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 MDDBACKGROUND
INFORMATIONThe 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 dailyBegin
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 dailyRESULTS 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 TwoContinue 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 ThreeSelect what the PMHNP
should do next:Decision Point Three
Select what the PMHNP should do next:
Encourage
client to re-start drug at previous doseRe-start
drug at 50% initial doseChange 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.
- Decision #1