems and illnesses such as obesity, cardiovascular disease, and type 2 diabetes. This may impair the efficacy of MDD treatments while also increasing patients’ susceptibility to adverse effects and the risk of harmful drug interactions. Collateral information from a patient’s family and friends is an essential component of psychiatric evaluation. A thorough physical examination, including a neurological examination, should be carried out. Any underlying medical/organic causes of a depressive disorder must be ruled out. A complete medical history, as well as the medical and psychiatric histories of the patient’s family, should be obtained. The mental status examination is critical in the diagnosis and evaluation of MDD.

Click here to ORDER an A++ paper from our Verified MASTERS and DOCTORATE WRITERS: NURS 6630 How long have you been taking Zoloft and are you currently attending psychotherapy to help with grief support and experienced depression?

Appropriate Physical Tests and Diagnostic Examinations

The GDS (Geriatric Depression Scale) would be useful in assessing the level of depression in patients. Screening should also be considered in cases where bereavement effects persist 3 to 6 months after the loss, social isolation, persistent complaints of memory difficulties, chronic disabling illness, recent major physical illness, persistent sleep difficulties, significant somatic concerns or recent onset of anxiety, refusal to eat or neglect of personal care, recurrent or prolonged hospitalization, and dementia diagnosis. Even if the patient denies suicidal ideation, this should be done as a baseline during the office visit. The degree of depression and whether the patient is at risk will be determined by an assessment of the patient’s overall mood. To rule out organic or medical causes of depression, laboratory testing should include a complete blood count with differential, a comprehensive metabolic panel, thyroid-stimulating hormone, free T4, vitamin D, urinalysis, and toxicology screening. CMP testing will check kidney function and electrolytes; this medication may affect these levels. CMP sodium levels should be checked one month after starting Zoloft. Nausea, dry mouth, insomnia, somnolence, agitation, diarrhea, excessive sweating, and, less commonly, sexual dysfunction are common side effects of SSRIs. There is an increased risk of elderly patients due to declining renal function associated with aging. developing hyponatremia as a result of an antidiuretic hormone secretion syndrome (Wiese, 2011).

Differential Diagnosis

MDD is frequently comorbid with physical problems and illnesses including obesity, cardiovascular disease and diabetes mellitus. This may affect the efficacy of treatments for MDD as well as increasing the vulnerability of patients to adverse effects and risk of harmful drug interactions. Laboratory screenings during visits should consist of CBC, TSH, CMP, Vitamin D3. Neurological causes such as cerebrovascular accident, multiple sclerosis, subdural hematoma, epilepsy, Parkinson disease, Alzheimer disease should be considered during evaluation. Consideration of endocrine, metabolic disorders and nutritional deficits should be considered when obtaining labs that could be the primary cause for Major Depressive Disorder.

Appropriate Treatment

The patient is currently taking an SSRI, sertraline 100mg daily for MDD treatment. The provider should consider increasing patient sertraline to 150 mg. Selective serotonin reuptake inhibitors (SSRIs) are regarded as the treatments of choice for first line management of elderly depressed patients. The selective serotonin reuptake inhibitors (SSRIs) and the newer antidepressants bupropion, mirtazapine, moclobemide, and venlafaxine (a selective norepinephrine reuptake inhibitor or SNRI) are all relatively safe in the elderly. They have lower anticholinergic effects than older antidepressants and are thus well tolerated by patients with cardiovascular disease (Weise, 2011). This medication is safe for this patient’s depression treatment and dosage can be increased for patients up to 200mg daily. It would be appropriate for the provider to augment the sertraline with a low dose TCA, such as Trazodone, to be taken at bedtime. Patients should be educated on feelings of over sedation and discontinuation of TCA taken at HS could be lowered or discontinued.

Contraindications

The BEERS Criteria should be utilized prior to prescribing psychotropic medication treatment since the patient is older than 65 years of age.

Sertraline use requires caution in patients 65 years and older. It is identified in the Beers Criteria as a high-risk medication in geriatric patients, as it may induce a syndrome of inappropriate antidiuretic hormone or hyponatremia.

Check Points

Patients should be scheduled for in office follow-up in 2-3 weeks to follow up on medication changes as well as their depression. The provider should repeat their GDS as well as evaluate any further mood changes or concerns.

