Bipolar TherDescent/Ancestry

BACKGROUND INFORMATION

The client is a 26-year-old woman of Korean descent who presents to her first appointment following a 21-day hospitalization for onset of acute mania. She was diagnosed with bipolar I disorder.

Upon arrival in your office, she is quite “busy,” playing with things on your desk and shifting from side to side in her chair. She informs you that “they said I was bipolar, I don’t believe that, do you? I just like to talk, and dance, and sing. Did I tell you that I liked to cook?”

She weights 110 lbs. and is 5’ 5”

SUBJECTIVE

Patient reports “fantastic” mood. Reports that she sleeps about 5 hours/night to which she adds “I hate sleep, it’s no fun.”

You reviewed her hospital records and find that she has been medically worked up by a physician who reported her to be in overall good health. Lab studies were all within normal limits. You find that the patient had genetic testing in the hospital (specifically GeneSight testing) as none of the medications that they were treating her with seemed to work.

Genetic testing reveals that she is positive for CYP2D6*10 allele.

Patient confesses that she stopped taking her lithium (which was prescribed in the hospital) since she was discharged two weeks ago.

MENTAL STATUS EXAM

The patient is alert, oriented to person, place, time, and event. She is dressed quite oddly- wearing what appears to be an evening gown to her appointment. Speech is rapid, pressured, tangential. Self-reported mood is euthymic. Affect broad. Patient denies visual or auditory hallucinations, no overt delusional or paranoid thought processes readily apparent. Judgment is grossly intact, but insight is clearly impaired. She is currently denying suicidal or homicidal ideation.

The Young Mania Rating Scale (YMRS) score is 22

RESOURCES

§ Chen, R., Wang, H., Shi, J., Shen, K., & Hu, P. (2015). Cytochrome P450 2D6 genotype affects the pharmacokinetics of controlled-release paroxetine in healthy Chinese subjects: comparison of traditional phenotype and activity score systems. European Journal of Clinical Pharmacology, 71(7), 835-841. doi:10.1007/s00228-015-1855-6

Decision Point One

Select what the PMHNP should do:

Begin Lithium 300 mg orally BID

Begin Risperdal 1 mg orally BID

Begin Seroquel XR 100 mg orally at HS

 Decision Point One

Begin Lithium 300 mg orally BID

RESULTS OF DECISION POINT ONE

• Client returns to clinic in four weeks
• Client informs the PMHNP that she has been taking her drug “off and on” only when she “feels like she needs it”
• Today’s presentation is similar to the first day you met her

Decision Point Two

Select what the PMHNP should do next:

Increase Lithium to 450 mg orally BID

RESULTS OF DECISION POINT TWO

Client returns to clinic in four weeks
• Client returns reports that she is still taking the medication when she feels that she needs it
• She remains quite manic and reports that her family is getting really upset because she likes to play her new guitar at night

Decision Point Three

Select what the PMHNP should do next:

Assess for rationale for non-compliance and educate client

Guidance to Student
The PMHNP should further assess for dangerousness to self or others. The client should be assessed for self-care, to including hygiene, eating, sleeping, etc. Hospitalization may be indicated if the client remains non-compliant and is a danger to self. If the client is not a danger to self, and hospitalization is not indicated, the PMHNP needs to assess for rationale for non-compliance. Many clients enjoy mania as it is a nice feeling to be consistently happy. When clients are successfully treated for mania, they often describe themselves as feeling ‘down’ or ‘flat.’ The PMHNP needs to assess for depression at this point as opposed to normalization of mood. Abilify is also FDA approved as monotherapy for mania and mixed presentations, but at a dose of 15 mg. day., so although you may be tempted to begin Abilify- be certain to use correct dose. Also, because it can be “activating” you need to dose this drug in the morning. However, the client is non-compliant and therefore, eliciting reasons for non-compliance is essential to the care of this client.
Start Over

