Discussion: Decision Making When Treating Psychological Disorders
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.
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.
Read a selection of your colleagues’ responses and respond to at least two of your colleagues on two different days who selected a different interactive media piece on a psychological disorder, and provide recommendations for alternative drug treatments to address the patient’s pathophysiology.
Note: For this Discussion, you are required to complete your initial post before you will be able to view and respond to your colleagues’ postings. Begin by clicking on the “Post to Discussion Question” link, and then select “Create Thread” to complete your initial post. Remember, once you click on Submit, you cannot delete or edit your own posts, and you cannot post anonymously. Please check your post carefully before clicking on Submit!
According to Rosenthal & Burchum (2021), approximately 15 million people in the United States alone suffers from depression, making it the most common of psychiatric disorders. Rosenthal et al. (2021) further explain that the hallmark symptom of depression is a depressed mood or loss of pleasure or interest in one’s usual activities. In addition, a person with depression may also experience insomnia or hypersomnia, weight loss or weight gain, loss of concentration, feelings of worthlessness, low self-esteem, and even suicidal ideations (Rosenthal & Burchum, 2021). A diagnosis of depression can be made and documented when the individual has experienced these symptoms nearly daily for about two weeks.
The case study selected from the media is about a 70 years old Hispanic American male originally from Mexico and who migrated to the united states as a teenager after losing his mother. He presented with complaints of depression and was referred by his PCP. Subjective findings reviewed he always felt like an outsider, being teased when he was younger, decreased interest in usual activities, and recent weight gain and insomnia. A mental status exam showed the patient is fully oriented, has clear speech but limited eye contact, and constricted affect. The patient denies hallucinations or paranoia and denies self-harm or suicidal ideation. He scored a 51 on the MADRS scale, which qualifies him to have severe depression. The three-drug choices available were Zoloft 25mg/day, Effexor XR 37.5mg/day, and Phenelzine 15mg TID.
According to Bayes and Parker (2019), “the choice of an antidepressant (AD) medication
is influenced by multiple variables relating to the prescriber, the patient, illness characteristics
and the drug itself” (pg. 281). Selective serotonin reuptake inhibitor (SSRI).
SSRIs are the first-line pharmacologic intervention for major depression (Salehi et al., 2019); therefore, Sertraline (Zoloft) 25mg by mouth daily will be the first drug to prescribe for this patient. SSRIs increase the availability of serotonin to multiple postsynaptic
serotonin receptors by inhibiting the function of the transmembrane presynaptic serotonin
transporter (Salehi et al., 2019).
MAOI’s such as Phenelzine is not typically first-line drugs as they are less tolerated and have more adverse effects. The patient reported back in four weeks with a 25% decrease in symptoms but with a new onset of erectile dysfunction, a common adverse effect of SSRIs. A practical solution to sexual dysfunction is to add another antidepressant that can overcome the issue, such as bupropion, which has the lowest incidence of sexual dysfunction (Fava et al., 2005). After adding bupropion IR 150mg to the patient’s medication, the depressive symptoms decreased even more, and the sexual dysfunction abated. However, the patient later reported feeling jittery and nervous. The jitters experienced are most likely caused by the immediate release of the Wellbutrin. Bupropion (Wellbutrin) is an atypical antidepressant-like structure of amphetamine (Rosenthal & Burchum, 2021). This explains why a patient may experience jitters if the CNS is stimulated.
After the patient reported the jitteriness and nervousness, the decision was to change Wellbutrin from IR to XL to address the side effect while keeping the dosage the same. By changing the dose to an extended-release, the nervousness and jittering should diminish. The combination of Bupropion and Sertraline has been shown to have improved effectiveness due to the synergism of their two separate antidepressant mechanisms involving serotonergic, dopaminergic, and noradrenergic systems (Marshall et al, 1995). At this point, the two medications will be continued and supplemental education will be provided.
