Respond to Post

Respond to  your colleague  in one of the following ways:

If your colleagues posts influenced your understanding of these concepts, be sure to share how and why. Include additional insights you gained.
If you think your colleagues might have misunderstood these concepts, offer your alternative perspective and be sure to provide an explanation for them. Include resources to support your perspective.

Treatment for a Patient With a Common Condition

            Jane Doe, a 75-year-old woman, presents by private vehicle with a chief complaint of insomnia.  She is A&Ox3 and able to communicate verbally for all needs.  The client has a diagnosis of diabetes, hypertension, and major depressive disorder.  Her husband of 41 years passed away ten months ago.  Since then, she has had an exacerbation of symptoms, a worsening of depression, and difficulty sleeping.  She denies having suicidal thoughts and states that she had no prior history of depression prior to the death of her husband.  Her primary care physician manages her medical conditions whom she sees twice a year. 

BP: 132/86, Temp: 98.6 F

Current weight: 88kg / 194lbs

Current height: 64in / 53

BMI: 34.4 (obesity)

Current medication regimen:

Metformin 500mg BID
Januvia 100mg daily
Losartan 100mg daily
HCTZ 25mg daily
Sertraline 100mg daily

List three questions you might ask the patient if she were in your office.  Provide a rationale for why you might ask these questions.

Are you taking your prescribed medications?

Globally, rates of noncompliance among patients with severe mental illness range between 30% and 65%.  Noncompliance significantly increases the risk of exacerbation of symptoms, illness, and hospitalization (Gebeyehu et al., 2019).  SSRIs are the first line of treatment for MDD (Gauthier et al., 2017), although drawbacks include delayed response, poor benefit for insomnia, and sexual adverse effects (Schneier et al., 2015).  Sleep problems, particularly insomnia, are reported in up to 90% of MDD patients and can have a significant impact on both the severity of depression and the course of the illness (Geoffroy et al., 2018). 

Can you tell me about your sleep patterns and sleep hygiene?

Good sleep hygiene is all about putting oneself in the best position to sleep well each night.  Sleep hygiene can improve sleep quality (Al-Kandari et al., 2017).  Some healthy sleep practices include being consistent with bedtime, ensuring the bedroom is quiet, dark, relaxing, and a comfortable temperature; removing electronics (i.e., TVs, computers, and smartphones); avoid large meals, caffeine, and alcohol prior to bed (Al-Kandari et al., 2017). 

Have you ever attempted or had thoughts of suicide or self-harm?

Suicide, deliberate self-harm, and psychiatric illness are all increased risks following the death of a close relative, particularly in susceptible subgroups (Guldin et al., 2017).  These risks are increased for at least ten years following the loss but are greatest during the first year (Guldin et al., 2017).  Additionally, studies discovered increased risks for those who have lost a child or a spouse, with those over 60 years of age being at the greatest risk, particularly for prolonged or complicated grief and suicide (Guldin et al., 2017). 

Identify people in the patients life you would need to speak to or get feedback from to further assess the patients situation. Include specific questions you might ask these people and why.

Naturally, collateral reports are necessary when assessing older adults to determine their ability to self-report and their functioning (Ivanova et al., 2021).  Consistencies and inconsistencies between informants can provide critical information about how the assessed person behaves in various contexts and his or her level of self-awareness (Ivanova et al., 2021).  Additionally, they can provide complementary perspectives, with collateral informants better equipped to assess certain overt problems (e.g., impulsive, or disruptive behavior) and assessed individuals better equipped to report on their internal experiences (e.g., feeling worried or sad) (Ivanova et al., 2021). 

Have you noticed any changes in the clients mood, cognition, or attention span?
Have you noticed any changes in the clients behaviors, engagement, or appetite?
Are all the clients needs being met?
Does the client appear to be compliant with the medication regimen?

Explain what, if any, physical exams and diagnostic tests would be appropriate for the patient and how the results would be used. 