References

Cheruvu, V. & Chiyaka, E. (2019). Prevalence of depressive symptoms among older adults who

reported medical cost as a barrier to seeking health care: findings from a nationally representative sample. BMJ Geriatrics. https://bmcgeriatr.biomedcentral.com/articles/10.1186/s12877-019-1203-2

Rush, J. (2022). Patient education: Depression treatment options for adults (Beyond

the Basics). UpToDate.

Weise, B. (2011). Geriatric depression: The use of antidepressants in the elderly. The British

Medical Journal, 53(47). Geriatric depression: The use of antidepressants in the elderly | British Columbia Medical Journal (bcmj.org)

As a PNP, insomnia will be one of the most common medical issues you encounter. Insomnia is a prevalent symptom of numerous mental disorders, including anxiety, depression, schizophrenia, and attention deficit hyperactivity disorder (ADHD) (Abbott, 2016). Multiple research have proven the two-way connection between sleeplessness and mental disorders. In reality, over 50% of persons with insomnia have a mental health condition, and up to 90% of adults with depression have sleep problems (Abbott, 2016). Due to the interrelated nature of psychopathology, it is crucial that you, as a PNP, comprehend the significance of the effects that certain psychopharmacologic treatments may have on a patient’s mental health condition and sleep patterns. For optimal health and well-being, it is crucial that you comprehend and reflect on the evidence-based research when formulating treatment plans to prescribe correct sleep practices to your patients and appropriate psychopharmacologic treatments.

NURS 6630 Discussion Treatment for a Patient With a Common Condition

_{Reference: Abbott, J. (2016). What’s the link between insomnia and mental illness? Health. https://www.sciencealert.com/what-exactly-is-the-link-between-insomnia-and-mental-illness#:~:text=Sleep%20problems%20such%20as%20insomnia%20are%20a%20common,bipolar%20disorder%2C%20and%20attention%20deficit%20hyperactivity%20disorder%20%28ADHD%29}

Review the case Learning Resources and the case study excerpt offered for this Discussion. Consider the therapeutic approaches you might use to analyze, diagnose, and treat the patient’s health requirements in light of the case study extract.

By the third day of Week 7,

Respond to each of the following:

Make a list of three questions you would ask the patient if she came into your clinic. Give an explanation for why you might ask these questions.
Determine who in the patient’s life you need to speak with or acquire feedback from in order to further assess the patient’s situation. Include precise questions and reasons for asking them.
Explain whether physical exams and diagnostic tests, if any, would be suitable for the patient, as well as how the results would be used.
Make a list of possible diagnoses for the patient. Choose the one you believe is most likely and explain why.
Based on pharmacokinetics and pharmacodynamics, list two pharmacologic agents and their dosing that would be appropriate for the patient’s antidepressant therapy. Provide an explanation for why you might prefer one agent over the other in terms of mechanism of action.
Identify any contraindications to usage or dosing changes that may need to be considered based on ethical prescription or decision-making for the pharmacological therapy you choose. Discuss why the contraindication or modification you’ve identified exists. That is, depending on ethical prescribing guidelines or decision-making, what would be problematic with using this drug in individuals?
Include any “check points” (e.g., follow-up data at Week 4, 8, 12, etc.) and any therapeutic changes you would make based on likely results given your treatment options.

NURS 6630 Discussion Treatment for a Patient With a Common Condition

Read some of your coworkers’ responses.

By the sixth day of Week 7,

Respond to at least two of your coworkers in one of the following ways on two different days:

Share how and why your colleagues’ posts influenced your knowledge of these issues. Include any other information you learned.
If you believe your colleagues have misconstrued these notions, express your alternate viewpoint and be sure to explain why. Include resources to back up your point of view. Read a sample of your colleagues’ replies and respond to at least two of them on two separate days.

Please keep in mind that you must complete your initial post before you may access and comment to your colleagues’ postings in this Discussion. Begin by clicking on the “Post to Discussion Question” option, then “Create Thread” to finish your first post. Remember that after you hit the Submit button, you can’t delete or change your own posts, and you can’t publish anonymously. Please double-check your post before clicking the Submit button!

