Depression and anxiety therapies are unique because clients could respond differently to treatment.
2 days ago
Ernesto Hernandez
Volume 1, Case #5
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Ernesto Hernandez: Main Post
Introduction
Anxiety disorders are the most prevalent psychiatric disorders, and they are associated with a high burden of illness (Bandelow, Michaelis, & Wedekind, 2017). Anxiety disorders include the following: generalized anxiety disorder, panic disorder/agoraphobia, social anxiety disorders, and others. Treatment for anxiety disorders include psychological therapy, pharmacotherapy, or a combination of both. Treatment is indicated when a client shows marked distress or suffers from complications resulting from the disorder (Bandelow, Michaelis, & Wedekind, 2017). The purpose of this discussion will be to examine the selected case study and provide evidence-based literature that supports screening, diagnosing, and treating the disorder.
Scenario
The client is a 44-year-old woman with a chief complaint of anxiety. she had an onset of anxiety and depression at about age 15, which she began self-medicating with alcohol. After graduating from high school, she started college and was about to leave study abroad when she experienced a panic attack for which she was treated in the emergency room. She was then hospitalized and treated for alcohol abuse ate age 18, and she has remained sober ever since, although she does admit to some possible alprazolam abuse in 1999 as well as one overdose with alprazolam. She has had multiple hospitalizations for major depression. She also has history of endorsing suicidal ideation and suicide attempts. She has history of a divorce and two miscarriages. She received electroconvulsive therapy (ECT) at age 30, 7 sessions as an inpatient and 23 as an outpatient. Throughout her life, she has received numerous psychotropic medications including antidepressants, antipsychotics, and mood stabilizers, all with poor results. She was improving with ECT treatment, but she was beginning to experience severe memory impairment.
The client had a recurrence of her depression one year ago, severe enough to become disabled and needing to resign from her job as an office worker. She continues to be disabled from depression and has a great deal of anxiety, subjectively more disturbed by her anxiety than by her depression. She has been married since 1996 and has no children. She denies smoking. Her husband is supportive and works as an architect. Her medical history is as follows: narcolepsy, restless legs syndrome, nighttime urinary incontinence (possible related to highly sedating medications), and body mass index (BMI) of 26. Current blood pressure is 120/78, and she has a normal fasting blood glucose and triglycerides. Her grandmother has history of depression and history of treatment with ECT with good results. She is currently on Bupropion XL 450mg/day, Ziprasidone 60mg in the morning and 180mg at night, Lamotrigine 200mg in the morning and 150mg at night, Gabapentin 300mg in the morning, 600mg at noon and 900mg at night, Pramipexole 1mg/night for restless leg syndrome, Methylphenidate extended-release 54mg/day for day time sleepiness, Sodium oxybate in 9mg in one dose at night for narcolepsy and daytime sleepiness, and Desmopressin 0/4mg/night for bedwetting.
Three Questions
1. What do you feel is contributing to your anxiety, and do you feel like the medication is helping?
It is important know the triggers or stressors that may be contributing to the client’s anxiety. According to Robichaud, Koerner, and Dugas (2019), identifying the stressors that contribute to a client’s anxiety is important because medication will only temporarily relieve the feeling of anxiety; however, the medication will not address the underlying cause of the anxiety. It is important to know if there are underlying triggers or stressors because the client may benefit from both pharmacotherapy and psychotherapy. The psychotherapy could help the client cope with negative feelings and stressors, and pharmacotherapy could help relieve the anxiety. The goal, if possible, would be to have the client manage their own anxiety without the use of medications. Knowing if the medications are helping with help the practitioner know if the medications ordered for anxiety are helping. According to Robichaud, Koerner, and Dugas (2019), when many medications are ordered together, it could be difficult to know how a medication could be affecting the client.
2. What do you feel is contributing to your depression, and is the medication helping?
Like the question about anxiety, it is important to know if there are any triggers or stressors that may be contributing to the depression. According to Gibson, Cooper, Rae, and Hayes (2019), knowing the factors or stressors that contribute to depression will allow the practitioner to focus on therapeutic approaches that can be utilized to assist the client in developing healthier ways of coping with the stressors. The client’s anxiety could also be stemming from the depression. If the stressors that contribute to the depression are addressed, this could possibly relieve the anxiety that the client is experiencing. Knowing if the medications for depression are helping will help the practitioner know what steps must be taken to adjust or change medications (Gibson, Cooper, Rae, & Hayes, 2019).
3. Describe your sleep patterns throughout the day and night.
Knowing the sleep patterns of the client are important to determine how well the medications are working for the client. According to Cox, Sterba, Cole, Upender, and Olatunji (2018), previous research has linked sleep disturbance to anxiety. This would allow the practitioner to determine what medications need to be changed or adjusted. This would also show if the client’s anxiety or depression are contributing to the client feeling sleepy during the day or having difficulty staying asleep at night.