Conduct a thorough initial exam and collect family medical and mental history.
Collect routine baseline monitoring lab work- CBC, CMP, TSH, A1c, Lipid Panel, B12, and Urinalysis.
Mini-Mental State Exam (MMSE) is a widely used test of cognitive function among the elderly; it includes tests of orientation, attention, memory, language, and visual-spatial skills (nce et al., 2021). 
Geriatric Depression Scale (GDS) is a short screening used to diagnose and evaluate depression in elderly individuals (Shin et al., 2019).
Prolonged Grief-13 (PG-13) is a scale meant to capture the grieving respondents intensity of his or her reaction to loss (Surkan et al., 2021).  This diagnostic tool helps assess a persons risk of developing prolonged grief disorder following the death of a loved one (Surkan et al., 2021).
Clinician-Administered PTSD Scale (CAPS) is a structured diagnostic interview to assess PTSD status and symptom severity (Weathers et al., 2018). 
Berlin Questionnaire is a screening tool that identifies patients at an increased risk for OSA who may benefit from further diagnostic testing (Siwasaranond et al., 2018). 

List a differential diagnosis for the patient. Identify the one that you think is most likely and explain why. 

OSA- Type 2 DM and OSA share several clinical findings: obesity, hypertension, and impaired glucose tolerance (Siwasaranond et al., 2018).  Nearly half of adults with type 2 DM are at high risk for OSA, and symptoms of depression also increased the risk (Siwasaranond et al., 2018). 
MDD- Depressed mood for more than two weeks, representing a change from the persons baseline (Van Velzen et al., 2020).  The patient may experience changes in sleep, appetite, activities, energy, concentration, feelings of worthlessness, and suicidality (Van Velzen et al., 2020).  MDD is likely the diagnosis for this client. 
Symptom duration is too long for adjustment disorder with depressed mood and not long enough for persistent complex bereavement disorder.

List two pharmacologic agents and their dosing that would be appropriate for the patients antidepressant therapy based on pharmacokinetics and pharmacodynamics. From a mechanism of action perspective, provide a rationale for why you might choose one agent over the other. 

Mirtazapine 7.5mg QHS

Augmenting an SSRI with mirtazapine may be a viable therapeutic option because it can help increase the efficacy of the prescribed SSRI while dampening the activating or anxiety-like effects of some SSRIs, which may aid in relaxation and sleep (Vickery & Morrisette, 2018).  The combination of an SSRI and mirtazapine has been studied in patients with MDD, PTSD, and OCD, and it has been found to improve symptoms of those conditions due to the medications complementary mechanisms of action (Vickery & Morrisette, 2018).   
FDA Indication: Major Depression (Vickery & Morrisette, 2018).
Off-label Uses: Panic disorder; PTSD; GAD; Insomnia; Nausea; Appetite stimulant (Vickery & Morrisette, 2018).

Trazodone 50mg QHS

Augmenting an SSRI with trazodone has been shown to be effective for treating depression with insomnia (Stahl, 2020). 
FDA Indication: Major depression (Stahl, 2020).
Off-label Uses: Insomnia and anxiety (Stahl, 2020).

For the drug therapy you select, identify any contraindications to use or alterations in dosing that may need to be considered based on ethical prescribing or decision-making. Discuss why the contraindication/alteration you identify exists. That is, what would be problematic with the use of this drug in individuals based on ethical prescribing guidelines or decision-making?

Mirtazapine 7.5mg QHS

Monitor: Weight and serotonin syndrome (Vickery & Morrisette, 2018). 
Side effects: somnolence, increased appetite, weight gain; Rare: Agranulocytosis or severe neutropenia (Vickery & Morrisette, 2018).
Metabolized primarily through CYP1A2, 2D6, and 3A4; t 20-40 hours
Avoid use with MAOIs. Caution with induces of 1A2 or 3A4 (e.g., Carbamazepine), which could reduce the efficacy of mirtazapine (Vickery & Morrisette, 2018). 
If patients experience too much sedation at the initial dose, consider increasing the dose; Mirtazapine has an increased noradrenergic effect relative to antihistaminergic effect at higher doses (Vickery & Morrisette, 2018). 

Trazodone 50mg QHS

Monitor: Serotonin syndrome (Stahl, 2020).
Side effects: drowsiness, dry mouth, dizziness or lightheadedness, orthostatic hypotension, headache, blurred vision, nausea, or vomiting; Rare: syncope (Stahl, 2020).
Metabolized primarily through CYP3A4 to active metabolite (mCPP), which in turn is metabolized by 2D6; induces P-glycoprotein; t : 7-10 hours (Stahl, 2020).
Avoid use with MAOIs (Stahl, 2020).
Patients taking trazodone may test positive for MDMA (Stahl, 2020).
I would probably utilize trazodone first because of the lesser half-life. 

Include any check points (i.e., follow-up data at Week 4, 8, 12, etc.), and indicate any therapeutic changes that you might make based on possible outcomes that may happen given your treatment options chosen. 

