he Assignment

Examine Case Study: An Elderly Hispanic Man With Major Depressive Disorder. You will be asked to make three decisions concerning the medication to prescribe to this client. Be sure to consider factors that might impact the client’s pharmacokinetic and pharmacodynamic processes.

• At each decision point stop to complete the following:
  • Decision #1
    • Which decision did you select?
    • Why did you select this decision? Support your response with evidence and references to the Learning Resources.
    • What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
    • Explain any difference between what you expected to achieve with Decision #1 and the results of the decision. Why were they different?
  • Decision #2
    • Why did you select this decision? Support your response with evidence and references to the Learning Resources.
    • What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
    • Explain any difference between what you expected to achieve with Decision #2 and the results of the decision. Why were they different?
  • Decision #3
    • Why did you select this decision? Support your response with evidence and references to the Learning Resources.
    • What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
    • Explain any difference between what you expected to achieve with Decision #3 and the results of the decision. Why were they different?

    Adult/Geriatric
    Depression
    Hispanic Male With MDD

    

    BACKGROUND
    INFORMATION

    The client is a 32-year-old
    Hispanic American male who came to the United States when he was in high school
    with his father. His mother died back in Mexico when he was in school. He
    presents today to the PMHNPs office for an initial appointment for complaints
    of depression. The client was referred by his PCP after “routine” medical
    work-up to rule out an organic basis for his depression. He has no other health
    issues with the exception of some occasional back pain and “stiff” shoulders
    which he attributes to his current work as a laborer in a warehouse.

    SUBJECTIVE

    During today’s clinical
    interview, client reports that he always felt like an outsider as he was
    “teased” a lot for being “black” in high school. States that he had few
    friends, and basically kept to himself. He describes his home life as “good.”
    Stating “Dad did what he could for us, there were 8 of us.” He also reports a
    remarkably diminished interest in engaging in usual activities, states that he
    has gained 15 pounds in the last 2 months. He is also troubled with insomnia
    which began about 6 months ago, but have been progressively getting worse. He
    does report poor concentration which he reports is getting in “trouble” at
    work.

    MENTAL STATUS EXAM

    The client is alert, oriented to
    person, place, time, and event. He is casually dressed. Speech is clear, but
    soft. He does not readily make eye contact, but when he does, it is only for a
    few moments. He is endorsing feelings of depression. Affect is somewhat
    constricted, but improves as the clinical interview progresses. He denies
    visual or auditory hallucinations, no overt delusional or paranoid thought
    processes readily apparent. Judgment and insight appear grossly intact. He is
    currently denying suicidal or homicidal ideation. The PMHNP administers the “Montgomery-
    Asberg Depression Rating Scale (MADRS)” and obtained a
    score of 51 (indicating severe depression).

    RESOURCES

    § Montgomery, S. A., & Asberg,
    M. (1979). A new depression scale designed to be sensitive to change. British
    Journal of Psychiatry, 134, 382-389.

    Decision Point One

    Select what the PMHNP should do:

    
    Begin
    zoloft 25 mg orally daily

    Begin
    Effexor XR 37.5 mg orally daily
    

    
    Begin
    Phenelzine 15 mg orally TID

    
    
    Adult/Geriatric Depression
    Hispanic Male With MDD

    
    

    Decision Point One

    Begin
    zoloft 25 mg orally daily

    RESULTS OF DECISION POINT ONE

    ·
    Client
    returns to clinic in four weeks

    
    ·
    Reports
    a 25% decrease in symptoms

    
    ·
    Client
    is concerned over the new onset of erectile dysfunction

    
    Decision
    Point Two

    Continue same dose and counsel client

    RESULTS OF DECISION POINT
    TWO

    ·
    Client
    returns to clinic in four weeks

    
    ·
    Client
    informed the PMHNP that he stopped taking the drug because his inability to
    perform sexually was worsening his self-esteem

    
    Decision
    Point Three

    Select what the PMHNP
    should do next:

    Decision Point Three

    Select what the PMHNP should do next:

    
    Encourage
    client to re-start drug at previous dose

    Re-start
    drug at 50% initial dose

    Change to Wellbutrin XL
    Guidance to Student
    Encouraging client to restart at previous dose would not be
    appropriate. Obviously, the side effect did not abate- so there is no reason to
    assume that it would abate at the previous dose. Re-starting the drug at 50% of
    starting dose may be appropriate to determine whether or not side effect is
    dose dependent. If the side effect of erectile dysfunction returns once the
    drug is returned to full dose, the PMHNP would need to change the drug.
    Changing to Wellbutrin XL may be appropriate at this point, but may worsen his
    insomnia. Additionally, guidelines tell us that another SSRI should be
    attempted for an adequate trial before switching drug classes.