Guidance to Student
The client has a complex neuropathic pain syndrome that may never respond to pain medication. Once that is understood, the next task is to explain to the client that pain level expectations need to realistic in nature and understand that he will always have some level of pain on a daily basis. The key is to manage it in a manner that allows him to continue his activities of daily living with as little discomfort as possible. Next, it is important to explain that medications are never the final answer but a part of a complex regimen that includes physical therapy, possible chiropractic care, heat and massage therapy, and medications. Savella is a SNRI that also possesses NMDA antagonist activity which helps in producing analgesia at the site of nerve endings. It is specifically marketed for fibromyalgia and has a place in therapy for this gentleman. Tramadol is never a good option along with other opioid type analgesics. Agonists at the Mu receptors does not provide adequate pain control in these types of neuropathic pain syndromes and therefore is never a good idea. It also has addictive properties which can lead to secondary drug abuse. Reductions in Savella can help control side effects but at a cost of uncontrolled pain. It is always a good idea to start with dose reductions during parts of the day that pain is most under control. The addition of Celexa with Savella needs to be done cautiously. Both medications inhibit the reuptake of serotonin and can, therefore, lead to serotonin toxicity or serotonin syndrome.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
Harvard Health Publishing. (2018). Going off antidepressants. Retrieved September 11, 2019, from https://www.health.harvard.edu/diseases-and-conditions/going-off-antidepressants
Laureate Education. (2016). Case study: An elderly Hispanic man with major depressive disorder [Interactive media file]. Baltimore, MD: Author
Li, J. M., Zhang, Y., Su, W. J., Liu, L. L., Gong, H., Peng, W., & Jiang, C. L. (2018). Cognitive behavioral therapy for treatment-resistant depression: A systematic review and meta-analysis. Psychiatry Research, 268, 243–250. Doi:10.1016/j.psychres.2018.07.020
Masuda, K., Nakanishi, M., Okamoto, K., Kawashima, C., Oshita, H., Inoue, A., … Akiyoshi, J. (2017). Different functioning of prefrontal cortex predicts treatment response after a selective serotonin reuptake inhibitor treatment in patients with major depression. Journal of Affective Disorders, 214, 44-52. Doi:10.1016/j.jad.2017.02.034
Mental Health.gov. (2017). Depression. Retrieved from https://www.mentalhealth.gov/what-to-look-for/mood-disorders/depression
Montgomery, S. A., & Asberg, M. (1979). A new depression scale designed to be sensitive to change. British Journal of Psychiatry, 134, 382-389. Retrieved from https://www.researchgate.net/publication/224773098_A_New_Depression_Scale_Designed_to_be_Sensitive_to_Change
National Alliance on Mental Illness. (2018a). Bupropion (Wellbutrin). Retrieved from https://www.nami.org/Learn-More/Treatment/Mental-Health-Medications/bupropion-(Wellbutrin)
National Alliance on Mental Illness. (2018b). Sertraline (Zoloft). Retrieved from https://www.nami.org/Learn-More/Treatment/Mental-Health-Medications/sertraline-(Zoloft)
Park, L. T., & Zarate, C. A. (2019). Depression in the primary care setting. The New England Journal of Medicine, 380, 559-568. Doi:10.1056/NEJMcp1712493
Rajkumar, R. P., & Kumaran, A. K. (2015). Depression and anxiety in men with sexual dysfunction: A retrospective study. Comprehensive Psychiatry, 60, 114-118. bDoi:10.1016/j.comppsych.2015.03.001
Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practic
Savella 12.5 mg once daily on day 1; followed by 12.5 mg BID on day 2 and 3; followed by 25 mg BID on days 4-7; followed by 50 mg BID thereafter
