GR, a 45-year-old African American woman, seeks psychiatric evaluation at the clinic. This patient had anxiety, nightmares, depression, and melancholy.

Objectives of this Presentation

 

· A minimum of four to five symptoms of major depression, generalized anxiety, and post-traumatic stress disorder (PTSD) should be known by all members of the group.

 

· Each member of the group is responsible for naming one diagnostic or screening tool for each of the mental health conditions.

 

· Members of this group will understand the value of combining psychotherapy and medication in the treatment of some mental health illnesses and will be able to name at least three benefits of adjunct therapy.

 

· This discussion group will include at least three arguments for why a thorough discharge plan, medication education, and follow-up information are crucial for the client’s symptom management and control.

 

SUBJECTIVE:

 

Patient’s Background Information

 

Name: GR

 

Gender: Female

 

Age: 45 Years

 

CC (chief complaint): “I am experiencing depression, anxiety, sleep issues, sadness, and

 

tearfulness.”

 

HPI: GR, a 45-year-old African American woman, seeks psychiatric evaluation at the clinic. This patient had anxiety, nightmares, depression, and melancholy. She says she has problems establishing and keeping friends because she is easily agitated, has trouble sleeping, worries about everything, and is afraid to leave the house. The patient feels exhausted, unmotivated, and despondent. After losing her six-month pregnancy to a spontaneous abortion and undergoing a hysterectomy, she began mental health treatment in 1998. The patient states that during that time, her PCP assigned her to both a therapist and a psychiatrist. She attended treatment twice a week for four years but stopped seeing the psychiatrist and taking the antidepressant. The client takes 50 mg of Duloxetine orally daily. Although the drug relieved her problems and had no adverse effects on her, she stopped taking it without seeing her doctor. The woman said her psychiatrist only refilled her prescriptions when they ran out without caring about her. Since her fiancé died last year, the patient has been grieving without reason. Worsening anxiety and melancholy, she has more nightmares. Lack of appetite caused her to lose 20 pounds in six months. The client felt emotional throughout the PMHNP evaluation. She denies hallucinating, delusions, or psychotic symptoms like suicidal or homicidal ideas.

 

Past Psychiatric History: After being diagnosed with depression in 1998, the client was prescribed duloxetine 50 mg daily. The client took the medicine until May 2021 and stopped without telling her doctor. She claims no family history of mental illness.

 

Medication Trial and current medication: GR took 50 mg of duloxetine daily from 1998 until 2021.

 

Psychotherapy or previous psychiatric diagnosis: Since 1998, the client has been under the care of a therapist, whom she sees twice a month. Substance Current Use: Denies substance use Medical History: Allergies: No known Allergy Reproductive Hx: GR had hysterectomy in 1998 because of spontaneous abortion.

 

ROS: GENERAL: No complaints of pain were made during the examination, although a history of arthritis, fibromyalgia, diabetes, and neuropathy were noted. There were no reports of psychomotor difficulties on her walk to the clinic. HEENT: There is no blurring or loss of vision, no pain or trouble swallowing, no sore throat, and no nasal obstruction, discharge, congestion, or loss of sense of smell. SKIN: No skin discoloration, wounds, or sores are reported.

 

CARDIOVASCULAR: Disputes the presence of chest pain, discomfort, or tightness. RESPIRATORY: No instances of respiratory difficulties, such as wheezing, dyspnea, or coughing, were documented. GASTROINTESTINAL: As of right now, no reports of nausea, vomiting, or diarrhea, nor of stomach pain, have been made. GENITOURINARY: There are no reports of flank discomfort or any other urinary issues.