Consider hospitalization

Guidance to Student
The PMHNP should further assess for dangerousness to self or others. The client should be assessed for self-care, to including hygiene, eating, sleeping, etc. Hospitalization may be indicated if the client remains non-compliant and is a danger to self. If the client is not a danger to self, and hospitalization is not indicated, the PMHNP needs to assess for rationale for non-compliance. Many clients enjoy mania as it is a nice feeling to be consistently happy. When clients are successfully treated for mania, they often describe themselves as feeling ‘down’ or ‘flat.’ The PMHNP needs to assess for depression at this point as opposed to normalization of mood. Abilify is also FDA approved as monotherapy for mania and mixed presentations, but at a dose of 15 mg. day., so although you may be tempted to begin Abilify- be certain to use correct dose. Also, because it can be “activating” you need to dose this drug in the morning. However, the client is non-compliant and therefore, eliciting reasons for non-compliance is essential to the care of this client.
Start Over

Change to abilify 10 mg orally at HS

Guidance to Student
The PMHNP should further assess for dangerousness to self or others. The client should be assessed for self-care, to including hygiene, eating, sleeping, etc. Hospitalization may be indicated if the client remains non-compliant and is a danger to self. If the client is not a danger to self, and hospitalization is not indicated, the PMHNP needs to assess for rationale for non-compliance. Many clients enjoy mania as it is a nice feeling to be consistently happy. When clients are successfully treated for mania, they often describe themselves as feeling ‘down’ or ‘flat.’ The PMHNP needs to assess for depression at this point as opposed to normalization of mood. Abilify is also FDA approved as monotherapy for mania and mixed presentations, but at a dose of 15 mg. day., so although you may be tempted to begin Abilify- be certain to use correct dose. Also, because it can be “activating” you need to dose this drug in the morning. However, the client is non-compliant and therefore, eliciting reasons for non-compliance is essential to the care of this client.
Start Over

Assess rationale for non-compliance to elicit reason for non-compliance and educate client re: drug effects, and pharmacology

RESULTS OF DECISION POINT TWO

Client returns to clinic in four weeks
• Client states that the drug makes her nauseated and gives her diarrhea
• Client states that she stops taking it until these symptoms abate, at which point she re-starts only to experience the symptoms again

Decision Point Three
Select what the PMHNP should do next:

Change to Depakote ER 500 mg at HS

Guidance to Student
In this case, the client is having nausea and diarrhea, classic side effects of lithium therapy. Changing the client to an extended release formulation can often prevent these symptoms while at the same time affording the client the benefit of lithium’s mood stabilizing properties. Also, lithium is a good choice for control of mania and has also been shown to decrease risk of suicide, which adds to its overall benefits. Depakote may be an option if changing to sustained release lithium does not alleviate the side effects. Oxcarbazpine (Trileptal) is an option, but is a second line therapy and is not appropriate at this stage as the client has not had an adequate trial of first line agents.
Start Over

Change Lithium to sustained release preparation at same dose and frequency

Guidance to Student
In this case, the client is having nausea and diarrhea, classic side effects of lithium therapy. Changing the client to an extended release formulation can often prevent these symptoms while at the same time affording the client the benefit of lithium’s mood stabilizing properties. Also, lithium is a good choice for control of mania and has also been shown to decrease risk of suicide, which adds to its overall benefits. Depakote may be an option if changing to sustained release lithium does not alleviate the side effects. Oxcarbazpine (Trileptal) is an option, but is a second line therapy and is not appropriate at this stage as the client has not had an adequate trial of first line agents.
Start Over

Change to trileptal 300 mg orally BID

Guidance to Student
In this case, the client is having nausea and diarrhea, classic side effects of lithium therapy. Changing the client to an extended release formulation can often prevent these symptoms while at the same time affording the client the benefit of lithium’s mood stabilizing properties. Also, lithium is a good choice for control of mania and has also been shown to decrease risk of suicide, which adds to its overall benefits. Depakote may be an option if changing to sustained release lithium does not alleviate the side effects. Oxcarbazpine (Trileptal) is an option, but is a second line therapy and is not appropriate at this stage as the client has not had an adequate trial of first line agents.
Start Over

