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Discussion replies # 1
Depression and Insomnia.
List three questions you might ask the patient if she were in your office. Provide a rationale for why you might ask these questions.
The first question that I would ask the patient is if she takes the medications as they were prescribed. This is important as it would help me in finding out if the patient has insomnia and low mood as a result of the failure of the medications or if there is poor adherence. I would also ask the patient about her sleep hygiene. This would be important as it also affects the development of insomnia. I would also find out if the patient takes some coffee before she gets to bed. This would be an important question since the use of coffee before getting to bed increases the risk of insomnia.
Identify people in the patient’s life you would need to speak to or get feedback from to further assess the patient’s situation. Include specific questions you might ask these people and why.
I would first talk to the PCP of the patient with the aim of finding out if there is any deterioration in the condition of the patient. This would be important in choosing the mode of treatment. The other person that I would talk to would be the person that lives with the patient. This would be important in finding out the general behaviour of the patient. This is important in finding out if there is severe depression in the patient. I would also ask the caretaker of the patient about the adherence of the patient to the medications. This would be important in finding out why the patient has insomnia.
Explain what, if any, physical exams and diagnostic tests would be appropriate for the patient and how the results would be used.
The diagnosis of the condition is clinical; hence there are no physical examinations. The diagnostic tests in the patient would be the levels of the antidepressants in the blood so that adherence can be evaluated. The other tests would be the levels of thyroid hormones in the blood of the patient. This would be important because the clinical features of hypothyroidism can mimic those of depression. Therefore, the tests would be important in ruling out any other medical illness in the patient.
List a differential diagnosis for the patient. Identify the one that you think is most likely and explain why.
The most likely differential diagnosis for the patient’s presentation is central sleep apnea, sleeplessness and circadian sleep disorder. The most likely diagnosis, in this case, is insomnia because of depression. This is because the patient has a diagnosis of depression and is on medication. Insomnia is one of the common clinical features and complications of major depressive disorder (Patel et al., 2018).
Two pharmacologic agents and Rationale for choosing.
The two medications that
I would use in the treatment of the patient would be sertraline and mirtazapine. This is because there is insomnia in the setting of depression. In addition, I would choose these drugs because they are safe for elderly patients. The dose for sertraline would be 50mg per day, while mirtazapine would be 15mg per day (Avasthi & Grover, 2018).
Contraindications based on ethical prescribing guidelines or decision-making.
The contraindication is if there are any manic behaviours or suicidal ideations in the patient after taking the two drugs. This means there are side effects from the use of mirtazapine. This would therefore need to stop. If the patient has manic behaviours, the use of mirtazapine and sertraline will result in the exacerbation of the clinical features. Therefore, the use of antipsychotic medications is important (Corponi et al., 2020).
Include any “checkpoints, and indicate any therapeutic changes that you make based on possible outcomes that may happen given your treatment options chosen.
The checkpoints would be after the first three weeks. This would be important in the evaluation of the patient’s adherence to the treatment. In case there is good adherence, and the patient is responding well. I would encourage the continuation of the therapy. In case there is no change despite good adherence. I would change the patient’s treatment or refer her to a psychiatrist and a sleep therapist who can easily provide more specialized care that will result in better outcomes (Bragg et al., 2019).
Discussion replies # 2
Treatment for a Patient with a Common Condition
There has been an increase in the number of older individuals in the United States over the last few decades due to better healthcare and clinical research. However, older individuals are susceptible to chronic health issues. In fact, more than half of older individuals in the country have three or more chronic illnesses (Raghupathi & Raghupathi, 2018). Thus, when treating older individuals for psychiatric health issues, it is important to consider the fact that they could have other health issues and they could be on other medications. Therefore, proper history taking and assessment are necessary in order to come up with a safe and effective plan of care, especially when psychopharmacological interventions are considered.
Questions and Rationale
The elderly patient in the case has a history of MDD, HTN and DM. She is also currently taking 5 medications including sertraline and her chief complaint is insomnia. There are a number of questions that she needs to be asked. First, it is important to note what side effects she might be experiencing from the medications. This is necessary to establish if there are any drug-drug interactions from the 5 drugs that she is already taking. Secondly, it is important to ask her how often she takes the medications and whether she at times forgets to take her drugs. This is important in order to establish if failure to take her antidepressant could be associated with worse depressive symptoms including insomnia that has been worsening. Ideally, polypharmacy in elderly individual could cause confusion and lack of adherence to the prescribed medications (Gomes et al., 2020). Thirdly, it would be prudent to ask if she currently lives alone after her husband assed on. This is important when it comes to creating a plan of care after she leaves the office.
People in the Patient’s Life
People in her life such as children, her friends, and other relatives from the extended family that have constant interaction with her are the best individuals to speak to in order to get feedback from and further assess the patients. They need to report about details such as how often the patient goes out or engages in activities that she used to love before her husband passed on. They can provide information about things that she talks about in order to help in completing a proper mental status examination. The information from these people can help in determining if she is future oriented and still hopeful about life. Additionally, they can provide answers to questions about her behavior at home in order to rule out other possible causes of her current disturbances.
Physical Exams and Diagnostic Tests
A through physical exam should be done to rule out worsening physical health and to even rule out injuries due to falls if they happened before. Falls are common in order individuals that are poly-medicated (Morin et al., 2019). Diagnostic tests that should be ordered include blood glucose level test in order to help establish if she has been adhering to her diabetes medications. It would also be necessary to order tests such as CBC with differentials, urinary toxicology, and TSH level. These tests will help in ruling out organic causes of her disturbances or other possible underlying conditions that may affect her quality of life. In addition, it would be necessary to rule out intoxication or use of alcohol or illicit drugs.
The differential diagnoses in order of priority include major depressive disorder, adjustment disorder, and persistent complex bereavement disorder. Major depressive disorder is the priority and the insomnia in this case is secondary insomnia caused by depression. Depression is known to have a strong relationship with insomnia (Oh et al., 2019). The patient has already been diagnosed with depression and worsening depression is making it hard for her to find sleep. Therefore, focus should be to help manage the depression and this will also help her sleep better. There is a need to avoid the risk of inappropriate pharmacy by adding more medications that might lead to adverse outcomes, considering that she already has five medications on her list.
Pharmacological Agents for Antidepressant Therapy
The patient’s depression can be treated using sertraline or Escitalopram because of their safety profile in older individuals with depression (Lenze & Oughli, 2019). In this case, because of the fact that sertraline was already used and it has not been effective Escitalopram should be administered 10 mg orally daily.
Contraindications/Alterations based on Ethical Prescribing/Decision-Making
Beneficence and non-maleficence should be adhered to when prescribing Escitalopram. This drug is metabolized in the liver by CYP2C19 (Jukic et al., 2018). There is a need to do some tests in order to establish if she is a poor metabolizer. This way, she should be treated using low doses in order to prevent adverse drug events due to overdosing.
The patient needs to return after 4 weeks for a follow-up. Here, assessment shall be done to determine how she has been responding to the medication and whether there are any adverse effects or cases of drug interaction. It would be important to reduce her medications because she has two drugs for diabetes and two for hypertension. Optimizing medications in order to avoid unnecessary polypharmacy is important. This may require working in an interprofessional team where a pharmacist helps to optimize the medications that will help with the other comorbidities. Monitoring her weight is also necessary because she is obese and antidepressants may lead to weight gain. She has to be educated about the importance of dietary changes and exercising.