 

NEUROLOGICAL: Disputes assertions pertaining to the occurrence of cephalalgia, syncope, or sensations of tingling, numbness, or lightheadedness. MUSCULOSKELETAL: No musculoskeletal discomfort at the time. ST has history of arthritis and fibromyalgia. HEMATOLOGIC: No bleeding, bruising, or anemia reported

 

LYMPHATICS: No leg swelling, discomfort, or lymphadenopathy. ENDOCRINOLOGIC: ST has a diabetes history. She denies heat or cold sensitivity, thirst, and frequent urination. Objective:

 

Diagnostic screening and results:

 

To validate this client’s diagnosis, we referred to the DSM-5’s criteria for diagnosing major depressive disorder and generalized anxiety disorder. The client’s mood disorder symptoms were evaluated with the help of the mood disorder questionnaire. Patients were asked to fill out the PHQ-9, and their average score was 18. For use in medical and mental health settings, the PHQ-9 has been validated as an initial screening and diagnostic tool for depression in people of all ages. With a score of 18, the client has moderately severe major depressive disorder (Muoz-Navarro et al., 2017). This client may be recommended for antidepressant monotherapy, but she may also benefit from counseling.

 

A GAD-7 score of 14 indicates significant anxiety in the client (Jordan et al., 2017). Before initiating mental treatment, patients must have a medical history and routine lab tests such as blood pressure, blood sugar, thyroid, EEG, ECG, and urine. Laboratory testing assesses physical and mental disorders and rules out medical causes of client symptoms. Brain imaging is needed because brain alterations can affect behavior and emotions. However, laboratory testing should be combined with clinical diagnostics to get a mental diagnosis (Ali et al., 2016).

 

The patient was screened for PTSD using the PTSD Checklist (PCL-5). The client scored 31, which is consistent with PTSD. The PMHNP also used the Clinician Assessment of Posttraumatic Stress Disorder (CAPS) to evaluate PTSD. The CAPS assessment is considered the standard of care for PTSD diagnosis. The purpose of the DSM-5-aligned CAPS-5 is to determine whether a patient satisfies the diagnostic criteria for post-traumatic stress disorder. The duration of the client’s PTSD symptoms can also be determined using this tool. Clinicians use this 30-item survey to gain insight into their patients’ perspectives (Weathers et al., 2018). Assessment: Mental Status Examination: A 45-year-old African American woman, GR looks her age. Cognitively alert, calm, cooperative, and attentive. Without motor skill deficits, her grooming is precise and weather appropriate. The client’s voice is clear, coherent, and consistent in volume and rate. Her mind is clear and goal-oriented, and her linguistic abilities are intact. She has no psychotic symptoms like hallucinations, delusions, unusual behaviors, or loose associations. Acceptable, broad, mood-consistent affect. No suicidal or homicidal thoughts or history exist. Her knowledge base is complete and age appropriate. She has intact recent, immediate, and distant memories but lacks attention, vigor, insight, and judgment. The patient’s body language and posture indicate sadness, depression, or nervousness. The client takes everything too seriously and loses interest in tasks. She feels worthless and miserable about her pregnancy loss from 25 years ago, causing increased irritability and worry. When addressing her six-month-old pregnancy’s abrupt termination and her fiancé’s death, the woman makes decent eye contact but cries.

 

Diagnostic Impression:

 

Major Depressive Disorder (MDD), recurrent and moderate: (F33.1).: The DSM-5 describes major depressive disorder symptoms and criteria. A change in appetite, problems sleeping, psychomotor agitation or retardation, restlessness, loss of energy, feelings of worthlessness or guilt, an inability to focus, and even a desire to commit suicide are indications. The client satisfied the DSM-5 criteria for major depressive illness, which requires five or more symptoms for two weeks and a deterioration in functioning. MDD requires a daily sad mood with emotions of emptiness, despair, and hopelessness. Several of these indications may be observed. Severe depressive disorder can also include hunger changes, weight loss or increase of 5% or more in one month, and worthlessness. DSM-5 criteria confirmed significant depressive illness in the individual. To diagnose MDD using the DMS-5, at least five depressive symptoms must be present within two weeks, practically every day, and change the client’s functioning. A depressed mood, disinterest, or loss of enjoyment are required. The client’s history and current symptoms confirm my MDD diagnosis (Ng et al., 2016).

