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Critique the decision making of two of your peers in your response post.

Do you agree/disagree with their medication choice? Why?

Is there anything else you recommend including?

Compare peer’s decision making to yours—what are the advantages and disadvantages of each?

Your response should include evidence of review of the course material through proper citations using APA format.

Reply separately to two of your classmates’ post (see attached classmates, post#1 and post#2)

Your response should include evidence-based research to support your statements using proper citations and APA format.

Please, send me the two documents separately, for example one is the reply to my peers Post#1, and the second one is the reply to my other peer Post#2.

-Minimum of 300 words per peer reply.

-Turnitin Assignment.

Background: I live in South Florida; I am currently enrolled in the Psych Mental Health Practitioner Program. I am a Family Nurse Practitioner working in psychiatric area.

1

W5- DEPRESSION CASE STUDY 6

W5- Depression Case Study

Student Name:

Course Name:

Course Number:

Instructor’s Name:

Institution:

Date of Submission:

Case Study Questions

1. What information, if any, would you like to know that was not included in the case

Some of the other information that I would like to know include; the patient’s past medical and psychiatric history, family history, and substance use history. For instance, it would be necessary to inquire from the patient whether she has a history of any chronic disease or psychiatric illness. This would help in determining whether her symptoms are associated with any other medical condition or psychiatric illness. Moreover, it would be necessary to inquire from the patient about her substance use history. This would help in determining whether the use of drugs/substances may have contributed to the development of her problems. More importantly, it would be necessary to obtain information about the patient’s family history and inquire if she has a family history of any psychiatric illness. 

2. Which psychiatric symptoms are a treatment priority for this case?

The psychiatric symptoms that are treatment priority for this patient include; sleep disturbances, loss of interest, mood swings, impaired concentration, and memory problems. The treatment of these symptoms would help in improving the patient’s level of functioning and engagement in her daily activities. 

3. What are the non-pharmacologic issues in this case (problems/complaints that cannot be addressed by medication)?

Some of the non-pharmacological issues that cannot be resolved or addressed by the use of medications include; ineffective coping, negative beliefs and feelings, and social withdrawal. 

Medication Choice 1

4. List one medication that would be appropriate for this case. Include the name and starting dose.

Sertraline is one of the most appropriate medications that would help in improving the symptoms of this patient. As such, it would be prudent to start the patient on sertraline (50 mg per day) to help in improving her symptoms. The starting dose of this medication for the treatment of the major depressive disorder is 50 mg orally and taken once per day (Gartlehner et al., 2017). 

5. Describe your clinical decision-making. What is your rationale for choosing this medication? Also, include the mechanism of action for this medication choice, and the neurotransmitters and areas of the brain on which the medication is proposed to act on.

Based on the information provided in the case study, it is apparent that the patient has a major depressive disorder. The treatment of this disorder involves the use of antidepressant medications and SSRI (Selective serotonin reuptake inhibitors) like sertraline are usually considered as the first-line medication used in the treatment of this disorder, hence the selection of this medication. Moreover, SSRI medications like sertraline are usually considered to be safer and they have fewer adverse effects compared to the other antidepressants (Fekadu, Shibeshi & Engidawork, 2017). 

The mechanism of action for sertraline involves increasing the amount and level of serotonin in the brain, which helps in maintaining serotonin balance thereby improving the depression symptoms (Huddart et al., 2020). This medication usually acts on a chemical neurotransmitter that is known as serotonin, which is involved in the transmission of electrical impulses or signals from one nerve cell to the next (Huddart et al., 2020). Under normal circumstances, serotonin is reabsorbed quickly (Huddart et al., 2020). However, the use of an SSRI medication allows serotonin to stay longer in the synaptic cleft between the neurons, which enables this chemical neurotransmitter to convey additional messages or signals to the receiving nerve cells that help in improving the boosting an individuals’ mood and improving the depression symptoms (Huddart et al., 2020). 

6. What laboratory testing/monitoring is needed for safely prescribing this medication?

The laboratory testing/monitoring that is required to ensure safe prescription of this medication include; liver function tests like ALT, ALP, albumin, and AST tests, GFR (Glomerular filtration rate) test, thyroid test, blood pressure test, and the Hemoglobin A1c test. For instance, the use of this medication among individuals with kidney problems may affect their kidney function or result in severe side effects (Huddart et al., 2020). Therefore, it is necessary to perform a GFR test to assess the patient’s renal function that would help in ensuring the safe prescription of this medication. The liver function test would also help in determining whether the patient’s body would be able to process this mediation efficiently, which would help in minimizing the risk of severe side effects (Huddart et al., 2020). 

