Case 1: Volume 2, Case #16: The woman who liked the late-night TV
The 70-year-old woman shows several signs and symptoms related to mental illness such as depression. She is often sad due to her loneliness. Her husband died years ago, and the son no longer lives with her. Also, she experiences several unexplained pains and aches in different parts of her body. Her movement is substantially limited thus denying her a chance to join other people in society and participate in communal activities. Besides losing interest in doing things that she previously liked, she is also experiencing insomnia. She also admitted having experienced symptoms of Major Depression Disorder; thus indicating that she had historical family depression. Her mother suffered from the disease, despite the external family having the issues of Alcohol Use Disorder. The recent development of the hearing problem due to Major Depression Disorder (MDD) for both of her ears has dramatically affected her ability to communicate and interact with others. MDD has contributed to her sadness and the choice to remain alone rather than in a crowd (Stahl, 2013).
Questions and Rationales
Given the explanation of the signs experienced by the woman, the following are some of the questions the psychiatric mental health nurse practitioner (PMHNP) would consider asking patient as a way of establishing the cause and extent of her illness.
1. Have you been diagnosed with depression before? This way, it is easy to conclude whether the woman has a mental disorder or not (Ball, Dains, Flynn, Solomon, & Stewart, 2015).
2. Any other member of the family, apart from your mother, both nuclear and extended suffering or who have ever suffered from depression? The question is to help establish if the disease is genetic or not. Again, it would be the best way to develop the most effective medication to give to the patient, probably those that might have worked for the family members before. For instance, in the case of Major Depression Disorder (MDD), treatment is likely to be based on the medication that seemed useful for the family (Dains, Baumann, & Scheibel, 2016).
3. Do you suffer from any drug abuse? The family has a history of continued drug use disorder that might influence the development of depression due to inability to access the drugs (Ball et al., 2015). Therefore, it will be easy to draw a base and ground from which one can help uplift her spirit on awful days.
People in Patient’s Life to Give a Feedback
The first person that the psychiatric mental health nurse practitioner (PMHNP) would consider to reach and ask questions about the patient is the son (Stahl, 2013). Despite not being around his mother on a daily basis, he is the only family support that she has. Therefore, it is possible that he knows his mother’s condition in-depth. Again, he always accompanies her to her regular clinics for checkups. What this means is that the doctor keeps him updated on the improving or deteriorating state of his mother. He is a reliable source as the mother is also unlikely to hide any kind of pain and discomfort that she feels. The specific question to ask the son will be, when did you first notice a change in behavior in mother? The rationale is to establish a time frame of illness and to determine if the mother is an excellent historian and if what she said tallies with what happened. Another question will be what do you think may have triggered this behavior? Rationale, to assess if the trauma of losing her spouse engendered current illness and do you notice at any time if your mother used or is using street drugs or abusing any other substance? The reason is to rule our substance induced illness. Tell the PMHNP more about your mother? An open-ended question and answer that is free-flowing may reveal truths that the PMHNP may never have thought of asking (Ball et al., 2015). Another credible person as well is the home caretaker who takes care of the patient. He/she is responsible for catering to all the needs of the patient, thus understanding the progress of the woman regarding the mental sickness. The helper can also assist in identifying other psychological symptoms that the patient might have forgotten to mention. The PMHNP, without violating patient’s privacy will ask the caretaker, at any point in your care of the patient have you ever stumbled across any paraphernalia suggesting substance use by the patient? The PMHNP is still in search of the cause of patient’s illness to know how to assist client further. What does patient do during in her leisure time if any? The PMHNP want to gain insight into the patient’s daily behavior to determine the intensity of depression (Dains et al., 2016). The last individual the PMHNP will approach as he tries to understand the problems of the woman is the personal therapists who help her to fight against the mental disorder. Specific questions like what are the things you two talk about that change the patient’s mood from sad to happiness? There is a possibility of indicating activities and topics that they consider enjoyable to engage in that may be helpful to the PMHNP come up with a successful care plan. Also as the being the healthcare provider who has been caring for the patient, the therapist might be aware of the issues that might be considered to trigger the problem or even a medication that can help diagnose the further diseases. The progress of her illness is also essential since the therapist is always in constant communication with the patient. Therefore, the therapist might know more than anyone else could. People tend to be open with their health care providers because they tend to understand them better than all others (Davidson, 2016).
