Psychological disorders, such as depression, bipolar, and anxiety disorders can present several complications for patients of all ages. These disorders affect patients physically and emotionally, potentially impacting judgment, school and/or job performance, and relationships with family and friends. Since these disorders have many drastic effects on patients’ lives, it is important for advanced practice nurses to effectively manage patient care. With patient factors and medical history in mind, it is the advanced practice nurse’s responsibility to ensure the safe and effective diagnosis, treatment, and education of patients with psychological disorders.

For this Discussion, you will select an interactive media piece to practice decision making when treating patients with psychological disorders. You will recommend the most effective pharmacotherapeutic to treat the psychological disorder presented and examine potential impacts of pharmacotherapeutics on a patient’s pathophysiology.

· Review this week’s interactive media pieces and select one to focus on for this Discussion.

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· Reflect on the decision steps in the interactive media pieces, and consider the potential impacts from the administration of the associated pharmacotherapeutics on the patient’s pathophysiology.

Post a brief explanation of the psychological disorder presented and the decision steps you applied in completing the interactive media piece for the psychological disorder you selected. Then, explain how the administration of the associated pharmacotherapeutics you recommended may impact the patient’s pathophysiology. How might these potential impacts inform how you would suggest treatment plans for this patient? Be specific and provide examples.

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Adult/Geriatric Depression

Adult/Geriatric Depression
Hispanic Male With MDD

BACKGROUND INFORMATION

The client is a 70 year-old Hispanic American male who came to the United States when he was in high school with his father. His mother died back in Mexico when he was in school. He presents today to your office for an initial appointment for complaints of depression.
The client was referred by his PCP after “routine” medical work-up to rule out an organic basis for his depression. He has no other health issues with the exception of some occasional back pain and “stiff” shoulders which he attributes to his current work as a laborer in a warehouse.

SUBJECTIVE

During today’s clinical interview, client reports that he always felt like an outsider as he was “teased” a lot for being “black” in high school. States that he had few friends, and basically kept to himself. He describes his home life as “good.” Stating “Dad did what he could for us, there were 8 of us.” He also reports a remarkably diminished interest in engaging in usual activities, states that he has gained 15 pounds in the last 2 months. He is also troubled with insomnia which began about 6 months ago, but have been progressively getting worse. He does report poor concentration which he reports is getting in “trouble” at work.

MENTAL STATUS EXAM

The client is alert, oriented to person, place, time, and event. He is casually dressed. Speech is clear, but soft. He does not readily make eye contact, but when he does, it is only for a few moments. He is endorsing feelings of depression. Affect is somewhat constricted, but improves as the clinical interview progresses. He denies visual or auditory hallucinations, no overt delusional or paranoid thought processes readily apparent. Judgment and insight appear grossly intact. He is currently denying suicidal or homicidal ideation.
You administer the “Montgomery- Asberg Depression Rating Scale (MADRS)” and obtained a score of 51 (indicating severe depression).

RESOURCES

§ Montgomery, S. A., & Asberg, M. (1979). A new depression scale designed to be sensitive to change. British Journal of Psychiatry, 134, 382-389.

Decision Point One

Select what you should do:

Begin zoloft 25 mg orally daily

Begin Effexor XR 37.5 mg orally daily

Begin Phenelzine 15 mg orally TID

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Adult/Geriatric Depression

Adult/Geriatric Depression
Hispanic Male With MDD

Decision Point One

Begin zoloft 25 mg orally daily

RESULTS OF DECISION POINT ONE

• Client returns to clinic in four weeks
• Reports a 25% decrease in symptoms
• Client is concerned over the new onset of erectile dysfunction

Decision Point Two

Select what you should do next:

Decrease dose to 12.5 mg orally daily

RESULTS OF DECISION POINT TWO

Client returns to clinic in four weeks
• Erectile dysfunction has subsided
• Depressive symptoms have worsened

Decision Point Three

Select what you should do next:

Increase dose back to 25 mg orally daily

Guidance to Student
Increasing dose back to 25 mg orally daily may be appropriate as there is no guarantee that the side effect will return. If it does return at 25 mg orally daily, then you should consider changing to another drug. Changing to Paxil 20 mg may also be appropriate at this point, as not all SSRIs have the same side effect profile. Changing to an SNRI would not be appropriate at this point as the issue is not that the client has not responded to SSRI therapy, rather, he has had a negative side effect to one drug in the class.
Start Over