7. Are there any contraindications or safety issues associated with this medication?

The use of sertraline is contraindicated in patients who have certain medical problems or conditions like liver disease, cardiovascular diseases, kidney diseases, seizure disorders, bleeding problems, and glaucoma (Huddart et al., 2020). Therefore, it would be prudent to determine whether the patient has a history of any of these problems. 

Non pharmacologic Interventions

8. What non-pharmacologic interventions do you recommend? Do you recommend including but not limited to psychotherapy, complementary and holistic therapies?

Some of the non-pharmacological interventions that may be recommended to this patient include; psychotherapeutic interventions like interpersonal or cognitive behavioral therapy, counseling, stress-reduction or mind-body techniques like meditation, aerobic exercises, and guided imagery (Gartlehner et al., 2017). For example, psychotherapeutic intervention like cognitive behavioral therapy could help the patient findings appropriate ways to solve and cope with her problems and adopt healthy and positive behaviors (Gartlehner et al., 2017). 

Safety Risk Assessment

9. What are the safety concerns, if any, associated with this case? How will you address safety?

Some of the safety concerns, in this case, include; the risk of self-harm, injury or suicide, and medication overdose. For instance, the patient states that she has tried to kill herself once by medication overdose, hence the risk of medication overdose and self-harm. Thus, it would be necessary to ensure close monitoring of the patient to ensure her safety. For instance, it would be necessary to inform her sister of the need to ensure that she takes her medication as prescribe and monitor her closely for unusual behavior to ensure her safety. 

10. When would you follow up with this patient?

To ensure effective monitoring of the patient, it would be necessary to follow up with her through telephone calls, home visits, and clinical appointments. 

References

Fekadu, N., Shibeshi, W., & Engidawork, E. (2017). Major depressive disorder: pathophysiology and clinical management. J Depress Anxiety, 6(1), 255-257.

Gartlehner, G., Wagner, G., Matyas, N., Titscher, V., Greimel, J., Lux, L., … & Lohr, K. N. (2017). Pharmacological and non-pharmacological treatments for major depressive disorder: review of systematic reviews. BMJ open, 7(6), e014912.

Huddart, R., Hicks, J. K., Ramsey, L. B., Strawn, J. R., Smith, D. M., Babilonia, M. B., … & Klein, T. E. (2020). PharmGKB summary: sertraline pathway, pharmacokinetics. Pharmacogenetics and genomics, 30(2), 26.

Post#1-Depression Case Study by Paulette Sides Sasser

Based on the case study, answer the following questions.

Identification of target symptoms/problems:

1. What information, if any, would you like to know that was not included in the case? This interviewer appeared to follow the PHQ – 9 depression assessment tools, which is sufficient to begin the differential diagnosis (Brown et al., 2020). The interviewer seemed to ascertain the symptoms most important to the patient. She cannot concentrate, meet expectations, enjoy life, sleep, or find the energy to care for herself. Additional medication history, alcohol use, family history, and potential triggers are pertinent to the care plan (Brown et al., 2020). Medications do not mix well with alcohol. Determining how she has used alcohol over the years is essential. She identified alcohol as a critical factor during her suicidal attempt. Her medication history should also include her previous medication adherence (Brown et al., 2020). The history of mental health problems in her family and treatments that worked for first-degree relatives is valuable information to the prescriber (Brown et al., 2020). Patient participation in the medication selection is important. Several factors help narrow the list of potential medications for depression. Such factors include other health conditions, reproductive goals for women, cost, and benefit/risk evaluations for the individual patient (Brown et al., 2020).

2. Which psychiatric symptoms are a treatment priority for this case? The patient identifies the impact her depressive symptoms have had on her ability to function and relationships. The patient prioritized her lack of energy, sleep difficulties, inability to concentrate, and failure to manage responsibilities as critical needs. The practitioner should also prioritize the patient’s history of suicidal behaviors and alcohol use. Although the patient accessed professional services for her mental health needs, she needed the urging of her family to act on accessing care. During the interview, she describes a previous suicide attempt and alludes to alcohol use during the break–up of her marriage.

3. What are the non-pharmacologic issues in this case (problems/complaints that cannot be addressed by medication)? This patient reports feeling little self-worth, utilizing limited coping skills, and struggles with intimate relationships, which adds to her sense of hopelessness. Her judgment is concerning. She appears to have friends and family support. Other psychosocial needs should be evaluated by social services to support successful care.

Medication selection:

1. List one medication that would be appropriate for this case. Include the name and starting dose. Escitalopram is a substrate for CYP450 2C19 and 3A4with no significant actions on CYP 450 (Aldrich et al., 2019). With a dosage of 10 mg once daily, steady-state should be reached within a week, and the low dosage should provide some symptom relief within the first 1 – 2 weeks of administration (Aldrich et al., 2019). May take with food.