Bayes, A., & Parker, g. (2019). Hot to choose an antidepressant medication. Acta Psychiatrica
Scandinavica, 139(3), 280-291. https://doi-org.ezp.waldenulibrary.org/10.1111/acps.13001
Fava, M., Rush, A. J., Thase, M. E., Clayton, A., Stahl, S. M., Pradko, J. F., & Johnston, J. A. (2005). 15 years of clinical experience with bupropion HCl: from bupropion to bupropion SR to bupropion XL. Primary care companion to the Journal of clinical psychiatry, 7(3), 106– 113. doi:10.4088/pcc.v07n0305sd
Marshall R., Johannet C., Collins, P., Smith, H., Kahn, D., Douglass, C. (1995). Bupropion and
sertraline combination treatment in refractory depression. New York State Psychiatric Institute,
Columbia University College of Physicians and Surgeons, NY, USA.
Rosenthal, L. D., & Burchum, J. R. (2021). Lehne’s pharmacotherapeutics for advanced practice
nurses and physician assistants (2nd ed.). Elsevier.
Salehi, M., Hadizadeh, H., Chang, A., & Grados, M. A. (2019). Recommendations for
prescribing SSRIs. Contemporary Pediatrics, 36(11), 24-27.
he patient is a 70-year-old male with complaints of depression. The patient has already been cleared from a medical standpoint by his primary care physician. He is still employed as a laborer and has been having trouble at work due to inability to concentrate. He reports diminished interest in things he usually enjoys, insomnia that is worsening, and a substantial weight gain of 15 pounds in two months. The Montgomery- Asberg Depression Rating Scale (MADRS) score was 51, which indicates severe depression. The MADRS is a tool used to assess the severity of depression and detect changes resulting from antidepressant therapy. It was developed in 1979 and was modified in 2008 to include structured questions to improve standardization of administration (Blum, 2009).
Of the three medication options presented, I would choose to start the patient on Zoloft 25mg daily. I base this decision on the fact that Zoloft is a selective serotonin reuptake inhibitor (SSRI), which is more well tolerated than the serotonin-norepinephrine reuptake inhibitors (SNRI), such as Effexor. Phenelzine, which is a monoamine oxidase inhibitor (MAOI), has more side effects and is less well tolerated than first line agents. MAOIs are generally used for patients who do not respond to first line drugs such as the SSRIs and SNRIs (Rosenthal & Burchum, 2021).
When the patient returns to the clinic after four weeks of treatment, he reports a noticeable improvement in symptoms, but he is trouble by the side effect of erectile dysfunction. I decided to add Wellbutrin IR 150 mg in the morning. Atypical antidepressants can help men overcome the sexual dysfunction that can accompany SSRI use. Wellbutrin has been used to counteract sexual dysfunction side effects caused by SSRIs (Rosenthal & Burchum, 2021). Antidepressants should be given for a minimum of six weeks to establish a clinically effective dose but adding another antidepressant may be more effective than simply increasing the dose. Combination therapy carries the risks of polypharmacy, such as drug-drug interactions and increased adverse-effect burden (Warner & Philip, 2013). Another side effect of Wellbutrin that may benefit this patient is its appetite suppressant quality, since he initially complained of weight gain (Rosenthal & Burchum, 2021).
The patient reported continued improvement in depressive symptoms and reduced sexual dysfunction. Unfortunately, he is troubled by the increased stimulation from the Wellbutrin IR. I decided to change the Wellbutrin to the extended-release preparation. Siegel (2005) reported that the use of extended-release medications reduced the incidence of side-effects, improved medication compliance, symptoms, and patient ratings of quality of life. It would not be appropriate to add another medication to treat the side effects of Wellbutrin at this time without first trying to modify the medication causing the undesirable side effects (Laureate Education, 2019a).
Blum, L. (2009, September 21). Montgomery Asberg depression rating scale (MADRS) (N. Korner-Bitensky, Ed.). Stroke Engine. Retrieved July 20, 2021, from https://strokengine.ca/en/assessments/montgomery-asberg-depression-rating-scale-madrs/
Laureate Education (Producer). (2019a). Adult geriatric depression [Interactive media file]. Baltimore, MD: Author.
Rosenthal, L. & Burchum, J. (2021). Lehne's pharmacotherapeutics for advanced practice nurses and physician assistants (2nd ed.). Saunders.
Siegel, S. J. (2005, June). Extended release drug delivery strategies in psychiatry: Theory to practice. PubMed Central (PMC). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3000189/
Warner, J., & Philip, N. S. (2013). Augmentation strategies in MDD therapy. Psychiatric Times, 30(9).
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