NURS 6630 Discussion Treatment for a Patient With a Common Condition

SAMPLE 1

Questions and Rationale

The first question that I might ask the Patient is, “what brings you in today?”. By this question, you are forming a rapport with the Patient and making it for her to share his/her feelings openly. By asking an open-ended question, the Patient is more willing to share information with the provider (Stern, 2016). The second question that would be of beneficial knowledge during the interview is, “do you consume caffeine?” If so, how much caffeine do you consume in a day? Since caffeine consumption close to bedtime contributes significantly to insomnia. Lastly, “do you suffer from Gastro-Esophageal Reflux Disease (GERD)?”. GERD is a contributing factor to insomnia in elderly patients. The provider can rule out environmental factors by asking the above questions while assessing the Patient’s concerns with open-ended questions. (Farazdaq et al., 2018).

NURS 6630 Discussion Treatment for a Patient With a Common Condition

People in the Patient’s life, Questions, and feedback

The People in the Patient’s life that could help and give further information are her children or caretakers. Since they are in close contact with the Patient before admission to your office, questions that would be appropriate to ask the Patient’s children or caretaker would be, “Is there a recent decrease in her appetite, energy, mood, or interests?” By asking about these questions, external information will be provided, and further assessment that the Patient might be withholding or unaware of.

Appropriate Physical Examinations and Diagnostic Tests

A physical exam could be performed with the order of blood testing to rule out thyroid problems. Hyperthyroidism results in nervousness from the overactivity of this hormone, and insomnia is often a symptom. Administering the Hamilton Anxiety Rating Scale would assess the severity of the Patient’s anxiety. The HAM-A results would aid with further treatment of the Patient’s insomnia if related to anxiety. Also, insomnia relies heavily on self-report for a diagnosis (Levenson et al., 2015). Another appropriate scale to administer to this Patient is the Hamilton Depression Rating Scale. HDRS is an assessment that focuses on feelings of guilt, mood, suicidal ideation, activities, weight, various stages of insomnia, and many more critical areas (Hamilton, 1960) appropriate to the Patient’s condition.

Differential and Likely Diagnosis

The Patient has a previous diagnosis of depression. The differential diagnosis for this Patient is Generalized Anxiety Disorder (GAD), secondary to the husband’s death. There are many possible changes within the dynamics of life, such as financial stress, fear of being alone, fear of death, and sudden sleep alone. Generalized Anxiety Disorder (GAD) is characterized by persistent and excessive worry about several things. People with GAD may anticipate disaster and be overly concerned about money, health, family, work, or other issues. Individuals with GAD find it difficult to control their worries. They may worry more than seems warranted about actual events. This differential diagnosis fits the Patient given in the scenario. Changes within this Patient’s routine may be a cause of reported insomnia.

Appropriate Pharmacologic Agents

The two pharmacological agents appropriate for the Patient’s antidepressant therapy are Trazodone and Temazepam.

Trazodone is widely used for insomnia. It Is FDA approved for the treatment of major depression and used off-label for insomnia and anxiety. Trazodone inhibits serotonin reuptake, alpha-1 adrenergic receptor antagonist, and serotonin 5-HT2A and 5-HT2C receptor antagonist and is metabolized primarily through CYP3A4 to active metabolite mCPP, that is metabolized by 2D6, inducing P-glycoprotein. Trazodone, however, carries the side effect of daytime somnolence and dizziness (Cook et al., 2018).

Another good sleep aid choice is Temazepam. It is also FDA approved for insomnia and used off-label for anxiety disorders, acute mania, psychosis, and catatonia (Puzantian & Carlat, 2020). It is generally effective in the treatment of insomnia by enhancing the widespread inhibitory activity of GABA (Levenson et al., 2015). Temazepam is metabolized through the liver without CYP450. Temazepam is used to help people get to sleep. It is habit-forming and should not be used for more than seven to ten nights in a row but is safer in elderly patients, which suits the Patient in the scenario given. Although, trazodone is mainly used for its sleep-inducing effects (an off-label indication) rather than as an antidepressant. Only generic forms are available, which makes it a lot cheaper than some other sleep-inducing alternatives, and it is not classified as a controlled substance.

NURS 6630 Discussion Treatment for a Patient With a Common Condition

Contraindications and Patient Factors

The favorable medication for this Patient is Temazepam. Temazepam is a safer medication for elderly patients because of its lack of active metabolites, short half-life, and absence of drug interactions (Puzantian & Carlat, 2020). The Patient is currently taking Metformin, Januvia, Losartan, HCTZ, and Sertraline. The Patient is being treated for diabetes mellitus, hypertension, and depression based on the current medications. Adding Temazepam to the Patient’s medication regimen would not result in toxicity of other medications. Sleep is heritable and regulated by numerous genes. A genome broad association study found numerous single-nucleotide polymorphisms significantly associated with insomnia symptoms. The most significant SNPs occurred within genes involved in neuroplasticity, stress reactivity, neuronal excitability, and mental health.

