NURS 6630 treatment of Insomnia

1. Explain the agonist-to-antagonist spectrum of action of psychopharmacologic agents, including how partial and inverse agonist functionality may impact the efficacy of psychopharmacologic treatments.

An agonist-to-antagonist spectrum of action of psycho pharmacologic agents, -is explained as when a chemical binds or connect to a receptor, the receptor activates, and a biological response is produced. When agonists activate receptors, like hormones, neurotransmitters, and other endogenous regulators that activate the receptors to which they bind (Golier, J. A., & Yehuda, R. (2018). Antagonists have no effects on the receptor function, but it can block effectiveness and prevent receptor activation by endogenous molecules and drugs(Golier, J. A., & Yehuda, R. (2018).The antagonist can be a drug with an affinity to bind to a receptor but does not have any intrinsic activity.  The process is considered an example of a full agonist (Golier, J. A., & Yehuda, R. (2018).  A partial agonist means that the molecules do not elicit a full response therefore does not obtain the maximum response from system even when they bind to the same number of receptors as an agonist (Golier, J. A., & Yehuda, R. (2018). When there is an agonist and a partial agonist working at the same time the partial agonist becomes an antagonist because they are both fighting for space on the same receptors (Frånberg, O et al).. An antagonist refers to molecules that block agonist mediated responses. Inverse agonists are molecules that want to attach to the same receptors as agonists, but they produce an opposite response than the agonist on the target cell (Golier, J. A., & Yehuda, R. (2018).

1. Compare and contrast the actions of g couple proteins and ion gated channels.

G protein-coupled receptors (GPCRs) are a large family of cell surface receptors on the plasma membrane that transmit signals inside the cell through a type of protein called a G protein (Sunamita de Carvalho et al 2018).  G protein-coupled receptors serve many purposes in the body, and the disorder of GPCR signaling can cause disease. G proteins bind with nucleotide guanosinetriphosphate (GTP) (Sunamita de Carvalho et al 2018). G protein divides into two portions (one called the α subunit, the other consisting of the β and γ subunits), which are released from the GPCR (Sunamita de Carvalho et al 2018). The subunits can interact with other proteins, triggering other signaling pathways that lead to different responses.

When communication is allow to  occur from  one cell to  the next cell through a lipid membrane, charged molecules need assistance in the form of ion channels (Sunamita de Carvalho et al 2018). Ion channels control cellular excitability by using membrane-bound glycol proteins that contain pores filled with water (ion channels) which allows for the charged molecules to move from an extracellular to intracellular (Sunamita de Carvalho et al 2018). Charged molecules can go into the cell while allowing for uncharged molecules to move out of the cell in an organized, efficient manner. This movement of ions is important in the role of cell excitation, muscle contraction and intracellular signaling (Weir, 2020). G-protein-coupled receptors (GPCRs) are the largest category of receptors allowing for the bodies physiological function (Sunamita de Carvalho et al 2018). Most medications are made to target GPCRs due to their large distribution throughout the body. They are necessary membrane proteins used by cells to convert extracellular signals into intracellular responses by using hormones (Sunamita de Carvalho et al 2018).

1. Explain how the role of epigenetics may contribute to pharmacologic action.

Epigenetics is when the expression of a gene can be controlled, promoting or repressing the expression of the gene without changing the code or genome’s sequence (Kumsta, R. 2019).Epigenetics is  gene function is changed by an adaptation in the code. The role of epigenetics may contribute to pharmacologic action by changing a DNA molecule, resulting in amended gene expression. When a DNA molecule is amended, then pharmacologic action is then modified. Gene articulation can be modified because of the variation of the DNA molecule chromatin. Long-term effects of cognition and behavior can be a result of the alteration of development brought on by abuse or mistreatment in childhood (Kumsta, R. 2019). Heritability is an effect of gene expression changes in the long-term

1. Explain how this information may impact the way you prescribe medications to patients. Include a specific example of a situation or case with a patient in which the psychiatric mental health nurse practitioner must be aware of the medication’s action.