Switch to Depakote ER 500 mg orally at HS

RESULTS OF DECISION POINT TWO

Client returns to clinic in four weeks
• Client reports that she has been compliant and you notice a marked reduction in manic symptoms. Young Mania Rating Scale was 11 (50% reduction from first office visit)
• Client reports that she has gained 6 pounds over the last 4 weeks and wants to stop the medication because of this

Decision Point Three
Select what the PMHNP should do next:

Educate client regarding diet/weight loss and continue client on the same drug/dose

Guidance to Student
The PMHNP should begin by educating the client regarding weight loss/and importance of diet/exercise while taking Depakote which can cause weight gain. Decreasing the dose of Depakote would not be appropriate as she still has symptoms and decreasing dose of Depakote may result in some weight loss, it may result in a return of manic symptoms. The PMHNP can switch to Zyprexa but if weight gain is the issue, then this will be compounded by Zyprexa which is associated with significant weight gain (up to 20 kg over a 24 month period).
Start Over

Decrease Depakote ER to 250 mg orally at HS

Guidance to Student
The PMHNP should begin by educating the client regarding weight loss/and importance of diet/exercise while taking Depakote which can cause weight gain. Decreasing the dose of Depakote would not be appropriate as she still has symptoms and decreasing dose of Depakote may result in some weight loss, it may result in a return of manic symptoms. The PMHNP can switch to Zyprexa but if weight gain is the issue, then this will be compounded by Zyprexa which is associated with significant weight gain (up to 20 kg over a 24 month period).
Start Over

Switch medication to Zyprexa 15 mg orally daily at HS

Guidance to Student
The PMHNP should begin by educating the client regarding weight loss/and importance of diet/exercise while taking Depakote which can cause weight gain. Decreasing the dose of Depakote would not be appropriate as she still has symptoms and decreasing dose of Depakote may result in some weight loss, it may result in a return of manic symptoms. The PMHNP can switch to Zyprexa but if weight gain is the issue, then this will be compounded by Zyprexa which is associated with significant weight gain (up to 20 kg over a 24 month period).
Start Over

The Assignment

Examine Case Study: An Asian American Woman With Bipolar Disorder. You will be asked to make three decisions concerning the medication to prescribe to this client. Be sure to consider factors that might impact the client’s pharmacokinetic and pharmacodynamic processes.

At each decision point stop to complete the following:

• Decision #1

  Which decision did you select?
  Why did you select this decision? Support your response with evidence and references to the Learning Resources.
  What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
  Explain any difference between what you expected to achieve with Decision #1 and the results of the decision. Why were they different?

• Decision #2

  Why did you select this decision? Support your response with evidence and references to the Learning Resources.
  What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
  Explain any difference between what you expected to achieve with Decision #2 and the results of the decision. Why were they different?

• Decision #3

  Why did you select this decision? Support your response with evidence and references to the Learning Resources.
  What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
  Explain any difference between what you expected to achieve with Decision #3 and the results of the decision. Why were they different?

Also include how ethical considerations might impact your treatment plan and communication with clients.

Running Head:

Bipolar Therapy a Client of Korean Descent

2

Bipolar Therapy a Client of Korean Descent 2

Bipolar Therapy a Client of Korean Descent

Silifat Jones-Ibrahim

NURS 6630

A 22-year old Korean woman who presents herself for a 21-day hospitalization for the onset of acute mania has bipolar, but she doesn’t agree. She has a fantastic mood, sleeps 5 hours, claiming that sheets too, alert, oriented to people time and event. Genetic testing reveals that she is positive for the CYP2D6*10 allele. The purpose of her treatment is to help her resume her daily duties, reduce the unrest, and reduce destructive behaviors.

