Evaluating Life Review and Reminiscence Therapy in Alleviating
23 hours ago
Jo-el Benn
Week 10 Discussion
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NRNP 6640: Psychotherapy with Individuals
Week Ten Discussion
Therapy with Older Adults
For the week ten discussion, I will present a care/treatment plan constructed with the data provided by a case study from the week ten course material. The data will include my presumptions about the patient’s diagnosis (based on how his symptoms match up with characteristics of mental health disorders categorized in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) (2013), diagnostic tests/tools I would use to identify the diagnosis, differential diagnosis(es) that should be considered, the method of treatment (both pharmacological and non-pharmacological) that I would prescribe for the case-study patient, what education I would provide and encourage, and what standard guidelines I would employ to treat/assess this patient.
Case Study
The case study featured a widowed, sixty-nine year old African American man who has been exhibiting worsening symptoms of anxiety and depression (including loss of interest in routine activities, poor sleep, fatigue, and frequently feeling as if he is moving in slow-motion) in the recent wake of both his father’s imminent death, and his own diagnosis of prostate cancer (Walden University, 2020).
Treatment Plan
The treatment plan I would prescribe for this patient would consist of the following:
Diagnosis: According to the DSM-V (2013), the patient’s report of depressed mood, fatigue, disinterest in routine activities, diminished ability to concentrate, and co-occurring anxiety (for which he has been taking 1mg of Ativan twice daily) most closely resembles the signs and symptoms of major depressive disorder (MDD), mild, with anxious distress. Although these symptoms most resemble this disorder, because the case-study does not give us a definitive timeline for the presence of the patient’s symptoms, it would be impossible to fully determine the diagnosis (American Psychiatric Association, 2013). As the patient has a past history of treatment for depression that spans several years, his symptoms appear to be recurrent (Walden University, 2020). Although it represents the second most common psychiatric disorder in older individuals, depression is not considered a conventional or expected feature of aging (Knöchel et al., 2015; Wheeler, 2014).
DSM-V Coding: The DSM-V coding for recurrent, mild MDD would fall under 296.31 (F33.0) (American Psychiatric Association, 2013).
Diagnostic Tests: Diagnostic tests I would consider using to screen this patient and identify the most appropriate diagnosis to associate with his symptoms would be the Geriatric Depression Scale (GDS), and the Penn State Worry Questionnaire (PSWQ). Frequently used as a tool to screen for symptoms of depression, the GDS can also be utilized to measure the effectiveness of subsequent treatment (Dafsari et al., 2019; Wheeler, 2014). Given the patient’s co-occurring anxiety, it may also be prudent to screen this patient with the PSWQ in order to measure and identify the patient’s worries/stressors that may be contributing to his overlying condition; generalized anxiety disorder (GAD), and MDD having many overlapping characteristics (Wheeler, 2014; Yao et al., 2016).
Differential Diagnosis: A differential diagnosis I would consider as an alternative for this patient would be adjustment disorder with depressed mood. Although this mood disorder variant shares many of the characteristics with MDD (i.e. depressed mood, and potential for self-harm), adjustment disorder involves a precipitating event(s) that act as a catalyst for the individual’s depression; which could in this care be characterized by the patient’s concern with his dying father, and feelings about his own recent cancer diagnosis (American Psychiatric Association, 2013; Walden University, 2020).
Standard Guidelines: I would utilize the fourth and thirteenth clinical guidelines on psychological practice with older adults designed by the American Psychological Association (APA) which emphasize that the health care provider not only be aware of the social and psychological dynamics that may occur with the aging process (such as life transitions, social isolation, or widowhood as in the case of the patient in this case-study), but also knowledgeable of the latest and most effective treatment modalities available to help the patient manage their issues as demonstrated by evidence-based practice (Hinrichsen et al., 2014). Being versed in knowledge of the current and effective treatment interventions may be especially prudent for the patient in this case, as his being from an ethnic minority (non-European) background places him at a greater risk of experiencing barriers to available and successful treatment (Hinrichsen et al., 2014; Rawlings & Bains, 2020). According to Wheeler (2014), it is also important to establish the importance of psychotherapy and the therapeutic process in the older patient, who may not be as familiar with such treatment modalities and concepts (p. 637).
Treatment Strategy: Although the patient has recently engaged in psychotherapy-based treatment, he also has a past history of poor response to mood-stabilizer pharmacotherapy; thus, it may be prudent to treat this patient with a multimodal approach, combining both psychotherapy and pharmacotherapy (Knöchel et al., 2015; Walden University, 2020). As the patient is faced with the mortality of his father as well as his own, it may be beneficial to use Life Review (LR) therapy, which is a time-limited iteration of psychotherapy in which the patient examines major life events, works toward coming to terms with challenging or difficult past events, enhancing their sense of self-esteem, and finding meaning in life (Knöchel et al., 2015; Rubin et al., 2019).
Despite the fact that the patient has already been on a variety of meds, there is research evidence to suggest that SNRI’s (serotonin-norepinephrine reuptake inhibitors) may be associated with a higher risk of producing adverse effects in older individuals, which could generate complications with this patient who already has a host of other health issues in addition to his recent cancer diagnosis (Sobieraj et al., 2019; Walden University, 2020). As the case-study mentions that he had some partial response to certain meds, but does not specify which, it may be worth revisiting SSRI (serotonin-reuptake inhibitor) drugs with which he had shown some improvement (Walden University, 2020).