Checkpoints and Therapeutic Changes.

The starting dose of Temazepam is lower in the elderly population (Puzantian & Carlat, 2020). The proper dose to begin with this Patient is Temazepam 7.5mg tab PO QHS. At the 4-week checkup, the expected outcome would be an increased ability to sleep and reduced anxiety. If these results have not been achieved, Temazepam 15mg tab PO Q HS would be ordered. Temazepam does have the risk of weakness and dizziness, so great care and caution would need to be taken when increasing the dose. There needs to be an evaluation of the effects at week 8, or sooner if needed. The maximum dose of Temazepam is 30mg PO Q HS, and even lower in the elderly (Cook et al., 2018).

NURS 6630 Discussion Treatment for a Patient With a Common Condition

Lessons Learned and Therapeutic Application

The lesson I’ve learned from the given case study is that depression and sleep have a bidirectional relationship. This means that poor sleep can contribute to the development of depression and that having depression makes a person more likely to develop sleep issues. Sleep problems often accompany most people who have experienced depression. At the same time, sleep problems can exacerbate depression, leading to a negative cycle between depression and sleep that can be challenging to break, not only to elderly patients but in all types of life development from kids to adolescents, adults up to elderly patients. Depression and sleep are closely intertwined and must be prioritized, and should not be taken lightly. I could apply this in my practice by giving health teachings, counseling, or educating patients about the basic knowledge on depression. Not to be scared to talk about their feelings to others, their healthcare provider, doctors, and families. Patients with this kind of situation are most likely to feel better after they open up their situation.

References:

Cook, B., Creedon, T., Wang, Y., Lu, C., Carson, N., Jules, P., Alegría, M. (2018). Examining racial/ethnic differences in patterns of benzodiazepine prescription and misuse. Drug and Alcohol Dependence, 187, 29-34. DOI: 10.1016/j.drugalcdep.2018.02.011

Farazdaq, H., Andrades, M., & Nanji, K. (2018, December 31). Insomnia and its correlates among elderly patients presenting to family medicine clinics at an academic center. Malaysian family physician: the official journal of the Academy of Family Physicians of Malaysia. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6382090/

https://adaa.org/understanding-anxiety/generalized-anxiety-disorder-gad

Hamilton, M. (1960). Hamilton Rating Scale for Depression. PsycTESTS Dataset, 23, 56-62. https://doi.org/10.1037/t04100-000

Levenson, J. C., Kay, D. B., & Buysse, D. J. (2015). The Pathophysiology of Insomnia. Chest, 147(4), 1179-1192. https://doi.org/10.1378/chest.14-1617

List three questions you might ask the patient if she were in your office. Provide a rationale for why you might ask these questions.

Do you drink caffeinated drinks? If yes, how many do your drink a day and at what time?

Rationale: Caffeine is a stimulant. Individuals who drink caffeine during the day cause a reduction in 6-sulfatoxymelatonin (the main metabolite of melatonin) at night, which leads to sleep disturbance (O’Callaghan et al., 2018). The lack of sleep affects cognitive functioning and psychomotor response (O’Callaghan et al., 2018).

How many hours of sleep are you getting each night?

Rationale: According to Levenson et al., when a person is living with unpleasant thoughts or worrying excessively, it can lead to sleep disturbances (2015). The decreased sleep can cause the person to worry about not getting enough sleep, leading to more anxiety and insomnia (Levenson et al., 2015).

Have you had any feelings of depression, hopelessness, or feeling down in the past month?

Rationale: Individuals who have suffered a significant loss are at high risk for depression. Individuals with depression often experience insomnia. This question is one of two that can be used to assess a patient for depression and determine if further treatment is warranted (Assessment of Depression in Adults in Primary Care, 2020). The patient’s husband died ten months ago in the given scenario. If the patient responds positively to this question, it is critical to also assess for suicide risk.

Identify people in the patient’s life you would need to speak to or get feedback from to further assess the patient’s situation. Include specific questions you might ask these people and why.