2. Describe your clinical decision-making. What is your rationale for choosing this medication? Also, include the mechanism of action for this medication choice and the neurotransmitters and areas of the brain in which the medication is proposed to act on. Depression is linked with low levels of serotonin (as well as low levels of dopamine, norepinephrine, and other brain chemicals) (Langmia et al., 2021). When the SSRI is administered, the serotonin reuptake pump is blocked (Stahl, 2013, p.p. 290 – 300). Initially, the somatodendritic area of the serotonin neuron is changed, followed by the 5HT1a autoreceptor desensitizing and downregulating (Stahl, 2013, p.p. 290 – 300). After a delay, 5HT is released in the axon terminal, thus addressing the reduced serotonin associated with depression (Stahl, 2013, p.p. 290 – 300). Postsynaptic desensitization of 5HT may explain the reduction of side – effects were seen in SSRIs over time (Stahl, 2013, p.p. 290 – 300). Escitalopram is a better version of other SSRIs because it used the best effects of s enantiomer while leaving behind the antihistamine properties and weak inhibition of CYP 2D6 (Stahl, 2013, p.p. 290 – 300). The patient is overweight, and her smoking status is unknown. Other antidepressants have potential side – effects that could make adherence to the medication more unlikely or even medically contraindicated, like weight gain (Aldrich et al., 2019). Citalopram and escitalopram have correlations with a longer QT duration than the other medications in this class (Aldrich et al., 2019). Although infrequent, medications that increase serotonin activity may cause serotonin syndrome, especially when taken with MAOIs and linezolid (Aldrich et al., 2019). Financial considerations were researched. Given a comparable occupation in this country, using a medication approved by the Medicaid formulary for a new trial antidepressant is appropriate.

3. What laboratory testing/monitoring is needed for safely prescribing this medication? An EKG may be an option for patients with cardiac risk factors to monitor for QT prolongation and arrhythmias, weight regularly measured (adverse metabolic changes), and vital signs (Aldrich et al., 2019). In addition, anxiety, insomnia, and sexual dysfunction require regular assessment (Aldrich et al., 2019).

4. Are there any contraindications or safety issues associated with this medication? Seizure disorder, caution in patients with bipolar disorder, possible serotonin syndrome, and potential activation of suicidal ideation (Aldrich et al., 2019). Should side – effects become intolerable or unsatisfactory, tapering may be done in a short period of time (Langmia et al., 2021). As previously noted, citalopram and escitalopram have an increased risk of cardiotoxicity due to QT prolongation, which can progress to severe arrhythmias (Aldrich et al., 2019). Blackbox warnings increased the risk of suicidal thinking and behavior in children, adolescents, and young adults taking antidepressants for major depressive disorder (MDD) and other psychiatric disorders (Aldrich et al., 2019). Escitalopram oxalate is not approved for use in pediatric patients under 12 years of age (Aldrich et al., 2019).

Non – pharmacological

1. What non – pharmacological interventions do you recommend? Do you recommend psychotherapy, complementary and holistic therapies? Sunlight therapy, B vitamins, diet, and exercise have shown positive correlations with reduced depression (Ijaz et al., 2018). In a literature review, cognitive-based therapy and omega – 3 showed positive results for treating depression (Hallahan et al., 2016).

Safety assessment

1. What are the safety concerns, if any, associated with this case? How will you address safety? In addition to the medication complications, the patient recounted a suicidal act during a previous personal crisis. She described an impulsive attempt fueled by alcohol. Regular suicide assessment and freedom of communication among all medical and psychiatric care providers are required to ensure a robust safety plan (Ijaz et al., 2018). She did not reach out for help during that time until now. A suicide prevention plan needs to be a partnership with the patient. Including people, she trusts is critical (Ijaz et al., 2018).

2. When would you follow – up with the patient? The effect of SSRIs may take up to 6 weeks before the patients feel the effects of treatment (Aldrich et al., 2019). However, if patients tolerate the current dose well, the clinician can consider increasing dosage in 10 – 12 weeks (Aldrich et al., 2019).