 

Generalized Anxiety Disorder: GAD (F41.1): The DSM-5 specifies worry as a generalized anxiety disorder symptom. No threat appears; hence the client’s concerns are baseless. Most people with generalized anxiety overthink harmless things. GAD is diagnosed when excessive concern is persistent, hard to moderate, and lasts at least six months. In addition to anxiety and worry, generalized anxiety disorder requires somatic or cognitive symptoms such weariness, difficulty concentrating, restlessness, or anger. Along with discomfort, restlessness, anxiety, quick cognition, and erratic conduct increase. GAD is diagnosed if the symptoms cannot be attributable to another medical illness or substance addiction (Roberge et al., 2015).

 

Post-Traumatic Stress Disorder (PTSD): (F 43.10).: Post-traumatic stress disorder symptoms are also present. A DSM-5 diagnosis of PTSD involves exposure to a traumatic and stressful incident (Armenta, 2018). The patient’s life was terrible after losing her boyfriend and their six-month pregnancy in 1998. She had a hysterectomy, making her infertile. Constant worrying, irritation, lack of interest in activities, nightmares, difficulties sleeping, and poor focus are hurting her family and social life, she claims. PTSD often exhibits these symptoms (Armenta, 2018).

 

Reflection

 

Major depressive illness, generalized anxiety disorder, and post-traumatic stress disorder can be treated with medication and psychotherapy. Psychotherapy and medication have been shown to treat anxiety and depression without substance abuse or other medical conditions. By continuing sessions, the therapist believes this client will be better prepared for future challenges. CBT, coupled with psychopharmacology, is beneficial for several mental health disorders (Yin et al., 2021). The client should contact her family doctor for additional exams, including diagnostic tests. Since this client works, her work environment may have contributed to her stress. Based on the evaluation, I will prescribe holistic treatments, including continuing therapy, joining support groups, and trying stress management approaches. Due to the client’s lack of appetite and weight loss, her eating habits were evaluated, and referrals made. Referrals may involve meal planning and dietician consulting because proper nutrition is vital to health. A thorough economic and financial study was done to establish the client’s ability to finance treatment continuation and follow-ups. The client’s cultural beliefs and customs will certainly influence her decisions; therefore, include them in the therapy plan.

 

Type of treatment approach chosen: Depression can be treated with medicine, counseling, psychotherapy, deep brain stimulation, or a combination of non-invasive and invasive techniques. Patients may react differently to different therapies. Even though disease cure or recurrence is uncertain, the question of whether these treatments are worth the risks poses ethical and legal concerns.

 

Case Formulation and Treatment Plan:

 

The client complains of poor mood, melancholy, increasing concern, nightmares, exhaustion, worthlessness, and disinterest in past activities and routines. She struggles to concentrate and sleep; she is emotional and worries excessively. She claims she has problems making and keeping friends and leaving the house, which affects her work attendance and productivity. The client began mental examination and treatment in 1998 and finished in 2021. She stopped taking the prescription because her doctor didn’t care about her. One of the client’s worst losses was a 1998 six-month miscarriage. She misses her dearest friend and rock, her fiancé, who died in 2022. The client has complained of everyday crying, poor mood, increased concern, and nightmares since then. The client alleges loss of appetite caused her 20-pound weight loss in six months. During the PMHNP evaluation, she denied suicidal or homicidal thoughts, hallucinations, delusions, and other psychosis symptoms.

 

Treatment Plan

 

This client receives psychotherapy and medications. McDowell et al. (2017) say psychotherapy helps people change their moods and habits. The purpose of treatment is to build resilience against adversity. Psychotherapy and psychopharmacology may help this person recover faster from depression and anxiety.

 