As a provider, when prescribing medication, it is necessary to treat each patient as individual patient with his or her own familiar history. The assessment should include genetic questing that will be use for the implementation of diagnosing implementation for treatment. Will also access for allergy since most antipsychotics’ medication are commonly cause allergy reaction. Closely monitor medications prescribed for the treatment of psychosis and behavioral and psychological symptoms of dementia in elderly patients for any adverse reaction (Kumsta, R. 2019)   Monitoring should always continue; it should not only be at the beginning of the therapy because patient can develop tolerance to medication and eventually medication or doses that use to work might not work. Doses should be monitor and adjusted appropriately.   Also, since aging can affect drug metabolism and clearance, additional pharmacokinetic and pharmacodynamic changes  require additional attention (Kumsta, R. 2019).

References:

Sunamita de Carvalho Lima, Lucas de Carvalho Porta, Álvaro da Costa Lima, Joana D’Arc Campeiro, Ywlliane Meurer, Nathália Bernardes Teixeira, Thiago Duarte, Eduardo Brandt Oliveira, Gisele Picolo, Rosely Oliveira Godinho, Regina Helena Silva, & Mirian Akemi Furuie Hayashi. (2018). Pharmacological characterization of crotamine effects on mice hind limb paralysis employing both ex vivo and in vivo assays: Insights into the involvement of voltage-gated ion channels in the crotamine action on skeletal muscles. PLoS Neglected Tropical Diseases, 12(8), e0006700. https://doi.org/10.1371/journal.pntd.0006700

Frånberg, O., Wiker, C., Marcus, M., Konradsson, Å., Jardemark, K., Schilström, B., Shahid, M., Wong, E., & Svensson, T. (2008). Asenapine, a novel psychopharmacologic agent: preclinical evidence for clinical effects in schizophrenia. Psychopharmacology, 196(3), 417–429. https://doi.org/10.1007/s00213-007-0973-y

Kumsta, R. (2019). The role of epigenetics for understanding mental health difficulties and its implications for psychotherapy research. Psychology and Psychotherapy: Theory, Research and Practice, 92(2), 190–207. https://doi.org/10.1111/papt.12227

Golier, J. A., & Yehuda, R. (2018). Mifepristone as a Psychopharmacologic Agent: Consideration of Efficacy, Plasma Levels, and Mechanism of Action. Biological Psychiatry, 84(1), 5–

Sample Answer 3 for NURS 6630 treatment of Insomnia

The case depicts a 31-year-old male patient with a complaint of deteriorating insomnia for six months now. He states that he is experiencing problems falling and remaining asleep at night. The patient reports that the sleeping difficulties began after the death of his fiancé six months ago. He is concerned that the problem impairs his job performance because he falls asleep when working because of inadequate sleep at night.  He has previously taken diphenhydramine to stimulate sleep, but he dislikes its morning side effect. His medical history reveals an opiate abuse history following a hydrocodone/apap prescription, but he has not gotten an opiate analgesic prescription in the last four years. He reports consuming alcohol to induce sleep, roughly four beers before going to bed. His MSE is unremarkable with no identified hallucinations and intact judgment, reality contact, and insight. Besides, he is future-oriented and denies having suicidal or homicidal ideations.

The treatment plan for persons with insomnia is influenced by medical history, history of abuse, response to previous treatments, comorbidities, current medications, side effects, and cost. Consequently, each treatment plan should be individualized as per the patient’s factors but should aim at attaining the key goals of improving sleep quality and quantity and lessening insomnia-associated daytime impairments. The patient factors that may impact treatment decisions include his history of opiate abuse and response to past treatments with hydrocodone/apap. The clinician will have to avoid drugs that have a potential for abuse to prevent relapse of abuse and drugs that are in the same class with hydrocodone/apap.

Decision Point One

Begin Zolpidem 10 mg daily at bedtime.

Why Did I Select This Decision?

I selected Zolpidem, benzodiazepine receptor agonists, which is the currently preferred treatment of insomnia. Zolpidem is the first-line drug for sleep onset and maintenance and allows for 7–8 hours of total sleep time (Bragg et al., 2019). Jeffar et al. (2017) found that Zolpidem improves subjective sleep latency and effectively treats insomnia connected to difficulty with sleep latency and maintenance.