Collateral Information
Since the client does not have any children, I would like to obtain information from the client’s husband. Interviewing her husband would hopefully provide me with information about the client’s mood, behavior, and activities. I would also like to speak to the client’s friends because they may have experienced her behavior and noticed changes. According to Hinton (2017), depression does not just affect the depressed person, but everyone around them. There are times where the client will be evasive and guarded with questions and responses. It is important to involve the family in the treatment plan, to ensure success and the highest possible outcome for the client.
The following are questions that I would ask the clients family and friends (if applicable):
Could you describe your wife’s behavior the last three months?
Rationale: There may be times where clients withhold information from their provider, if they feel that their provider does not care or is paying more attention to the screen (Alonzo & Colon, 2020). Asking the family about the client’s behavior the last couple of months could provide the practitioner with an idea of the symptoms occurring and the impact that the anxiety and depression is having on the client’s activities and routine.
Have there been any recent stressors that your wife has experienced?
Rationale: Stressors can play a role in causing depression or be a symptom of it (Marchand et al., 2016). Since stressful situations can trigger feelings of depression, practitioners must ensure to address the factors contributing to the depression. If these factors are not addressed, there could be times where medication alone will not be enough to manage the client’s symptoms.
When did your first notice the anxiety or depression start affecting her ability to perform activities that she previously enjoyed?
Rationale: It is important to identify when symptoms first started. This could provide the practitioner with a timeline, and it could allow him to focus on the time period where the anxiety or depression started. According to Marchand et al. (2016), knowing when the anxiety or depression started will allow the practitioner to ask questions about events and stressors that could have happened when the symptoms began. There are clients that do not know what contributes to their anxiety and depression, this could allow the provider to have an idea of other factors that may have contributed to the anxiety and depression, without the client realizing it. This could possibly include physiological, psychosocial, and environmental factors.
Physical Exams and Diagnostic Tests
In addition to conducting a thorough mental health/health history and physical examination, practitioner could also turn to imaging tests to obtain more information. Computed tomography (CT) or positron emission tomography (PET) scans are imaging tests that allow providers to show decreased brain activity, indicative of depression (Dols et al., 2017). There are many screening tools available to screen for anxiety and depression. For example, the patient health questionnaire- nine item (PHQ-9) is a screening tool that is commonly used to screen for depression in adults in primary care settings (Mitchell, Yadegarfar, Gill, & Stubbs, 2016). Screening tools are used by clinicians to aid in determining treatment decisions, formulate a diagnosis, and for treatment planning (Patrick & Connick, 2019). Another tool use to aid in diagnosing depression and anxiety is the mental status examination (MSE). The MSE is a series of observations and examinations that are aimed towards revealing normal or pathological findings (Narang, Gandhi, Sarkaria, Mekala, & Lippmann, 2018). This exam will allow the practitioner to observe for any signs and symptoms that are indicative of depression, by observing behavior and appearance.
I would also consider ordering the following tests:
Thyroid Panel (TSH, Free T3, Free T4): Hypothyroidism is a condition that is caused by an underactive thyroid gland, and it is associated with depressive symptoms (Samuels, 2018). Obtaining this level would be important because it is important to address the underlying condition that be contributing the signs and symptoms.
Vitamin D Level: A Vitamin D deficiency has been associated with sleep problems and depression (Parker, Brotchie, & Graham, 2017). If deficient in vitamin D, I would order a supplement and encourage the client to take this supplement. Like hypothyroidism, it is important to address the underlying condition that may be contributing to the disorder.
Multiple Sleep Latency Test (MSLT): The multiple sleep latency test (MSLT) is a diagnostic tool that measures the time that it takes the individual to fall asleep in ideal quiet conditions during the day (Plante, 2017). It measures daytime sleepiness. MSLT is the standard tool used to diagnose narcolepsy and idiopathic hypersomnia (Plante, 2017).
Differential Diagnosis
Generalized Anxiety with Major Depressive Recurrent Unipolar Disorder: I believe that this diagnosis is the most likely. The client has a long history of recurrent depression and anxiety. Research suggests that generalized anxiety disorder usually precedes depression and that it if eventually develops into depression (Dols et al., 2017). This client has a history of self-medicating to help with her anxiety and depression. Since her last recurrence on depression, she has experienced multiple financial and psychosocial stressors that may have contributed to her anxiety and depression. It is because of these symptoms that she is not able to work or participate in activities that she once enjoyed. It is because of this evidence that I believe this is most likely the correct diagnosis for this client.