With consideration to the patient’s various co-morbidities, Citalopram (Celexa) may be a good choice (if previously effective) to administer with adjacent psychotherapy as it tends to be well tolerated in older adults when compared with other SSRIs (Stahl, 2018). Although this patient has been taking Lorazepam 1mg twice a day for years and this drug has proven effective for treating anxiety symptoms when given in conjunction and SSRI or SNRI, it has a risk for dependence (when given longer than twelve months) and sedation (especially in older adults) (Stahl, 2018). As recurrent thoughts of death or suicide is a possible characteristic that may manifest with MDD, and a higher risk of suicide is represented by older adults that are part of the baby boomer generation (65 years and older), consideration and frequent assessment for this patient’s safety and any changes in these thoughts is paramount as treatment proceeds (American Psychiatric Association, 2013; Wheeler 2014).
Psychoeducation: I would emphasize psychoeducation in being able to recognize increasing symptoms of anxiety and depression (including thoughts of self-harm), stress management techniques, mindfulness techniques, and how to adjust treatment expectations/goals as the patient’s symptoms improve or worsen (Larouche et al., 2019; Wheeler, 2014).
References
American Psychiatric Association. (2013). Diagnostic and Statistical
Manual of Mental Disorders (5th ed.). Washington, DC: Author.
Dafsari, F. S., Bewernick, B., Biewer, M., Christ, H., Domschke, K.,
Froelich, L., Hellmich, M., Luppa, M., Peters, O., Ramirez, A.,
Riedel-Heller, S., Schramm, E., Vry, M.-S., Wagner, M.,
Hautzinger, M., & Jessen, F. (2019). Cognitive Behavioural
Therapy for the Treatment of Late Life Depression: Study
Protocol of a Multicentre, Randomized, Observer-Blinded,
Controlled Trial (CBTlate). BMC Psychiatry, 19(1), 1–12.
https://eds-a-ebscohost-com.ezp.waldenulibrary.org/eds/
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Hinrichsen, G., Brickman, A., Edelstein, B., Vacha-Haase,
T., Hiroto, K., & Zweig, R. (2014). Guidelines
for Psychological Practice with Older Adults. American
Psychologist. 69. 34-65.
https://www.apa.org/pubs/journals/features/older-adults.pdf
Knöchel, C., Alves, G., Friedrichs, B., Schneider, B., Schmidt-Rechau,
A., Wenzler, S., Schneider, A., Prvulovic, D., Carvalho, A. F.,
& Oertel-Knöchel, V. (2015). Treatment-Resistant Late-Life
Depression: Challenges and Perspectives. Current
Neuropharmacology, 13(5), 577–591.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4761630/
Larouche, E., Hudon, C., & Goulet, S. (2019). Mindfulness Mechanisms
and Psychological Effects for aMCI Patients: A Comparison
with Psychoeducation. Complementary Therapies in Clinical
Practice, 34, 93–104.
https://www-sciencedirect-com.ezp.waldenulibrary.org/science/
article/pii/S1744388118305516?via%3Dihub
Rawlings, G. H., & Bains, M. (2020). Experiences of Depression in Older
Adults from Non-White and Ethnic Minority Groups: A Thematic
Synthesis of Qualitative Studies. Journal of Affective
Disorders, 266, 341–348.
https://www-sciencedirect-com.ezp.waldenulibrary.org/
science/article/pii/S0165032719323432?via%3Dihub
Rubin, A., Parrish, D. E., & Miyawaki, C. E. (2019). Benchmarks for
Evaluating Life Review and Reminiscence Therapy in Alleviating
Depression among Older Adults. Social Work, 64(1), 61–72.
https://eds-a-ebscohost-com.ezp.waldenulibrary.org/eds/
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Sobieraj, D. M., Martinez, B. K., Hernandez, A. V., Coleman, C. I.,
Ross, J. S., Berg, K. M., Steffens, D. C., & Baker, W. L.
(2019). Adverse Effects of Pharmacologic Treatments of Major
Depression in Older Adults. Journal of the American Geriatrics
Society, 8, 1571.
https://onlinelibrary-wiley-com.ezp.waldenulibrary.org/
doi/full/10.1111/jgs.15966
Stahl, S. M. (2018). Stahl’s Essential Psychopharmacology: Prescribers Guide
(6th ed.). Cambridge, United Kingdom: Cambridge University Press.
Walden University. (2020). NURS 6640: Psychotherapy with Individuals
Week 10: Case Study. [Case-Study Word Document] Minneapolis,
MN.
https://class.content.laureate.net/d349e71b6e7092d12070901
c8b5ca9b4.html
Wheeler, K. (Eds.). (2014). Psychotherapy for the Advanced Practice
Psychiatric Nurse: A How-to Guide for Evidence-Based Practice
(2nd ed.). New York, NY: Springer Publishing Company.
Yao, B., Sripada, R. K., Klumpp, H., Abelson, J. L., Muzik, M., Zhao, Z.,
Rosenblum, K., Briggs, H., Kaston, M., & Warren, R. (2016). Penn
State Worry Questionnaire – 10: A New Tool for Measurement-Based
Care. Psychiatry Research, 239, 62–67.
https://www-sciencedirect-com.ezp.waldenulibrary.org/
science/article/pii/S0165178115305977?via%3Dihub
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41 minutes ago
Loraine Fleming Walden Instructor Manager
RE: Week 10 Discussion
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Thank you for your post, Jo-el. Can you elaborate on the education you would provide to the patient?
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