Change to Paxil 20 mg orally daily

Guidance to Student
Increasing dose back to 25 mg orally daily may be appropriate as there is no guarantee that the side effect will return. If it does return at 25 mg orally daily, then you should consider changing to another drug. Changing to Paxil 20 mg may also be appropriate at this point, as not all SSRIs have the same side effect profile. Changing to an SNRI would not be appropriate at this point as the issue is not that the client has not responded to SSRI therapy, rather, he has had a negative side effect to one drug in the class.
Start Over

Change to Cymbalta 40 mg orally daily

Guidance to Student
Increasing dose back to 25 mg orally daily may be appropriate as there is no guarantee that the side effect will return. If it does return at 25 mg orally daily, then you should consider changing to another drug. Changing to Paxil 20 mg may also be appropriate at this point, as not all SSRIs have the same side effect profile. Changing to an SNRI would not be appropriate at this point as the issue is not that the client has not responded to SSRI therapy, rather, he has had a negative side effect to one drug in the class.
Start Over

Continue same dose and counsel client

RESULTS OF DECISION POINT TWO

Client returns to clinic in four weeks
• Client informed you that he stopped taking the drug because his inability to perform sexually was worsening his self-esteem

Decision Point Three

Select what you should do next:

Encourage client to re-start drug at previous dose

Guidance to Student
Encouraging client to restart at previous dose would not be appropriate. Obviously, the side effect did not abate- so there is no reason to assume that it would abate at the previous dose. Re-starting the drug at 50% of starting dose may be appropriate to determine whether or not side effect is dose dependent. If the side effect of erectile dysfunction returns once the drug is returned to full dose, you would need to change the drug. Changing to Wellbutrin XL may be appropriate at this point, but may worsen his insomnia. Additionally, guidelines tell us that another SSRI should be attempted for an adequate trial before switching drug classes.
Start Over

Re-start drug at 50% initial dose

Guidance to Student
Encouraging client to restart at previous dose would not be appropriate. Obviously, the side effect did not abate- so there is no reason to assume that it would abate at the previous dose. Re-starting the drug at 50% of starting dose may be appropriate to determine whether or not side effect is dose dependent. If the side effect of erectile dysfunction returns once the drug is returned to full dose, you would need to change the drug. Changing to Wellbutrin XL may be appropriate at this point, but may worsen his insomnia. Additionally, guidelines tell us that another SSRI should be attempted for an adequate trial before switching drug classes.
Start Over

Change to Wellbutrin XL

Guidance to Student
Encouraging client to restart at previous dose would not be appropriate. Obviously, the side effect did not abate- so there is no reason to assume that it would abate at the previous dose. Re-starting the drug at 50% of starting dose may be appropriate to determine whether or not side effect is dose dependent. If the side effect of erectile dysfunction returns once the drug is returned to full dose, you would need to change the drug. Changing to Wellbutrin XL may be appropriate at this point, but may worsen his insomnia. Additionally, guidelines tell us that another SSRI should be attempted for an adequate trial before switching drug classes.
Start Over

Add augmenting agent such as Wellbutrin IR 150 mg in morning

RESULTS OF DECISION POINT TWO

Client returns to clinic in four weeks
• Client stated that depressive symptoms have decreased even more and his erectile dysfunction has abated
• Client reports that he has been feeling “jittery” and sometimes “nervous”

Decision Point Three

Select what you should do next:

Discontinue Zoloft altogether and continue with Wellbutrin

Guidance to Student
You should be aware that Zoloft or Wellbutrin could be responsible for the client complaints of Jitteriness. This feeling is usually temporary with SSRIs, however. The cause of the client’s complaint of “jitteriness” is most likely related to the Wellbutrin immediate release. As a result, the most appropriate answer would be to change the Wellbutrin to an extended release formulation. It would not be appropriate to add Ativan as you should never add an additional medication to treat the side effect of another medication without first attempting to modify/change the medication causing the side effect.
Start Over