Desicion#1 begins Risperdal 1mg orally BID, for this is a typical antipsychotic that has verified to be extremely useful in the running of bipolar disorders. It does so by trying to effect a rebalance in serotonin and dopamine, thus ensuing in moral behavior. Because the patient had bipolar mix-up, Risperdal occurs to be the best alternate, also seeing that it is readily reachable (Culpepper, 2014). In the previous treatment, the patient happened to avoid lithium. So, it wouldn’t be a smart choice to start lithium 300mg because the probabilities of the patient not obeying to treatment are high. It leaves Risperdal as the most excellent decision in this situation. Likely Result, in four weeks on treatment, the patient is projected to display immense improvement. The patient would be relaxing and be able to conduct her actions of everyday life with slight or no trouble (John & Antai-Otong, 2016). It also expects that the patient’s self-destructive practices and tension would reduce and will reply to her atmosphere and public connections positively (Fang et al., 2017).

Likely Results and Real Result after four weeks, the patient returned to the clinic escorted by a parent. They, yet, settled that the patient’s self-destructive practices had expressively reduced. The client’s mother clarified that the client had been sluggish for about a week after the last appointment.

Decision#2 reducing Risperdal to 1mg HS; this is for the patient’s improvement in the second visit, it was evident that Risperdal was effective in achieving therapeutic goals of treatment. Nevertheless, the unwanted side effects were the key worries. It is then wise to cut the dosing to deal with the side effects rather than change to a new drug. Reducing the dose to one mg HS would be the best substitute that will aid to lessen the critical influence of the side effects (Culpepper, 2014). Giving the patient backing to adjust to an alternative dose of the same medicine will also advance their devotion, belief, and understanding to cooperate in attaining the treatment goals—likely Result (John & Antai-Otong, 2016). Reducing the dose to one mg HS will cut the quantity of Risperdal accrued in the body and following side effects of lethargy and sedation. By this, I expect that the client will record some constructive improvement concerning reduced self-destructive activities, ease in acting operations of daily life, and thinking patterns (Fang et al., 2017). I also expect that the client will have slight incidents of lethargy and sedation.

Likely results and real results. After four weeks, the client came back to the hospital. She was less sedated, less sluggish, and displayed massive development in signs. The new mania score gage had also reduced from 22 to 16, an illustration that there was more than a 25% decrease in symptoms. (John & Antai-Otong, 2016)

Decision #3 carry on with the same dose of 1 mg HS. Because of the first visit, it was clear that the client has decent development in the relation of decreasing self-destructive actions and handling of the medicines’ side effects. Continuing this dose and reexamining the client after four weeks will contribute to the attainment of the active goals for both the client and the present mental health physician. The first dosage of 1 mg BID had turned out to be detrimental to the patient’s wellbeing (Fang et al., 2017). Likely Results within four weeks, the patient will record massive improvement by reducing self-destructive actions. Also, she will report very slight or no side effects from Risperdal. She will have a decent state of mind, behavior, and moral thinking outlines. Risperdal is FDA approved for managing bipolar signs and has confirmed to be extremely useful with controllable side effects.

Likely Results and Real Results, the patient has some noteworthy progress and very minimal side effects of lethargy and sedation. The analysis proved that Risperdal had effectively helped to attain the vital treatment goals in the whole path of treatment. Given the pharmacodynamics and pharmacokinetics of Risperdal, these are indeed the results that must anticipate. Subsequently, the customer is for positive for the CYP2D6*10 allele; Risperdal might be clearing at a measurable sum resulting in higher than usual points in the blood (Fang et al., 2017). Instead, a mental physician must reflect, giving the patient some of the best accessible choices for handling to maximize the supports of treatment (Ratheesh et al., 2017).