It would be important to gain information from outside sources such as family, friends, and caretakers familiar with the patient’s daily life. If possible, individuals who have been around the patient from before her husband passed until now. You could ask the patient how she got to the appointment and if someone brought her, you could ask if she would be OK with you speaking with them. There are several questions you could ask.

Have you noticed a change in her interest in doing things?

Have you she seemed down or hopeless?

How has she been eating?

Do you know if she is taking her medications or noticed any side effects from her medications?

Have you noticed any anxiety or changes in memory?

Explain what, if any, physical exams and diagnostic tests would be appropriate for the patient and how the results would be used.

Upon the initial interview, it is possible to screen the patient for depression. There are several ways this can be done. Practitioners can use the Mini-Mental State Exam MMSE), Geriatric Depression Scale Short Form (SGDS), or the Cornell Scale for Depression in Dementia (CSDD) (Brown et al., 2015). It is important to note that older adults with depression can also have dementia, so screening for dementia would also be important (Brown et al., 2015). The CSDD can detect depression in individuals with cognitive impairment. The SGDS is used because it is fairly easy and short and can detect depression in older adults (Brown et al., 2015). Laboratory testing is also important as many organic illnesses can lead to insomnia and depression. Baseline lab work should include glucose, liver function, complete blood count, Erythrocyte Sedimentation Rate, urea, creatinine, electrolytes, B-12, and Iron studies.

List a differential diagnosis for the patient. Identify the one that you think is most likely and explain why.

A differential diagnosis for depression in an elderly patient could be Vascular Depression. It is found in adults over 60 years of age and with no prior history of depression (Small, 2009). It can be found in patients with hypertension or a history of vascular disease believed to cause inflammation within the vascular system leading to the release of cytokines, especially after a stressful event (Jeon & Kim, 2018). When reviewing the patient’s medications, she is taking bother Losartan and hydrochlorothiazide to manage her hypertension, so the differential diagnosis of Vascular Depression is possible.

List two pharmacologic agents and their dosing that would be appropriate for the patient’s anti-depressant therapy based on pharmacokinetics and pharmacodynamics. From a mechanism of action perspective, provide a rationale for why you might choose one agent over the other.

The patient is currently taking Sertraline 100mg daily. If the patient takes the medication as prescribed, the patient should see improvement in depressive symptoms. The scenario does not state how long the patient has been taking Sertraline. One side effect of SSRIs is that they can cause insomnia. At this time, it is appropriate to consider augmenting the Sertraline with a low dose TCA like trazodone. Research suggests that short-term use of a TCA can improve sleep as soon as the first dose (Wichniak et al., 2017). It is important to remember that when the patient’s depression symptoms improve, the TCA should be lowered or discontinued because it can cause oversedation (Wichniak et al., 2017).

Sertraline makes it difficult to keep blood sugar stable. It can also be recommended to switch the anti-depressant to Bupropion. Studies have shown that in patients with diabetes, burproprione successfully treats depression and controls blood sugar levels (Darwish et al., 2018). It would be necessary to monitor the patient’s blood pressure as bupropion can elevate blood pressure (Darwish et al., 2018).

For the drug therapy, you select, identify any contraindications to use or alterations in dosing that may need to be considered based on ethical prescribing or decision-making. Discuss why the contraindication/alteration you identify exists. That is, what would be problematic with the use of this drug in individuals based on ethical prescribing guidelines or decision-making?

Sertraline is contraindicated in patients taking thioridazine, pimozide, or monoamine oxidase inhibitors, including linezolid or methylene blue, and it should not be taken with other serotonergic medications (Singh & Saadabad, 2020). Buspirone is contradicted in patients with kidney and liver disease as the drug’s effects may increase due to slow kidney or liver removal. Trazadone is contraindicated for anyone taking an MAOI or has taken an MAOI in the past 14 days (Shin & Saadabadi, 2020).

Include any “check points” (i.e., follow-up data at Week 4, 8, 12, etc.), and indicate any therapeutic changes that you might make based on possible outcomes that may happen given your treatment options chosen.

It would be necessary to follow up with the patient in four weeks to see if adding Trazadone improves the patient’s sleep. If there is no improvement in the patient’s sleep or depressive symptoms, it would be time to consider changing the patient’s medication to buspirone.