Physical Exams and Diagnostic Tests
The PMHNP will recommend for in-depth scrutiny of the patient’s well-being. Patient’s continued fatigue, especially in the morning, has not yet been established (Stahl, 2013). Therefore, it is difficult to prescribe any medication to her without the accurate medical information. In this case, the patient needs to be investigated in the affairs of obstructive sleep apnea. Lack of adequate sleep may result in patient always exhausted. Other examples like snoring and day-time sleeping are among the obstructive sleep apnea (OSA) that she experiences. Although there are high chances of concluding that she was suffering from the disease, there is a need for the physicians to conduct in-depth research on the same (Stahl, 2013).
Also, there should be implantation of the cochlear implant to help in depressing the major depression disorder (MDD). The confusion is stated to have not been under medication, thus the eternal suffering as a result of the illness. The use of the implant will help to regulate the level and impact of the disorder the patient experiences from time to time (Stahl, 2013).
The introduction of the Actigraphy to measure the movements made by the patient may also be an excellent way to monitor her sleep and wake cycles (Ancoli-Israel, Cole, Alessi, Chambers, Moorcroft, & Pollak, 2003). The device, worn on the wrist, records all the activities including the physical movement of the patient. It will show the resting and activity cycle of the patient. For that reason, it will be easy to assess the severity of insomnia (Stahl, 2013). Lastly, Polysomnography test (sleep study) should be conducted to establish the advancement of the sleeping disorder (Ancoli-Israel et al., 2003). The equipment is used to measure and record the brain activities that influence the sleeping ability of individual and other issues in the body such as breathing. The study examines the availability of oxygen in the body, heart rate, eye movement, as well as leg movement (Ancoli-Israel et al., 2003). With the study on the sleep patterns and cycles, it will be possible to establish the further cause of sleeplessness in the patient.
1. Major Depressive Disorder, Recurrent Episode severe (American Psychiatric Association, 2013; DSM-5, 2018).
2. Generalized Anxiety Disorder (American Psychiatric Association, 2013; DSM-5, 2018).
3. Obstructive Sleep Apnea (OSA) (American Psychiatric Association, 2013; DSM-5, 2018).
From the review of the case study, there are two significant illnesses. First, the patient is suffering from the major depression disorder (MDD) specified under the DSM-5 (American Psychiatric Association, 2013). People were suffering from the condition exhibit the symptoms of both mania and depression. For a patient who experiences mixed features, she needs to be diagnosed and treated with an antidepressant to suppress the disorder (Stahl, 2014b). In addition to the antidepressant that might work or not work on its own, there is a need to accompany the medication with more drugs. Typical antipsychotics such as Saphris, Latuda, Zyprexa, and Seroquel can help to effectively bring down the effects of the depression that is running in her family (Stahl, 2014b). Another reason for deciding to combine the medication is due to the (tenacity) stubbornness of the illness towards common drugs. Mood stabilizers like lithium and Depakote should be used to ensure that it sustains the spirit of the patient thus dealing with the issues of sadness and frequent cries. It should minimize the down periods and instead promote happiness from a few things that they enjoy doing.
Further diagnosis will be Generalized Anxiety Disorder (GAD) (DSM-5, 2018). Stillness and spending times all alone were the causes of anxiety and stress which later became the depression. Valium, a sedative will be used to help her with the sleep (Stahl, 2014b). Despite the previous medication being effective in promoting sleep, she still cannot help sleeping early. Therefore, she needs to use sleeping pills to encourage more rest.