Change Wellbutrin to XL 150 mg orally daily in AM

Guidance to Student
You should be aware that Zoloft or Wellbutrin could be responsible for the client complaints of Jitteriness. This feeling is usually temporary with SSRIs, however. The cause of the client’s complaint of “jitteriness” is most likely related to the Wellbutrin immediate release. As a result, the most appropriate answer would be to change the Wellbutrin to an extended release formulation. It would not be appropriate to add Ativan as you should never add an additional medication to treat the side effect of another medication without first attempting to modify/change the medication causing the side effect.
Start Over

Add Ativan 0.5 mg orally TID/PRN for anxiety

Guidance to Student
You should be aware that Zoloft or Wellbutrin could be responsible for the client complaints of Jitteriness. This feeling is usually temporary with SSRIs, however. The cause of the client’s complaint of “jitteriness” is most likely related to the Wellbutrin immediate release. As a result, the most appropriate answer would be to change the Wellbutrin to an extended release formulation. It would not be appropriate to add Ativan as you should never add an additional medication to treat the side effect of another medication without first attempting to modify/change the medication causing the side effect.
Start Over

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Adult/Geriatric Depression

Adult/Geriatric Depression
Hispanic Male With MDD

Decision Point One

Begin Effexor XR 37.5 mg orally daily

RESULTS OF DECISION POINT ONE

• Client returns to clinic in four weeks
• Client reports that there is no change in depressive symptoms at all

Decision Point Two

Select what you should do next:

Increase dose to 75 mg of Effexor XR orally daily

RESULTS OF DECISION POINT TWO

Client returns to clinic in four weeks
• Client reports an improvement in depressive symptoms
• Montgomery- Asberg Depression Rating Scale (MADRS) decreased from 51 to 38 (25% reduction)

Decision Point Three

Select what you should do next:

Increase dose to 112.5 mg orally daily

Guidance to Student
At this point, you would have two choices to discuss with the client- the current dose of drug can be maintained if the client is feeling better and is not offering any complaints of side effects. The dose can also be increased at this point, but you must counsel client regarding the possibility of side effects. The use of an augmenting agent is not appropriate at this time as we have not reached a maximum dose with Effexor (in fact, 75 mg is still a relatively small dose), displaying primarily SSRI properties only (recall that at lower doses, Effexor exerts a greater effect on serotonergic receptors than norepinephrine at low doses).
Start Over

Continue same dose of medication

Guidance to Student
At this point, you would have two choices to discuss with the client- the current dose of drug can be maintained if the client is feeling better and is not offering any complaints of side effects. The dose can also be increased at this point, but you must counsel client regarding the possibility of side effects. The use of an augmenting agent is not appropriate at this time as we have not reached a maximum dose with Effexor (in fact, 75 mg is still a relatively small dose), displaying primarily SSRI properties only (recall that at lower doses, Effexor exerts a greater effect on serotonergic receptors than norepinephrine at low doses).
Start Over

Augment with Wellbutrin XL 150 mg orally daily

Guidance to Student
At this point, you would have two choices to discuss with the client- the current dose of drug can be maintained if the client is feeling better and is not offering any complaints of side effects. The dose can also be increased at this point, but you must counsel client regarding the possibility of side effects. The use of an augmenting agent is not appropriate at this time as we have not reached a maximum dose with Effexor (in fact, 75 mg is still a relatively small dose), displaying primarily SSRI properties only (recall that at lower doses, Effexor exerts a greater effect on serotonergic receptors than norepinephrine at low doses).
Start Over

Change to Cymbalta 30 mg orally daily

RESULTS OF DECISION POINT TWO

Client returns to clinic in four weeks
• Client reports that his depressive symptoms are “not really any better”
• Client has noticed that his back pain and shoulder stiffness have improved, which he was not expecting
• Client is asking if he could be kept on the current medication due to its favorable effect on his pain

Decision Point Three

Select what you should do next:

Continue current dose of Cymbalta

Guidance to Student
Maintaining the current dose would be appropriate if the client were showing an improvement in depressive symptoms, but since he is not showing improvement, something needs to be done. Increasing Cymbalta to 60 mg orally daily would be the most appropriate choice as 30 mg is a small dose, and with an effective dose range of 60 to 120 mg orally daily, it would be prudent to increase the client’s dose to a therapeutic dose. Changing to Elavil, a tricyclic antidepressant is not the best choice as it can be associated with increased side effects and although it can treat pain symptoms as well, there is no indication that changing drug therapy at this point would be appropriate as we have not trialed the client with an adequate duration or dose of Cymbalta. It is always beneficial when we can select medications that will treat co-morbid conditions. So Cymbalta should be trialed at an appropriate dose for an appropriate duration to treat the clients pain and depression.
Start Over