References

Assessment of depression in adults in primary care [PDF]. (2020). Best Practice Medicine Journal New Zealand. https://bpac.org.nz/magazine/2009/Adultdep/docs/bpjse_adult_dep_assess_pages8- 12.pdf

Brown, E., Raue, P. J., & Halpert, K. (2015). Evidence-based practice guideline: Depression detection in older adults with dementia. Journal of Gerontological Nursing, 41(11), 15– 21. https://doi.org/10.3928/00989134-20151015-03

Darwish, L., Beroncal, E., Sison, M., & Swardfager, W. (2018). Depression in people with type 2 diabetes: Current perspectives. Diabetes, Metabolic Syndrome and Obesity: Targets and Therapy, Volume 11, 333–343. https://doi.org/10.2147/dmso.s106797

Jeon, S., & Kim, Y.-K. (2018). The role of neuroinflammation and neurovascular dysfunction in major depressive disorder. Journal of Inflammation Research, Volume 11, 179–192. https://doi.org/10.2147/jir.s141033

Levenson, J. C., Kay, D. B., & Buysse, D. J. (2015). The pathophysiology of insomnia. Chest, 147(4), 1179–1192. https://doi.org/10.1378/chest.14-1617

O’Callaghan, F., Muurlink, O., & Reid, N. (2018). Effects of caffeine on sleep quality and daytime functioning. Risk Management and Healthcare Policy, Volume 11, 263–271. https://doi.org/10.2147/rmhp.s156404

Park, L. T., & Zarate, C. A. (2019). Depression in the primary care setting. New England Journal of Medicine, 380(6), 559–568.https://doi.org/10.1056/nejmcp1712493

Shin, J., & Saadabadi, A. (2020). Trazadone. StatPearls. https://doi.org/https://www.ncbi.nlm.nih.gov/books/NBK470560/

Singh, H. K., & Saadabad, A. (2020). Sertraline. StatPearls. https://doi.org/https://www.ncbi.nlm.nih.gov/books/NBK547689/

Small, G. W. (2009). Differential diagnoses and assessment of depression in elderly patients. The Journal of Clinical Psychiatry, 70(12), e47. https://doi.org/10.4088/jcp.8001tx20c

Wichniak, A., Wierzbicka, A., Walęcka, M., & Jernajczyk, W. (2017). Effects of antidepressants on sleep. Current Psychiatry Reports, 19(9). https://doi.org/10.1007/s11920-017-0816-4

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Week 7 Discussion

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Edwina Etienne

07/12/2022

Case: An elderly widow who just lost her spouse.

Subjective: A patient presents to your primary care office today with chief complaint of insomnia. Patient is 75 YO with PMH of DM, HTN, and MDD. Her husband of 41 years passed away 10 months ago. Since then, she states her depression has gotten worse as well as her sleep habits. The patient has no previous history of depression prior to her husband’s death. She is awake, alert, and oriented x3. Patient normally sees PCP once or twice a year. Patient denies any suicidal ideations. Patient arrived at the office today by private vehicle. Patient currently takes the following medications:

Metformin 500mg BID
Januvia 100mg daily
Losartan 100mg daily
HCTZ 25mg daily
Sertraline 100mg daily

Current weight: 88 kg

Current height: 64 inches

Temp: 98.6 degrees F

BP:132/86

Post a response to each of the following:

List three questions you might ask the patient if she were in your office. Provide a rationale for why you might ask these questions.
Identify people in the patient’s life you would need to speak to or get feedback from to further assess the patient’s situation. Include specific questions you might ask these people and why.
Explain what, if any, physical exams, and diagnostic tests would be appropriate for the patient and how the results would be used.
List a differential diagnosis for the patient. Identify the one that you think is most likely and explain why.
List two pharmacologic agents and their dosing that would be appropriate for the patient’s antidepressant therapy based on pharmacokinetics and pharmacodynamics. From a mechanism of action perspective, provide a rationale for why you might choose one agent over the other.
For the drug therapy you select, identify any contraindications to use or alterations in dosing that may need to be considered based on the client’s ethnicity. Discuss why the contraindication/alteration you identify exists. That is, what would be problematic with the use of this drug in individuals of other ethnicities?
Include any “check points” (i.e., follow-up data at Week 4, 8, 12, etc.), and indicate any therapeutic changes that you might make based on possible outcomes that may happen given your treatment options chosen.