Why Did I Not Select the Other Two Options Provided?

I did not select Trazodone because it is not an FDA-approved drug for insomnia and is usually used as an off-label drug. According to Matheson and Hainer (2017), the evidence supporting Trazodone in insomnia treatment is weak, and it should not be considered first-line treatment. I did not opt for Hydroxyzine because it is an antihistamine in the same class as hydrocodone/apap. According to Bragg et al. (2019), antihistamines are associated with next-day sedating effects, and some patients experience paradoxical reactions such as anxiety and agitation.

What I Was Hoping to Achieve By Making This Decision

I was hoping that initiating Zolpidem would improve sleep latency, increase the patient’s quality and duration of sleep, and reduce daytime sleepiness. According to Liu (2020), Zolpidem improves sleep latency, total sleep time, and sleep quality and may reduce wake time after sleep onset.

Ethical Considerations Impacting the Treatment Plan and Communication

Ethical considerations that influenced the treatment plan include nonmaleficence and autonomy. Nonmaleficence is the moral duty to cause no harm, while autonomy entails respecting a patient’s treatment decisions (Bipeta, 2019). Nonmaleficence impacted the treatment plan since the drug options were evaluated for side effects, and those with debilitating effects were not selected. Autonomy impacted communication since the PMHNP had to seek consent to initiate treatment and before sharing the patient information with a third party.

Decision Point Two

Discontinue Zolpidem. Initiate therapy with trazodone 50–100 mg daily at bedtime

Why Did I Select This Decision?

I discontinued Zolpidem because it was associated with parasomnia of sleepwalking, which explains the patient’s memory loss. I started Trazodone because it is recommended as an off-label agent to treat primary and secondary insomnia at doses of 50-100 mg. According to Liu (2020), Trazodone is an antidepressant, primarily a serotonin antagonist and reuptake inhibitor with a low anticholinergic and moderate antihistamine activity. The efficacy of Trazodone has been established in increasing sleep quality and duration and reducing sleep latency.

Why Did I Not Select the Other Two Options Provided?

I did not decrease the zolpidem dose because the drug is associated with rare side effects of parasomnias such as sleepwalking, Sleep-Related Eating Disorder, and sleep-driving, which occurred in the patient (Bragg et al., 2019).  I did not initiate Eszopiclone due to its unpleasant taste that affects almost one-third of patients (Matheson & Hainer, 2017). Besides, it a Z-drug associated with an abuse potential, which can trigger the patient’s abuse.

What I Was Hoping to Achieve By Making This Decision

I was hoping that prescribing Trazodone would improve the quality of the patient’s sleep, increase sleep duration, and reduce daytime sleepiness within two weeks of starting treatment. I was also hoping that the patient’s adverse effects of sleepwalking and memory loss would also abate. Jeffar et al. (2017) conducted a literature review, which established that there is adequate evidence supporting the efficacy and safety of Trazodone in low doses to treat insomnia.

Ethical Considerations Impacting the Treatment Plan and Communication

Beneficence and nonmaleficence impacted the treatment plan since the PMHNP had a duty to promote better health outcomes and prevent harm to the patient (Bipeta, 2019). The PMHNP changed treatment to reduce adverse effects of memory loss and parasomnia and improve sleep latency, quality, and duration, which upholds beneficence, and nonmaleficence.

Decision Point Three

Continue Trazodone dose and explain to the patient that he may split the 50 mg tablet in half. Follow up in 4 weeks.

Why Did I Select This Decision?

I selected this decision because the patient reported having next-day drowsiness. Drowsiness is a common adverse effect of Trazodone, which explains the patient’s concerns. I advised the patient to split the dose to reduce the side effect. Jaffer et al. (2017) explain that at low doses of 25 mg, trazodone triggers and maintains sleep without side effects of daytime drowsiness or tolerance due to its short half-life of 3–6 hours.