The weakening of vision and decision that is always considered by mania and temper events may render a patient as not able to provide informed consent nor incapable of making rational conclusions concerning their treatment. Also, some medical exhibitions, such as delusional thinking and irritability, might be peril in the dangerous therapeutic alliance that exists between a client and a mental healthcare provider. It notes that, due to the reverting-remitting nature of the bipolar disorder, there are instances where a patient might feel well and question the need to continue with treatment (Ratheesh et al., 2017). These places the treatment goals laid by the mental healthcare provider in conflict with the patient’s autonomy to make decisions.

References

Culpepper, L. (2014). The diagnosis and treatment of bipolar disorder: decision-making in primary care. The primary care companion for CNS disorders, 16(3).

Fang, F., Wang, Z., Wu, R., Calabrese, J. R., & Gao, K. (2017). Is there a ‘weight neutral’ second-generation antipsychotics for bipolar disorder?. Expert review of Neurotherapeutics, 17(4), 407-418.

John, R. L., & Antai-Otong, D. (2016). Contemporary Treatment Approaches to Major Depression and Bipolar Disorders. Nursing Clinics, 51(2), 335-351.

Ratheesh, A., Cotton, S. M., Davey, C. G., Adams, S., Bechdolf, A., Macneil, C., & McGorry, P. D. (2017). Ethical considerations in preventive interventions for bipolar disorder. Early intervention in psychiatry, 11(2), 104-112.

Assessing and Treating Adult Clients with Mood Disorders

A mood disorder describes a psychological disorder which is characterized as a fluctuation of one’s mood, such as a major depressive or bipolar disorder. An estimated 20 million individuals in the United States have depression which comprises of symptoms such as a loss of pleasure in activities, sadness, weight changes, feelings of hopelessness, fatigue as well as suicidal ideation; all of which can significantly impact daily functioning (Mental Health.gov, 2017). According to Park and Zarate (2019) onset of depression in adulthood continues to flourish where an estimated 30 percent of adults have a lifetime risk of experiencing a major depressive episode with a median age of 32.5. The author further indicates screening for depression, a thorough evaluation, and monitoring is necessary to ensure safety and wellbeing (Park & Zarate, 2019). Pharmacotherapy, along with psychotherapy are first-line therapies for effective outcomes (Park & Zarate, 2019). The purpose of this paper is to review a case study, choose the appropriate selection utilizing research, and discuss ethical considerations.

Case Study

A 32-year-old Hispanic American client presents to the initial appointment with depression.  Health history, along with medical workup, appears to be unremarkable except for the slight back and shoulder pain due to his occupation. The clinical interview reveals past feelings of being an “outsider” and has few friends (Laureate Education, 2016).  There is a decline in daily activities, a weight increase of 15 pounds over two months, along with diminished sleep and the inability to fully concentrate (Laureate Education, 2016).  The results of the depression screening administered by the psychiatric mental health nurse practitioner (PMHNP), indicates severe depression with a score of 51 (Montgomery & Asberg, 1979).

Decision Point One

The selections include Zoloft 25 mg orally daily, Effexor 37.5 XR mg orally daily, or Phenelzine 15 mg orally TID.  As a healthcare professional treating a client, Zoloft (sertraline) 25 mg is the first choice at decision point one.  Selective serotonin reuptake inhibitors (SSRIs) impede the reabsorption of this neurotransmitter; thus, increasing the serotonin levels of the nerve cells in the brain to allow for improvement in mood (Stahl, 2013).  SSRIs have been utilized as first-line therapy to treat major depressive disorder due to efficacy, fewer side effects, cost-effectiveness as well as a wider availability (Masuda et al., 2017). The therapeutic dosing range is typically 50 mg-200 mg (Stahl, 2017). However, beginning at 25 mg and gradually titrating the dose, depending on tolerability, is an appropriate health care decision (National Alliance on Mental Illness, 2018b). Therefore, a low dose of Zoloft appears to be the best option in caring for this client.