References

1. List your references.

Aldrich, S. L., Poweleit, E. A., Prows, C. A., Martin, L. J., Strawn, J. R., & Ramsey, L. B. (2019). Influence of CYP2C19 metabolizer status on escitalopram/citalopram tolerability and response in youth with anxiety and depressive disorders. Frontiers in Pharmacology, 10, 99. https://doi.org/10.3389/fphar.2019.00099

Brown, M. J., Adams, S. M., Vanderhoef, D., Schipani, R., & Taylor, A. (2020). Improving PHQ9 utilization rates in a primary care mental health integration setting. Journal of the American Psychiatric Nurses Association, 26(2), 206– 211.https://doi.org/10.1177/1078390319865331

Hallahan, B., Ryan, T., Hibbeln, J.R., Murray, I.T., Glynn, S., Ramsden, C.E., SanGiovanni, J.P., & Davis, J.M. (September 2016). Efficacy of Omega-3 Highly Unsaturated Fatty Acids in the Treatment of Depression. The British Journal of Psychiatry, 209 (3), 192–201. https://doi.org/10.1192/bjp.bp.114.160242

Ijaz, S., Davies, P., Williams, C.J., Kessler, D., Lewis, G., & Wiles, N. (May 2018). Psychological therapies for treatment-resistant depression in adults. The Cochrane Database of Systematic Reviews. 5(8). https://doi.org/10.1002/14651858.CD010558

Langmia, I. M., Just, K. S., Yamoune, S., Brockmöller, J., Masimirembwa, C., & Stingl, J. C. (2021). CYP2B6 functional variability in drug metabolism and exposure across populations-implication for drug safety, dosing, and individualized therapy. Frontiers in Genetics, 12, 692234. https://doi.org/10.3389/fgene.2021.692234

Stahl, S. (2013). Essential psychopharmacology: Neuroscientific basis and practical applications (4th ed.). Cambridge, England: Cambridge University Press.

Post#2 Depression Case Study by Jimmy Smith

Identification of target symptoms/problems

1. What information, if any, would you like to know that was not included in the case?

Additional information related to the well-being and ages of the children with specific information related to the direct care and supervision of the children. The client relates that the children care for themselves related to meals. Additional information related to the competency of the patient to care for the children could give more information related to degree of impairment as well as insight of whether there should be concern for children. Depression is associated with decreased or negative parenting and has long-tern effects on children’s mental and physical health (n.d., 2009).

2. Which psychiatric symptoms are a treatment priority for this case?

Suicidal thoughts and safety of the patient and the children is the primary concern and establishing a safety plan as well as identifying persons either family or friends that are available and willing to be supportive with increasing suicidal ideation. Sense of hopelessness and lack of joy in patients’ life and feeling of guilt for spending less time with her children is of high priority.

3. What are the non-pharmacologic issues in this case (problems/complaints that cannot be addressed by medication)?

Poor appetite, diet and weight loss as well as lack of exercise and social interaction at home and at the client’s job. Lack of exercise can lead to increase in obesity, poor diet, diabetes, metabolic abnormalities which all will increase depression. The positive effects of regular exercise for those that suffer from depression including providing an outlet to lessen thoughts of depression and stimulate positive self-emotions (Murri, et. al., 2018).

Medication Choice 1

4. List one medication that would be appropriate for this case. Include the name and starting dose.

Sertraline 50mg by mouth daily with increase up to 200mg taper as needed for effect (Woo & Robinson, 2020).

5. Describe your clinical decision making. What is your rationale for choosing this medication? Also, include the mechanism of action for this medication choice, and the neurotransmitters and areas of the brain in which the medication is proposed to act on.

Sertraline is cost affective choice as the patient relates difficulty with money. Cost with discounts is around ten dollars in the U. S. thought the cost in the U. K. has increased 500% over the past 2 years (Robinson, 2021). Sertraline inhibits reuptake of 5HT serotonin with limited effect on dopamine and norepinephrine uptake (Woo & Robinson, 2020).

6. What laboratory testing/monitoring is needed for safely prescribing this medication?

No monitoring required other than monitoring for mood symptoms or allergic reactions as well as increased suicidal thoughts (Woo & Robinson, 2020)

7. Are there any contraindications or safety issues associated with this medication?

Caution in those with bleeding disorders as can interfere with platelet aggregation. Caution in those with cardiac histories related to prolonged QT interval. Monitor closely in children and elderly for increase or initial suicidal thoughts (Singh & Saadabadi, 2021)

Non pharmacologic Interventions

8. What non-pharmacologic interventions do you recommend? Do you recommend including but not limited to psychotherapy, complimentary and holistic therapies

Exercise, dietary modifications, psychotherapy to include group therapy to integrate social understanding and networking for the patients with others that suffer from depression.

Safety Risk Assessment

9. What are the safety concerns, if any, associated with this case? How will you address safety?

Safety concern related to harm to self with increased feelings of worthlessness or side-effect from beginning antidepressant. Monitor for sighs of serotonin syndrome (Woo & Robinson, 2020).

10. When would you follow up with this patient?

7 days in person as well as providing contact information to patient and family for emergent or escalating symptoms.

References:

Singh HK, Saadabadi A. Sertraline. [Updated 2021 Aug 6]. In: Stat Pearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK547689/

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