Why Did I Not Select the Other Two Options Provided?

I did not begin treatment with Sonata because it is a Z-drug associated with complex behaviors, such as sleep eating, sleep-driving, and sleepwalking (Liu, 2020). It has the potential of causing side effects of sleepwalking as Zolpidem. It also has the potential of abuse which may cause a relapse of the patient’s abuse problem (Matheson & Hainer, 2017). I did not initiate Hydroxyzine because it is associated with blurred vision, dry mouth, increased heart rate, memory problems, difficulty urinating, and confusion, impairing the patient’s quality of life.

What I Was Hoping To Achieve By Making This Decision

I was hoping that reducing the Trazodone dose by half would reduce drowsiness. Jaffer et al. (2017) found that low doses of Trazodone 25 mg for insomnia have little to no adverse effects in non-depressed persons. Drowsiness in trazodone use is dose-dependent, and reducing the dose thus minimizes it.

Ethical Considerations Impacting the Treatment Plan and Communication

The treatment plan was impacted by the principles of beneficence and nonmaleficence, which requires the clinician to provide benefits and balance benefits and harm (Bipeta, 2019). In this case, the PMHNP reduced the dose to reduce the harm of the drug but maintained the drug to promote its associated benefits.

Conclusion

The case study presented a scenario of a patient with insomnia manifesting with difficulties falling and maintaining sleep. Patient factors that would influence the treatment plan include response to past treatments and history of opiate abuse. In the first step, I initiated the patient on Zolpidem 10 mg daily at bedtime because it is a recommended first-line medication to treat insomnia. It also improves insomnia by reducing sleep latency and increasing total sleep time (Bragg et al., 2019). However, Zolpidem was associated with side effects of sleepwalking, attributed to its documented but rare side effects of parasomnias (Bragg et al., 2019).  In decision two, I discontinued Zolpidem and initiated Trazodone 50-100 mg at bedtime. I initiated Trazodone because its efficacy and safety have been demonstrated for primary and secondary insomnia.

In decision three, I maintained treatment with Trazodone but advised the patient to divide the dose in half to minimize drowsiness. The decision was guided by evidence that shows that low doses of Trazodone have little to no adverse effects (Jaffer et al., 2017). Ethical considerations that influenced the treatment plan and communication with the patient include nonmaleficence, beneficence, and autonomy. Nonmaleficence and beneficence guided the PMHNP to evaluate the associated benefits and side effects of a drug (Bipeta, 2019). Lastly, autonomy required the PMHNP to obtain consent before initiating treatment or sharing the patient’s information.

References

Bipeta, R. (2019). Legal and Ethical Aspects of Mental Health Care. Indian journal of psychological medicine, 41(2), 108–112. https://doi.org/10.4103/IJPSYM.IJPSYM_59_19

Bragg, S., Benich, J. J., Christian, N., Visserman, J., & Freedy, J. (2019). Updates in insomnia diagnosis and treatment. The International Journal of Psychiatry in Medicine, 54(4-5), 275-289. https://doi.org/10.1177/0091217419860716

Jaffer, K. Y., Chang, T., Vanle, B., Dang, J., Steiner, A. J., Loera, N., Abdelmesseh, M., Danovitch, I., & Ishak, W. W. (2017). Trazodone for insomnia: a systematic review. Innovations in clinical neuroscience, 14(7-8), 24–34.

Liu, M. T. (2020). Current and emerging therapies for insomnia. Am J Manag Care, 26(4 Suppl), S85-S90.

Matheson, E., & Hainer, B. L. (2017). Insomnia: pharmacologic therapy. American family physician, 96(1), 29-35.

Also Read:

NURS 6630 major depressive disorder (MDD), obsessive compulsive disorder(OCD), panic disorder, posttraumatic stress disorder (PTSD), social anxiety disorder and premenstrual dysphoric disorder (PMDD)

NURS 6630 Post-Traumatic Stress Disorder (PTSD)

NURS 6630 characteristic of generalized anxiety disorder

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

NURS 6630 Case Study 53-year-old Puerto Rican Female with Comorbid Addiction