Effexor (venlafaxine) is classified as a selective serotonin-norepinephrine reuptake inhibitor (SNRI) which impedes the reabsorption of the neurotransmitters serotonin and norepinephrine changing the chemistry in the brain to regulate mood (Stahl, 2013). Bhat and Kennedy (2017) describe antidepressant discontinuation syndrome (ADS) as a “medication-induced movement disorder” along with various adverse reactions such as intense sadness and anxiety; periods of an “electric shock” sensation; sights of flashing lights; and dizziness upon movement (Bhat & Kennedy, 2017, p. E7).  These symptoms are often experienced a few days after sudden discontinuation of an antidepressant with a shorter-life (3-7 hours) such as venlafaxine or paroxetine (Bhat & Kennedy, 2017; Stahl, 2017). Moreover, Stahl (2017) indicates venlafaxine is one of the drugs with more severe withdrawal symptoms in comparison to other antidepressants. It may take some clients several months to taper off of this medicine; therefore, Effexor is not the optimal selection at this time.

Phenelzine is classified as an irreversible monoamine oxidase inhibitor (MAOI) which impedes the monoamine oxidase from deconstructing serotonin, dopamine, as well as norepinephrine.  Thus, boosting the levels of neurotransmitters in the brain to regulate mood (Stahl, 2017).  Park and Zarate (2019) purport the use of monoamine oxidase inhibitors have a higher risk profile; therefore, are not typically utilized unless a newer antidepressant is considered ineffective. Bhat and Kennedy (2017) indicate there is a need for a long taper with MAOIs. Further, this medication may lose effectiveness after long-term use, and it is considered to have habit-forming qualities for some individuals (Stahl, 2017). The initial dose for phenelzine is taken three times a day which research suggests medication adherence is often tricky when the administration is more than once a day (Goette & Hammwöhner, 2016).  Stahl (2017) describes certain risk factors comprising of frequent weight gain, interference of certain food products containing tyramine, drug interactions (serotonin syndrome), as well as a hypertensive crisis. When utilizing this medication for treatment-resistant depression, the advance practitioner is aware of the detrimental adverse reactions which may occur. Therefore, phenelzine is not the safest option for this client.

The overarching goal for this male client is to reduce the symptoms related to his major depressive disorder and to eventually achieve remission without relapse where he can maintain normalcy in his life. After four weeks, his depressive symptoms decrease by 25 percent which is progress; however, he has a new onset of erectile dysfunction (Laureate Education, 2016). Sexual dysfunction is a notable side effect of sertraline (Stahl, 2017). Therefore, the clinician will reevaluate the plan of care given this new information. The outcomes were to be expected as the client was started on a low dose of sertraline, and treatment is typically 50 mg to 200 mg.  A continuation in progress may require more time, approximately six to eight weeks in total (Stahl, 2017).  

Decision Point Two

The present selections include decrease dose to 12.5 daily orally, continue same dose and counsel client, or augment with Wellbutrin 150 IR in the morning.  The preference for decision point two is Wellbutrin (bupropion) 150 IR, which is considered a norepinephrine dopamine reuptake inhibitor (SDRI).  An SDRI elevates the neurotransmitters dopamine, noradrenaline, and norepinephrine in the brain to achieve an improvement in depressive symptoms (Stahl, 2017). The purpose of utilizing this agent is three-fold: (1) To boost mood (2) To treat the new onset of sexual dysfunction (3) To aid in weight-loss.  According to the National Alliance on Mental Illness [NAMI] (2018a), Wellbutrin is a medication administered for major depressive disorder often in conjunction with an SSRI (NAMI, 2018a).