Increase Cymbalta to 60 mg orally daily

Guidance to Student
Maintaining the current dose would be appropriate if the client were showing an improvement in depressive symptoms, but since he is not showing improvement, something needs to be done. Increasing Cymbalta to 60 mg orally daily would be the most appropriate choice as 30 mg is a small dose, and with an effective dose range of 60 to 120 mg orally daily, it would be prudent to increase the client’s dose to a therapeutic dose. Changing to Elavil, a tricyclic antidepressant is not the best choice as it can be associated with increased side effects and although it can treat pain symptoms as well, there is no indication that changing drug therapy at this point would be appropriate as we have not trialed the client with an adequate duration or dose of Cymbalta. It is always beneficial when we can select medications that will treat co-morbid conditions. So Cymbalta should be trialed at an appropriate dose for an appropriate duration to treat the clients pain and depression.
Start Over

Discontinue Cymbalta and begin Elavil 25 mg orally daily

Guidance to Student
Maintaining the current dose would be appropriate if the client were showing an improvement in depressive symptoms, but since he is not showing improvement, something needs to be done. Increasing Cymbalta to 60 mg orally daily would be the most appropriate choice as 30 mg is a small dose, and with an effective dose range of 60 to 120 mg orally daily, it would be prudent to increase the client’s dose to a therapeutic dose. Changing to Elavil, a tricyclic antidepressant is not the best choice as it can be associated with increased side effects and although it can treat pain symptoms as well, there is no indication that changing drug therapy at this point would be appropriate as we have not trialed the client with an adequate duration or dose of Cymbalta. It is always beneficial when we can select medications that will treat co-morbid conditions. So Cymbalta should be trialed at an appropriate dose for an appropriate duration to treat the clients pain and depression.
Start Over

Augment with an atypical antipsychotic

RESULTS OF DECISION POINT TWO

Client returns to clinic in four weeks
• Client reports that he has gained about 9 pounds in the past month
• Client states that his depression was a little better but his self-esteem is worsening as he is gaining weight

Decision Point Three

Select what you should do next:

Discontinue atypical antipsychotic

Guidance to Student
At this point, discontinuation of the atypical antipsychotic would be appropriate. It has contributed minimally to the client’s depressive symptoms, but has instead, decreased self-esteem due to weight gain. Weight gain associated with atypical antipsychotics can also represent a health issue due to its contribution to dyslipidemia, and hyperglycemia. Increasing the dose would most likely worsen these symptoms. If an atypical antipsychotic were needed to augment the antidepressant medication, it would be appropriate to counsel client about diet and exercise to decrease weight gain associated with atypical antipsychotic usage. However, antipsychotics should be discontinued and you should counsel client to help with weight loss caused by the atypical antipsychotic.
Start Over

Increase dose of atypical antipsychotic

Guidance to Student
At this point, discontinuation of the atypical antipsychotic would be appropriate. It has contributed minimally to the client’s depressive symptoms, but has instead, decreased self-esteem due to weight gain. Weight gain associated with atypical antipsychotics can also represent a health issue due to its contribution to dyslipidemia, and hyperglycemia. Increasing the dose would most likely worsen these symptoms. If an atypical antipsychotic were needed to augment the antidepressant medication, it would be appropriate to counsel client about diet and exercise to decrease weight gain associated with atypical antipsychotic usage. However, antipsychotics should be discontinued and you should counsel client to help with weight loss caused by the atypical antipsychotic.
Start Over

Counsel client about diet and exercise

Guidance to Student
At this point, discontinuation of the atypical antipsychotic would be appropriate. It has contributed minimally to the client’s depressive symptoms, but has instead, decreased self-esteem due to weight gain. Weight gain associated with atypical antipsychotics can also represent a health issue due to its contribution to dyslipidemia, and hyperglycemia. Increasing the dose would most likely worsen these symptoms. If an atypical antipsychotic were needed to augment the antidepressant medication, it would be appropriate to counsel client about diet and exercise to decrease weight gain associated with atypical antipsychotic usage. However, antipsychotics should be discontinued and you should counsel client to help with weight loss caused by the atypical antipsychotic.
Start Over