Medication Therapy: To treat client symptoms, appropriate medication is needed. Knowing the health benefits of drugs makes clients more inclined to take them as prescribed and reduces worry. The client’s daily duloxetine 50 mg cap/dose has been reinstated. This medication is an SNRI. Duloxetine (Cymbalta) is FDA-approved for treating major depressive disorder, diabetic neuropathy, and fibromyalgia discomfort. I believe duloxetine will stabilize the patient’s mood and manage her diabetes, knee arthritis, and fibromyalgia. While taking duloxetine, the client reported no side effects and improved symptom management. Additionally, the client received Hydroxyzine 25 mg po BID PRN for anxiety. Adults with GAD benefit from antihistamine hydroxyzine. The research participants accepted hydroxyzine well, and it significantly reduced GAD symptoms (Strawn et al., 2018). I suggested taking 50 mg of Trazadone before bed. Trazadone is officially licensed for major depressive disorder, but doctors prescribe it off-label for insomnia if the benefit outweighs the risk. The client was advised to take these prescriptions as prescribed. The client was told how often to take the drugs and how long until they started working, which helps them stay motivated and follow the treatment plan. The client was advised to continue taking her medications even if she felt better without consulting her doctor. The client was told to contact the clinic, dial 911, or go to the emergency department if she had any side effects from her drugs or thoughts of suicide or violence. Patients were instructed to return to the clinic every two weeks and subsequently every four weeks to report changes in medication effectiveness, risks, and side effects. The client was advised to get enough sleep, exercise, and eat well and offered a follow-up visit.

 

Antidepressants should not be given to MDD patients unless ECT is planned since they supplement primary treatment for mild to severe MDD. I agree with the patient’s choice of duloxetine. The initial choice of antidepressants will be based on the expected adverse effects, the tolerability or safety of these complications for the specific patient, and the pharmacological properties of the prescription because duloxetine has relatively similar efficacy across and within medication classes. For acute-severe depression, more continuous medication is needed. MDD was treated successfully with duloxetine alone. The recommended daily duloxetine dose is 50 mg. Clients should be examined regularly to determine long-term therapy and dosage.

 

Adults with major depressive disorder (MDD) may have depression exacerbations, suicidality, and other abnormal behavioral changes, regardless of duloxetine use. Until a large reduction occurs, this risk may persist. Major depressive disorder (MDD) and other mental diseases increase suicide risk. Duloxetine has long been suspected of worsening depression and increasing suicidality in some individuals at the start of medication

 

Sertraline works well for psychotropic medicine because of the patient’s appearance. Depression and social anxiety are commonly treated with sertraline. This medicine improves mood, appetite, energy, and sleep to restore everyday desire. It may reduce fear, anxiety, and panic attacks. An SSRI like sertraline Restoring serotonin balance in the brain makes it effective. Primary care depression patients may benefit from sertraline. These benefits are connected to anxiety and quality of life, not depression.

 

REFERENCES

 

Chow R.M., Issa M. (2017) Serotonin-Norepinephrine Reuptake Inhibitors. In: Yong R., Nguyen M., Nelson E., Urman R. (eds) Pain Medicine. Springer, Cham.

 

https://doi.org/10.1007/978-3-319-43133-8_44

 

Lewis, G., Duffy, L., Ades, A., Amos, R., Araya, R., Brabyn, S., … & Lewis, G. (2019). The clinical effectiveness of sertraline in primary care and the role of depression severity and duration (PANDA): a pragmatic, double-blind, placebo-controlled randomised trial. The Lancet Psychiatry, 6(11), 903-914.

 

https://doi.org/10.1016/S2215-0366(19)30366-9

 

Alexander W. (2012). Pharmacotherapy for Post-traumatic stress disorder in Combat Veterans: Focus on Antidepressants and Atypical Antipsychotic Agents. P & T: a peer-reviewed journal for formulary management, 37(1), 32–38.

 

Ali, G.-C., Ryan, G., & De Silva, M. J. (2016). Validated screening tools for common mental disorders in low and middle-income countries: A systematic review. PLOS ONE, 11(6). https://doi.org/10.1371/journal.pone.0156939

 

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).