 Further, Wellbutrin may be prescribed with an SSRI to reverse the effects of SSRI-induced sexual dysfunction (Stahl, 2017). Dunner (2014) purports combining antidepressants are safe and may enhance efficacy; however, the combination of medications may also be utilized as an approach to reduce the effects of antidepressant pharmacotherapy. Dunner (2014) concurs that bupropion is frequently used with an SSRI or SNRI to alleviate sexual dysfunction.  Stahl (2017), findings indicate the most common side effects of bupropion consist of constipation, dry mouth, agitation, anxiety, improved cognitive functioning, as well as weight loss. The client in this scenario has gained 15 pounds over two months; thus, this medication may aid in his desire to lose weight (Laureate Education, 2016).  Further, this agent typically is not sedating as it does not have anticholinergic or antihistamine properties yet have a mild stimulating effect (Guzman, n.d).

Decreasing the Zoloft dose from 25 mg daily to 12.5 mg would not prove feasible as the client has reached a 25 percent reduction in symptomology.  The treatment for adults is 50 mg-200 mg, taking an approximate six to eight weeks to see the results in some individuals (Stahl, 2017). If the provider is tapering the medication as part of the client’s plan of care, reducing the dose to 12.5 mg would prove beneficial.  Research finds that when taking an antidepressant, the neurons adapt to the current level of neurotransmitters; therefore, if discontinuing an SSRI too quickly some of the symptoms may return (Harvard Health Publishing, 2018). Under some circumstances, discontinuation signs may appear, such as sleep changes, mood fluctuations, unsteady gait, numbness, or paranoia (Harvard Health Publishing, 2018).  However, the client is experiencing slow and steady progress on his current dose of Zoloft, so no adjustments are warranted.

At this point, positive results have been verbalized with the current dose of Zoloft 25 mg daily, with the exception of the onset of erectile dysfunction, which is a priority at this time.  One study finds that comorbid depression and anxiety disorders are commonly seen in adult males with sexual dysfunction (Rajkumar & Kumaran, 2015). An estimated 12.5 percent of participants experienced a depressive disorder before the diagnosis of sexual dysfunction. The author’s findings suggest a significant increase in suicidal behaviors with this comorbidity.  Moreover, the study indicates, some men experienced a sexual disorder while taking prescribed medication such as an antidepressant (Rajkumar & Kumaran, 2015).  According to Li et al. (2018), cognitive-behavioral therapy (CBT) is a beneficial tool utilized with clients experiencing mood disorders.  The implementation of CBT may increase the response and remission rates of depression. However, the option of continuing the same dose and engaging in counseling services is not the priority at this time.  It is essential to address this side effect to enhance his current pharmacotherapy and prevent an increase in depressive symptoms.

The continued goal of therapy is to achieve “full” remission of this individual’s major depressive disorder and to enhance his wellbeing.  After four weeks, the client returns to the clinic with a significant reduction in depressive symptoms along with the dissipation of erectile dysfunction.  However, he reports feelings of “jitteriness” and on occasion “nervousness” (Laureate Education, 2016).  This course of treatment has proven successful thus far, and the outcomes are to be expected due to the medication trials.

Decision Point Three

The present selections are to discontinue Zoloft and continue Wellbutrin, change Wellbutrin to XL 150 mg in the morning, or add Ativan 0.5 mg orally TID/PRN for anxiety.  The selection for decision point three is to change the Wellbutrin from IR to XL 150 mg in the morning. The first formulation is immediate- release (IR) and the recommended dosing is divided beginning at 75 mg twice daily increasing to 100 mg twice daily, then 100 mg three times a day with the maximum of 450 mg (Stahl, 2017).   The second formulation is extended-release (XL), where the administration for the initial dose is once daily taken in the morning; the maximum is 450 mg in a single dose (Stahl, 2017).  The peak level of bupropion XL is approximately five hours; therefore, the side effects reported may subside as the absorption rate is slower than the IR dose (U.S. Food and Drug Administration, 2011a). The immediate-release peak level is approximately two hours which may account for the client’s notable feelings of being jittery and at times nervous (U.S. Food and Drug Administration, 2011b).  Furthermore, clients are switched to extended-release to improve tolerance and treatment adherence to once-daily treatment (Guzman, n.d). As a mental health provider, caring for this client, changing the formulation is the best decision at this point as well as to continue to monitor side effects.