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Adult/Geriatric Depression

Adult/Geriatric Depression
Hispanic Male With MDD

Decision Point One

Begin Phenelzine 15 mg orally TID

RESULTS OF DECISION POINT ONE

• Client returns to clinic in four weeks
• Client reports that he was rushed to the Emergency Room 2 weeks ago after collapsing at the warehouse where he works. He was taken by ambulance to the local community hospital. He was diagnosed with postural hypotension
• Client was treated with fluid bolus and told to stop taking his phenelzine and to follow up with his primary care provider within one week, and you within that same time frame

Decision Point Two

Select what you should do next:

Restart Phenelzine and counsel client on dietary choices and importance of hydration

RESULTS OF DECISION POINT TWO

• Client reports that although he had no more episodes of passing out, he has been dizzy when he gets up at night to use the bathroom
• Client also reports that at various times throughout the day when he goes from a sitting to a standing position, he feels light-headed

Decision Point Three

Select what you should do next:

Discontinue Phenelzine and start an SSRI

Guidance to Student
The best choice at this point would be to discontinue Phenelzine and begin SSRI therapy. While MAOIs can be powerful drugs used to treat depression, they are generally considered last-line therapy due to unfavorable side effect profiles as well as drug/food interactions. Client’s on MAOIs must be on the MAOI diet and avoid certain aged foods which contain Tyramine. Adding Midodrine would not be appropriate as you should never add a medication to treat the side effects of a medication unless there are no other alternatives. In this case, changing from an MAOI to another drug class would be reasonable and appropriate. Reduction of the Phenelizine dose could be appropriate, but decreased dosage would result in decreased likelihood of efficacy.
Start Over

Reduce dose of phenelzine to 7.5 mg orally BID

Guidance to Student
The best choice at this point would be to discontinue Phenelzine and begin SSRI therapy. While MAOIs can be powerful drugs used to treat depression, they are generally considered last-line therapy due to unfavorable side effect profiles as well as drug/food interactions. Client’s on MAOIs must be on the MAOI diet and avoid certain aged foods which contain Tyramine. Adding Midodrine would not be appropriate as you should never add a medication to treat the side effects of a medication unless there are no other alternatives. In this case, changing from an MAOI to another drug class would be reasonable and appropriate. Reduction of the Phenelizine dose could be appropriate, but decreased dosage would result in decreased likelihood of efficacy.
Start Over

Start Midodrine 10 mg TID during the daytime only

Guidance to Student
The best choice at this point would be to discontinue Phenelzine and begin SSRI therapy. While MAOIs can be powerful drugs used to treat depression, they are generally considered last-line therapy due to unfavorable side effect profiles as well as drug/food interactions. Client’s on MAOIs must be on the MAOI diet and avoid certain aged foods which contain Tyramine. Adding Midodrine would not be appropriate as you should never add a medication to treat the side effects of a medication unless there are no other alternatives. In this case, changing from an MAOI to another drug class would be reasonable and appropriate. Reduction of the Phenelizine dose could be appropriate, but decreased dosage would result in decreased likelihood of efficacy.
Start Over

Phenelzine is not reinitiated. Instead, we began therapy with Lexapro 20 mg orally daily after an appropriate “wash out” period (5 half-lives).

RESULTS OF DECISION POINT TWO

Client returns to clinic in four weeks
• Client had no more syncopal episodes or episodes of orthostatic hypotension
• Client reports a decrease in depressive symptoms by approximately 25 percent on the MADR scale

Decision Point Three

Select what you should do next:

Continue current dose

Guidance to Student
At this point, the PMHPM is seeing evidence of response to therapy without negative side effects. You could hold at the current dose for another 4 weeks to see if any more gains in efficacy are achieved. You should discuss these options with the client so that the client is aware of risks/benefits of maintaining current dose of medication vs. increasing dose. If the decision to increase is made, the increase should be to 25 mg orally daily. Increasing to 30 mg orally daily (a 50% increase from 20 mg) increases the risk of side effects. NOTE: The initiation of an SSRI or SNRI should not begin until an adequate “wash out” period of MAOI- this is generally defined as the time it takes for 5 half-lives of the drug to be metabolized.
Start Over