Major Depressive Disorder (MDD): The client has a long history of recurrent depression, and she has received multiple medications for the diagnosis, including ECT. Symptoms have lasted greater than two weeks, and her symptoms interfered with her ability to maintain a job and sleep (Dols et al., 2017). This diagnosis alone, however, does not support or include the client’s anxiety. It is possible that the anxiety stems from her depression.
Hyperinsomnia: Although weak, this is a diagnosis that should be considered because of the client’s excessive sleepiness during the day. Hyperinsomnia is a condition in which a person has trouble staying awake during the day (Barateau, Lopez, Franchi, & Dauvilliers, 2017). Hyperinsomnia could be either the underlying condition or be exacerbating the symptoms of anxiety and depression.
Pharmacologic Treatment
Methylphenidate: I would continue Methylphenidate extended release (Concerta) 54 mg/day orally for daytime sleepiness. According to Sangroula, Peteru, and Pillai (2018), excessive daytime sleepiness (EDS) could be induced by medications that are taken to treat psychiatric disorders. Methylphenidate is a psycho-simulant medication that can be used to treat EDS. It increases norepinephrine and dopamine actions by blocking their reuptake (Sangroula, Peteru, & Pillai, 2018). When considering pharmacokinetics and pharmacodynamics, Methylphenidate helps in enhancing dopamine and norepinephrine in the medial prefrontal cortex and hypothalamus, improving depression, fatigue, and sleepiness reuptake (Sangroula, Peteru, & Pillai, 2018). According to Sangroula, Peteru, and Pillai (2018), the mean plasma elimination half-life is approximately 2.2 hours. Methylphenidate does not inhibit CYP450 enzymes (Sangroula, Peteru, & Pillai, 2018).
Start Lithium: Lithium could help to boost her mood and mitigate risk of future relapse (Kugimiya, Kohno, Ishii, & Terao, 2019). Research supports that Lithium works well in conjunction with antidepressant therapy. Since she is already on Lamictal, I would start Lithium at a low dose of 150mg daily and titrate up to 300mg in the morning and bedtime or until improvement in anxiety and depression is noted. Lithium level will be checked every 1-2 weeks until a therapeutic level has been achieved. When considering pharmacokinetics and pharmacodynamics, Lithium has a half-life of 18-30 hours, and it has a lower absorption on an empty stomach (Kugimiya, Kohno, Ishii, & Terao, 2019). According to Kugimiya, Kohno, Ishii, and Terao (2019), Lithium is one of the most useful adjunctive agents to augment antidepressants for treatment-resistant unipolar depression. In relieving these symptoms, I would expect that the client would be able to sleep better. When considering the way that Lithium and Methylphenidate would improve the client’s sleep patterns, I would considering Methylphenidate over Lithium because Methylphenidate will directly improve sleep while Lithium would have secondary effects on sleep.
Alternative Treatment
Vagal Nerve Stimulation (VNS): This is used for treatment-resistant depression. A stimulation device is surgically implanted in the upper left chest, it delivers electrical impulse to the vagus nerve, and they usually last about 30 seconds every 5 minutes (Kumar et al., 2019).
Lessons Learned
This case was very complex because of the long history of recurrent depression and treatment failure with many medications. In my clinicals this semester, I have already encountered complex cases such as this one. Sometimes clients with a long history of depression present to the clinic without a detailed record of medications that were attempted and failed. This makes this process even more complex because the practitioner would not know where to start. It is also hard to determine whether insomnia contributes to anxiety and depression or which is causing or contributing to what. I learned that polypharmacy could make it difficult for providers to determine what medication is causing what side-effect, adverse effect, or therapeutic effect. It is important to slowly start the client on a medication and closely monitor the effects that it is having on the client. Furthermore, the medication should only be titrated until a desired effect is reached. The client should be on the lowest dose possible to reach a desired effect, to prevent the risk of adverse effects occurring.
This exercise helped me identify diagnostic tests, treatment options, and alternative forms of therapy that can be used for treatment resistance anxiety and depression. It is important to understand the positive effects that both psychotherapy and pharmacotherapy could have to treat depression and anxiety. Psychotherapy could help address the underlying stressors while medications can be used to temporarily treat the symptoms until the client could learn to cope with the symptoms without medications, if possible. This exercise also educated me on the importance of medication and the negative effects that it could have on clients. In this case, it is also important to consider the way that the medications ordered could interfere with the client’s sleep pattern.