As mentioned above, Zoloft, an SSRI, can be utilized as a first-line agent for major depressive disorder (Masuda et al., 2017).  Using Wellbutrin as an adjunct to the regimen has continued to reduce his symptoms of depression and has alleviated one of his primary concerns which is sexual dysfunction.  Therefore, discontinuing Zoloft and maintaining the use of Wellbutrin is not an appropriate option at this time.

Ativan (lorazepam) is a benzodiazepine with anxiolytic, anti-anxiety, and sedative properties. It provides short-term relief of anxiety symptoms or insomnia (U.S. National Library of Medicine [NLM], n.d.).  Lorazepam works by enhancing the effect of the inhibitory neurotransmitter GABA, which inhibits the nerve signals, in doing so, reducing the “nervous excitation” (NLM, n.d., para. 1).  In some instances, a low dose, 0.5 mg, may be administered short-term to reduce side effects from another medication. Stahl (2017), indicates many side effects will not improve with an augmenting drug. Common side effects consist of confusion, weakness, sedation, nervousness, and fatigue (Stahl, 2017). Further, Ativan has an increased risk for abuse potential as it is known to have habit-forming properties (Stahl, 2017). As a result, administering Ativan would not be in the best interest of the client.

The ultimate goal is to achieve remission of his mood disorder.  The medication regimen has proven effective; thus, considering this to be a successful plan of care.  Taking both the sertraline and bupropion can exhibit side effects of jitteriness; however, changing to the extended-release may aid in the dissipation of these feelings.  The addition of Ativan to relieve side effects, that are perhaps temporary, is against better judgment without first making an effort to change or modify the medication regimen (Laureate Education, 2016).

Summary with Ethical Considerations

Mood disorders affect millions of individuals in the United States on an annual basis. The prevalence of mental illness continues to flourish, impacting one’s quality of life. Initiating treatment, under the guidance of a healthcare professional, is of the utmost importance. Further, an individualized plan of care comprising of education, therapy, medication, and support is crucial for overall health and wellbeing.

The client is a Hispanic American male employed as a laborer in a warehouse (Laureate Education, 2016).  It is essential to assess his financial means before prescribing medications.  Although one cannot assume the client has financial hardships, having this knowledge will guide in the process of treatment. If the client is without insurance and has to pay out-of-pocket, medication adherence may not be sustainable.  Therefore, as a psychiatric nurse practitioner, providing a cost-effective means whether, through generic prescriptions, discount pharmacies, or prescribing a larger quantity may be a necessary option (Barker & Guzman, 2015).  Further, the partnership among clients and practitioners is essential; to establish trust and respect as well as understanding cultural preferences while avoiding stereotypes is vital.

References

Barker, K. K., & Guzman, C. E. (2015). Pharmaceutical direct‐to‐consumer advertising and US Hispanic patient‐consumers. Sociology of Health & Issues, 37(8), 1337-1351. Doi:10.1111/1467-9566.12314

Bhat, V., & Kennedy, S. H. (2017). Recognition and management of antidepressant discontinuation syndrome. Journal of Psychiatry & Neuroscience, 42(4), E7-E8. Doi:10.1503/jpn.170022

Dunner, D. L. (2014). Combining antidepressants. Shanghai Archives of Psychiatry, 26(6), 363-364. Doi:10.11919/j.issn.1002-0829.214177

Goette, A., & Hammwöhner, M. (2016). How important it is for therapy adherence to be once a day? European Heart Journal Supplements, 18 (1). Doi:10.1093/eurheartj/suw048

Guzman, F. (n.d). The psychopharmacology of bupropion: An illustrated overview. Retrieved from

https://psychopharmacologyinstitute.com/section/the-psychopharmacology-of-bupropion-an-illustrated-overview-2051-4056

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