The use of the Citalopram (Celexa), an SSRI, 10 mg/d to suppress the depression symptoms have been quite successful (Stahl, 2014b). Although she has not started sleeping completely, the rate of sadness in her has reduced implying that it is useful in suppressing the mood instability (Stahl, 2014b). Increasing the amount of the SSRI intake would help improve the status of the patient even more (Stahl, 2014b). Replacing the drug with another medication has a high likelihood of causing a relapse on the user. During a decline, the condition of the patient goes back to the original status or even worse. Stopping the generation of the chemical in the body means that the antibodies responsible for the well-being will be defeated. The inclusion of the noradrenergic or dopaminergic to the antidepressant would help to treat the fatigue she experienced (Stahl, 2014b). Hypnotic drugs will be used to treat the lack of sleep which the SSRI failed to address (Drugbank, 2018). Also, the auto-titrating continuous positive airway pressure (CPAP) will also enhance the ability to curb the sleep disorder. Therefore, the goal is that the patient will experience fewer occurrences of insomnia. Continued use of the Zaleplon (Sonata) 5 mg will supplement the ability of the rest of the drugs in curbing lack of sleep (Stahl, 2014b).
Ramelteon and doxepin are the hypnotic drugs that are considered to have no effects on the functionality of the psychomotor, the respiratory process or even become addictive. The two belong to the class of tricyclic antidepressants which increases the brain level of serotonin and norepinephrine. The two are the neurotransmitters used to transmit messages in the brain (Davidson, 2016). They are positive allosteric modulators (PAMs) used to relieve muscle spasm as well as providing medical sedation before performing medical procedures. Either of the two is an excellent choice to give the patient to stimulate sleeping cycles during the night. Unlike other drugs, the users are not expected to experience any after use adverse effects. Therefore, one will be sure on the treatment of the actual disease without side effects that tend to affect people differently. Augmenting the two drugs with the medications previously given the patient will help to increase her chances of sleeping. As a result, she will gain relief from the leg pain.
The case study indicated positive responses to facsimiles received back and forth with the therapist (Stahl, 2013). In enhancing patient’s ability to associate with people and engage in everyday activities, cochlear implantation is necessary so the patient can hear others easily hence ending her frustration. Patient ability to hear will further motivate her to engage with others in different activities with peers along with pharmacologic and non-pharmacologic intervention (Sadock, 2015).
The PMHNP knows that in this patient, the use of anti-stimulant is contraindicated. Instead, hypnotics augmented with SSRIs SNRIs may be prescribed. Additionally, for the neuropathic pain, gabapentin may be prescribed. The PMHNP due diligence in prescribing right drugs and making changes in medication where and when necessary will result in a patient living a more healthier, productive and fruitful life.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
Ancoli-Israel, S., Cole, R., Alessi, C., Chambers, M., Moorcroft, W., Pollak, C. P. (2003). The role of actigraphy in the study of sleep and circadian rhythms. American Academy of Sleep Medicine Review Paper. SLEEP 2003;26(3):342-92.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel’s guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby
Dains, J. E., Baumann, L. C., & Scheibel, P. (2016). Advanced health assessment and clinical diagnosis in primary care (5th ed.). St. Louis, MO: Elsevier Mosby
Davidson, J. (2016). Pharmacotherapy of post-traumatic stress disorder: Going beyond the guidelines. British Journal of Psychiatry, 2(6), e16-e18. i:10.1192/bjpo.bp.116.003707. Retrieved from http://bjpo.rcpsych.org/content/2/6/e16
Drugbank. (2018). Hypnotics medications. Retrieved from https://www.drugbank.ca/drugs/DB00402
Sadock, B. J., Sadock, V. A., & Ruiz, P. (2015). Kaplan & Sadock’s synopsis of psychiatry: Behavioral sciences/clinical psychiatry (11th ed.). Philadelphia: Wolters Kluwer.
Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (4th ed.). New York, NY: Cambridge University Press.
Stahl, S. M. (2014b). The prescriber’s guide (5th ed.). New York, NY: Cambridge University Press.
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