NURS6630 Week7: Psychopharmacological approach to treat psychopathology
Three questions that I would ask her include:
Specifics about her sleep pattern, such as if she has difficulty falling asleep, or if she can fall asleep but continuously wakes up throughout the night. Insomnia can mean different things to different people, so I would need to know the specifics of her sleeping issues because some medications help with getting to sleep, while others are better at keeping you sleep once you fall asleep.
I would also ask her if she is taking the Sertraline as prescribed and if any other OTC or herbal supplements for sleep.
I would also inquire about her mood, concentration, social performance, and daily activities to assess for anhedonia.
I would solicit information from anyone that lives with the patient or has close contact with the patient. Often, family members who live with the patient are able to report information of things they observe that the patient may not even be aware of themselves. I would contact the patient child(ren) or any other persons that is a part of her life.
A physical exam and/or diagnostic test that would be appropriate for this patient would include a comprehensive metabolic panel to determine liver and kidney function, as these systems could be compromised, making her high risk for medication toxicity. I believe the patient would also benefit from a dementia screening given her age to r/o symptoms that may be attributed to dementia.
Differential Diagnosis would include:
Major Depressive Disorder, moderate- This differential diagnosis can be substantiated by repeated episodes of depression, the current episode being of moderate severity, and without any history of mania (ICD-10 Version:2019, 2019
Insomnia- This diagnosis would be considered because the clinical diagnosis of insomnia is based on the complaint of trouble falling asleep, trouble staying asleep, or early morning awakening, and resultant daytime dysfunction (Krystal et al., 2019).
Anxiety- This diagnosis would be considered because insomnia is a risk factor for major depression, anxiety disorders, substance use disorders, suicidality, hypertension and diabetes (Krystal et al., 2019).
The most likely diagnosis for this patient would be Major Depression, recurrent moderate because the patient is suffering from anhedonia, and currently already has a diagnosis of MDD, which would make this episode recurring. With MDD, Sleep is usually disturbed and appetite diminished (ICD-10 Version:2019, 2019).
Two pharmacological agents that would be considered would be Trazadone 100mg PO qHS or Remeron. Both medications are anti-depressants that improve sleep quality and architecture and have been successfully used as monotherapies to treat insomnia and depression in some patients (Murphy & Peterson, 2015) Of the two medications, I would choose Trazadone because it will help sleep as well as serve as an adjunct to the Sertraline for depression. Trazodone is a generally safe therapeutic that has been repeatedly validated as an efficacious treatment for insomnia, particularly for patients with comorbid depression (Jaffer et al., 2017). I would schedule the patient to return in the clinic in two weeks to evaluate the effectiveness (due to her advanced age I would not wait 4 weeks), and if she was responding well and tolerating the medication, I would schedule another follow-up in 4 weeks. During the follow-up, I would expect the patient to report that she is obtaining at least 6 hours of quality sleep every night, not feeling fatigued throughout the day, and participating in activities that she previously enjoyed, without being over-sedated or feeling groggy in the morning.
References
Freudenreich, O., Goff, D. C., & Henderson, D. C. (2016). Antipsychotic drugs. In T. A. Stern,
M. Favo, T. E. Wilens, & J. F. Rosenbaum. (Eds.), Massachusetts General Hospital psychopharmacology and neurotherapeutics (pp. 72-85). Elsevier.
ICD-10 Version:2019. (2019). Icd.who.int. https://icd.who.int/browse10/2019/en#F33
Jaffer, K. Y., Chang, T., Vanle, B., Dang, J., Steiner, A. J., Loera, N., Abdelmesseh, M., Danovitch, I., & Ishak, W. W. (2017). Trazodone for Insomnia: A Systematic Review. Innovations in Clinical Neuroscience, 14(7-8), 24–34. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5842888/
ŒKrystal, A. D., Prather, A. A., & Ashbrook, L. H. (2019). The assessment and management of
insomnia: an update. World Psychiatry, 18(3), 337–352. https://doi.org/10.1002/wps.20674
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Name: NURS_6630_Week7_Discussion_Rubric