 

https://doi.org/10.1176/appi.books.9780890425596

 

Ansara, E., & Schulte, S. (2017). Anxiety disorders: Generalized anxiety disorder (GAD), panic disorder (PD), and Social Anxiety Disorder (SAD). Pharmacotherapy First: A Multimedia Learning Resource. https://doi.org/10.21019/pharmacotherapyfirst.anxiety_overview

 

Armenta, R.F., Rush, T., LeardMann, C.A. et al., (2018). Factors associated with persistence. Post-traumatic stress disorder among US military service members and veterans. BMC, Psychiatry 18, 48. https://doi.org/10.1186/s12888-018-1590-5

 

Jordan, P., Shedden-Mora, M. C., & Löwe, B. (2017). Psychometric analysis of the Generalized Anxiety Disorder scale (GAD-7) in primary care using modern item response theory. PloS one, 12(8), e0182162. https://doi.org/10.1371/journal.pone.0182162

 

Lenz, A. S., & Hollenbaugh, K. M. (2015). Meta-Analysis of Trauma-Focused cognitive behavioral therapy for Treating PTSD and Co-occurring depression among children and adolescents. Counseling Outcome Research and Evaluation, 6(1), 18-32.

 

https://doi:10.1177/2150137815573790

 

Muñoz-Navarro, R., Cano-Vindel, A., Medrano, L. A., Schmitz, F., Ruiz-Rodríguez, P., Abellán-Maeso, C., Font-Payeras, M. A., & Hermosilla-Pasamar, A. M. (2017). Utility of the PHQ-9 to identify the major depressive disorder in adult patients in Spanish Primary Care Centres. BMC Psychiatry, 17(1). https://doi.org/10.1186/s12888-017-1450-8

 

Ng, C. W., How, C. H., & Ng, Y. P. (2016). Major depression in primary care: making the diagnosis. Singapore medical journal, 57(11), 591–597.

 

https://doi.org/10.11622/smedj.2016174

 

Roberge, P., Normand-Lauzière, F., Raymond, I., Luc, M., Tanguay-Bernard, M., Duhoux, A Fournier, L. (2015). Generalized anxiety disorder in primary care: Mental health services use and treatment adequacy. BMC Family Practice, 16(1).

 

https://doi:10.1186/s12875-015-0358- y88b

 

Strawn, J. R., Geracioti, L., Rajdev, N., Clemenza, K., & Levine, A. (2018). Pharmacotherapy for generalized anxiety disorder in adult and pediatric patients: an evidence-based treatment review. Expert opinion on pharmacotherapy, 19(10), 1057–1070.

 

https://doi.org/10.1080/14656566.2018.149196

 

Weathers, F. W., Bovin, M. J., Lee, D. J., Sloan, D. M., Schnurr, P. P., Kaloupek, D. G., Keane, T. M., & Marx, B. P. (2018). The Clinician-Administered PTSD Scale for DSM-5 (CAPS5): Development and initial psychometric evaluation in military veterans. Psychological assessment, 30(3), 383–395. https://doi.org/10.1037/pas0000486

 

Yin, B., Teng, T., Tong, L., Li, X., Fan, L., Zhou, X., & Xie, P. (2021). Efficacy and acceptability of parent-only group cognitive-behavioral intervention for anxiety disorder treatment in children and adolescents: A meta-analysis of randomized controlled trials.

 

https://doi:10.21203/rs.2.21666/v2

 

Questions:

 

· I prescribed duloxetine to my diabetic and fibromyalgia patient because of its FDA approval for depression and chronic pain management, including neuropathic pain. Would a different antidepressant have helped this client’s symptoms and treatment? Please defend your answer.

 

· Psychopharmacology is safer when begun at a low dose and progressively escalated to therapeutic levels. However, my preceptor and I decided to put my client back on 50 mg of duloxetine. The client indicated this dosage worked well and had no side effects, so we chose it. Is our choice right, or would a modest dose and steady rise have be preferable for the customer?

 

· Given her medical history, what other psychotropic medications would you recommend for the client? Answer This Question Only

 

Provide a response to 1 of the 3 discussions prompts that your colleagues provided in their video presentations. You may also provide additional information, alternative points of view, research to support treatment, or patient education strategies you might use with the relevant patient.

 

Responses exhibit synthesis, critical thinking, and application to practice settings…. Responses provide clear, concise opinions and ideas that are supported by at least two scholarly sources…. Responses demonstrate synthesis and understanding of Learning Objectives…. Communication is professional and respectful to colleagues…. Presenters’ prompts/questions posed in the case presentations are thoroughly addressed…. Responses are effectively written in standard, edited English.

 

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