Conclusion
With mood disorders becoming more prevalent, it is very likely that practitioners will be treating clients with depression and anxiety often. Depression and anxiety therapies are unique because clients could respond differently to treatment. Practitioners must utilize screening tools, to screen for depression and anxiety. Providers should then use clinical judgement and skills to investigate further into the depression or anxiety. Practitioners must find the factors contributing to the disorder and use creative ways to treat clients. Treatment with psychotherapy, pharmacotherapy, and other forms of treatment are available. Treatment should be focused at addressing the underlying cause. To ensure that optimum care is provided, practitioners must educate their clients and be educated on how to thoroughly assess, diagnose, and treat clients suffering from mood disorders.
References
Alonzo, D., & Colon, M. (2020). Correlates of mental health service utilization among depressed individuals with suicidality. Social Work in Mental Health, 1-18.
Bandelow, B., Michaelis, S., & Wedekind, D. (2017). Treatment of anxiety disorders. Dialogues in clinical neuroscience, 19(2), 93.
Barateau, L., Lopez, R., Franchi, J. A. M., & Dauvilliers, Y. (2017). Hypersomnolence, hypersomnia, and mood disorders. Current psychiatry reports, 19(2), 13.
Cox, R. C., Sterba, S. K., Cole, D. A., Upender, R. P., & Olatunji, B. O. (2018). Time of day effects on the relationship between daily sleep and anxiety: An ecological momentary assessment approach. Behaviour research and therapy, 111, 44-51.
Dols, A., Bouckaert, F., Sienaert, P., Rhebergen, D., Vansteelandt, K., Ten Kate, M., … & van Exel, E. (2017). Early-and late-onset depression in late life: a prospective study on clinical and structural brain characteristics and response to electroconvulsive therapy. The American Journal of Geriatric Psychiatry, 25(2), 178-189.
Gibson, A., Cooper, M., Rae, J., & Hayes, J. (2019). Clients’ experiences of shared decision making in an integrative psychotherapy for depression. Journal of Evaluation in Clinical Practice.
Hinton, L., Sciolla, A. F., Unützer, J., Elizarraras, E., Kravitz, R. L., & Apesoa-Varano, E. C. (2017). Family-centered depression treatment for older men in primary care: a qualitative study of stakeholder perspectives. BMC family practice, 18(1), 88.
Kugimiya, T., Kohno, K., Ishii, N., & Terao, T. (2019). Case of drug eruption during treatment with lithium and lamotrigine implicating a possible role of additives in the lithium tablet. Psychiatry and clinical neurosciences, 73(5), 285-285.
Kumar, A., Bunker, M. T., Aaronson, S. T., Conway, C. R., Rothschild, A. J., Mordenti, G., & Rush, A. J. (2019). Durability of symptomatic responses obtained with adjunctive vagus nerve stimulation in treatment-resistant depression. Neuropsychiatric disease and treatment, 15, 457.
Marchand, A., Bilodeau, J., Demers, A., Beauregard, N., Durand, P., & Haines III, V. Y. (2016). Gendered depression: Vulnerability or exposure to work and family stressors?. Social science & medicine, 166, 160-168.
Mitchell, A. J., Yadegarfar, M., Gill, J., & Stubbs, B. (2016). Case finding and screening clinical utility of the Patient Health Questionnaire (PHQ-9 and PHQ-2) for depression in primary care: a diagnostic meta-analysis of 40 studies. BJPsych open, 2(2), 127-138.
Narang, P., Gandhi, R., Sarkaria, T., Mekala, H. M., & Lippmann, S. (2018). A 95-year-old man with treatment-resistant depression. Current Psychiatry, 17(1), 49.
Patrick, S., & Connick, P. (2019). Psychometric properties of the PHQ-9 depression scale in people with multiple sclerosis: A systematic review. PloS one, 14(2), e0197943. https://doi.org/10.1371/journal.pone.0197943
Parker, G. B., Brotchie, H., & Graham, R. K. (2017). Vitamin D and depression. Journal of affective disorders, 208, 56-61.
Plante, D. T. (2017). Sleep propensity in psychiatric hypersomnolence: A systematic review and meta-analysis of multiple sleep latency test findings. Sleep medicine reviews, 31, 48-57.
Robichaud, M., Koerner, N., & Dugas, M. J. (2019). Cognitive behavioral treatment for generalized anxiety disorder: From science to practice. Routledge.
Samuels, M. H. (2018). Subclinical hypothyroidism and depression: Is there a link?. The Journal of Clinical Endocrinology & Metabolism, 103(5), 2061-2064.
Sangroula, D., Peteru, S., & Pillai, P. (2018). Methylphenidate in the Treatment of Medication-induced Excessive Daytime Sleepiness: A Unique Case Report and Review of Literature. Int J Ment Health Psychiatry 4: 1. doi: 10.4172/2471, 4372, 2.
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