Post initial visit I would request the client start a sleep diary, engage in good hygiene practices, therapy services, and pharmacological treatment.  Provided patient education regarding medication, indications, side effects, and fall prevention.  A follow-up visit in four weeks, sooner if indicated.
Post four weeks from the initial visit reported improvement in mood and sleep.  Sleep diary complete, engaging in good sleep practices and maintaining pharmacological and therapy services.  No side effects were noted or reported.  If she reported oversedation, I would decrease to 25mg QHS, with a repeat of 25mg if needed.  If she continued to endorse insomnia, I would increase to 50mg with a 50mg repeat if needed.  Reinforce patient teachings, including fall prevention.  If no benefit with trazodone I would consider mirtazapine.

References

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Association between sleep hygiene awareness and practice with sleep quality among Kuwait University students. Sleep health, 3(5), 342-347. https://doi.org/10.1016/j.sleh.2017.06.004

Gauthier, G., Gurin, A., Zhdanava, M., Jacobson, W., Nomikos, G., Merikle, E., … & Perez, V.

(2017). Treatment patterns, healthcare resource utilization, and costs following first-line antidepressant treatment in major depressive disorder: a retrospective US claims database analysis. BMC psychiatry, 17(1), 1-12. https://doi.org/10.1186/s12888-017-1385-0

Gebeyehu, D. A., Mulat, H., Bekana, L., Asemamaw, N. T., Birarra, M. K., Takele, W. W., &

Angaw, D. A. (2019). Psychotropic medication non-adherence among patients with severe mental disorder attending at Bahir Dar Felege Hiwote Referral hospital, north west Ethiopia, 2017. BMC research notes, 12(1), 1-6. https://doi.org/10.1186/s13104-019-4126-2

Geoffroy, P. A., Hoertel, N., Etain, B., Bellivier, F., Delorme, R., Limosin, F., & Peyre, H.

(2018). Insomnia and hypersomnia in major depressive episode: prevalence, sociodemographic characteristics and psychiatric comorbidity in a population-based study. Journal of Affective Disorders, 226, 132-141. DOI:10.1016/j.jad.2017.09.032

Guldin, M. B., Ina Siegismund Kjaersgaard, M., FengerGrn, M., Thorlund Parner, E., Li, J.,

Prior, A., & Vestergaard, M. (2017). Risk of suicide, deliberate selfharm and psychiatric illness after the loss of a close relative: a nationwide cohort study. World Psychiatry, 16(2), 193-199. https://doi.org/10.1002/wps.20422  

nce, N., ztrk, M., Meseri, R., & Besler, H. T. (2021). Is obesity associated with lower mini

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M. M. (2015). Combined mirtazapine and SSRI treatment of PTSD: A placebocontrolled trial. Depression and anxiety, 32(8), 570-579. doi: 10.1002/da.22384

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Thakkinstian, A., & Reutrakul, S. (2018). The Relationship between Diabetes-Related Complications and Obstructive Sleep Apnea in Type 2 Diabetes. Journal of diabetes research, 2018, 9269170. https://doi.org/10.1155/2018/9269170

Stahl, S. M. (2020). Prescribers guide: Stahls essential psychopharmacology. Cambridge

University Press.

Surkan, P. J., Garrison-Desany, H. M., Rimal, D., Luitel, N. P., Kim, Y., Prigerson, H. G., … &

Murray, S. M. (2021). Adaptation and psychometric validation of the Prolonged Grief Disorder scale among widows in central Nepal. Journal of Affective Disorders, 281, 397-405. https://doi.org/10.1016/j.jad.2020.12.018

Weathers, F. W., Bovin, M. J., Lee, D. J., Sloan, D. M., Schnurr, P. P., Kaloupek, D. G., … &

Marx, B. P. (2018). The Clinician-Administered PTSD Scale for DSM5 (CAPS-5):

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Van Velzen, L. S., Kelly, S., Isaev, D., Aleman, A., Aftanas, L. I., Bauer, J., … & Schmaal, L.

(2020). White matter disturbances in major depressive disorder: a coordinated analysis across 20 international cohorts in the ENIGMA MDD working group. Molecular psychiatry, 25(7), 1511-1525. White matter disturbances in major depressive disorder: a coordinated analysis across 20 international cohorts in the ENIGMA MDD working group | Molecular Psychiatry (nature.com)

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