Increase Lexapro to 30 mg orally daily

Guidance to Student
At this point, the PMHPM is seeing evidence of response to therapy without negative side effects. You could hold at the current dose for another 4 weeks to see if any more gains in efficacy are achieved. You should discuss these options with the client so that the client is aware of risks/benefits of maintaining current dose of medication vs. increasing dose. If the decision to increase is made, the increase should be to 25 mg orally daily. Increasing to 30 mg orally daily (a 50% increase from 20 mg) increases the risk of side effects. NOTE: The initiation of an SSRI or SNRI should not begin until an adequate “wash out” period of MAOI- this is generally defined as the time it takes for 5 half-lives of the drug to be metabolized.
Start Over

Increase Lexapro to 25 mg orally daily

Guidance to Student
At this point, the PMHPM is seeing evidence of response to therapy without negative side effects. You could hold at the current dose for another 4 weeks to see if any more gains in efficacy are achieved. You should discuss these options with the client so that the client is aware of risks/benefits of maintaining current dose of medication vs. increasing dose. If the decision to increase is made, the increase should be to 25 mg orally daily. Increasing to 30 mg orally daily (a 50% increase from 20 mg) increases the risk of side effects. NOTE: The initiation of an SSRI or SNRI should not begin until an adequate “wash out” period of MAOI- this is generally defined as the time it takes for 5 half-lives of the drug to be metabolized.
Start Over

Re-start Phenelzine 7.5 mg orally TID

RESULTS OF DECISION POINT TWO

Client returns to clinic in four weeks
• Client reported that he still has a little dizziness
• Client also reports that that his depression has improved greatly (a 35% decrease in MADR scale from 51 to 33)

Decision Point Three

Select what you should do next:

Continue current drug dose and counsel client on dietary modifications and orthostatic hypotension safety

Guidance to Student
The initiation of an SSRI or SNRI should not begin until an adequate “wash out” period of MAOI- this is generally defined as the time it takes for 5 half-lives of the drug to be metabolized. Co-administration of SSRI, SNRI, or TCA with MAOI is contraindicated as it can cause serotonin syndrome and can actually be fatal. You can continue the current dose and counsel client as to dietary modifications as well as orthostatic hypotension safety, however, it should be remembered that he works in a warehouse and may be at risk for falls/injury due to orthostatic hypotension. A “watch and wait” approach may be appropriate if the client has failed all other antidepressants. Increasing the dose back to 15 mg orally TID is not indicated as his orthostatic hypotension will likely worsen.
Start Over

Augment with Lexapro 10 mg orally daily

Guidance to Student
The initiation of an SSRI or SNRI should not begin until an adequate “wash out” period of MAOI- this is generally defined as the time it takes for 5 half-lives of the drug to be metabolized. Co-administration of SSRI, SNRI, or TCA with MAOI is contraindicated as it can cause serotonin syndrome and can actually be fatal. You can continue the current dose and counsel client as to dietary modifications as well as orthostatic hypotension safety, however, it should be remembered that he works in a warehouse and may be at risk for falls/injury due to orthostatic hypotension. A “watch and wait” approach may be appropriate if the client has failed all other antidepressants. Increasing the dose back to 15 mg orally TID is not indicated as his orthostatic hypotension will likely worsen.
Start Over

Increase dose of Phenelzine back to 15 mg orally TID now that the client is tolerating lower dose

Guidance to Student
The initiation of an SSRI or SNRI should not begin until an adequate “wash out” period of MAOI- this is generally defined as the time it takes for 5 half-lives of the drug to be metabolized. Co-administration of SSRI, SNRI, or TCA with MAOI is contraindicated as it can cause serotonin syndrome and can actually be fatal. You can continue the current dose and counsel client as to dietary modifications as well as orthostatic hypotension safety, however, it should be remembered that he works in a warehouse and may be at risk for falls/injury due to orthostatic hypotension. A “watch and wait” approach may be appropriate if the client has failed all other antidepressants. Increasing the dose back to 15 mg orally TID is not indicated as his orthostatic hypotension will likely worsen.
Start Over