Psychiatric Disorders (Depression, Anxiety, Sleep) Discussion essay
Module IV: Psychiatric Disorders (Depression, Anxiety, Sleep) Discussion ? Must post first. Subscribe Benzodiazepines are commonly prescribed medications for several indications, including anxiety and sleep disorders. Let?s discuss their use in our health care systems and the impact on our patients. Things to consider might include (just getting you thinking): Safety: How could the side effect profile affect your patients? Efficacy: Are benzodiazepines efficacious for anxiety and sleep? Use: Are they under or over prescribed? How can we ensure safe use of these medications? Consider the following cases: KT is a 24 year old female completing her studies. While home for spring break, she presents to her primary care physician because she has been worried about her academic, professional, and personal future since class restarted in late August. She is constantly worried about passing all of her exams and that she is going to be the only one of her friends that graduates school without a ring on her finger. How would you help her assuming she meets the criteria for GAD? WD is a 49-year-old male who suffered a myocardial infarction one week ago. Upon discharge, it was noted that WD appeared depressed. At a follow-up visit with his physician a week later, WD met criteria for a diagnosis of major depressive disorder. His past medical history includes: treatment refractory hypertension, diabetes mellitus (type II), and severe uncontrolled narrow angle glaucoma How would you help him assuming he meets the criteria for MDD? JM is a 42 year old female who was referred for management of insomnia. She reports that she is unable to sleep at all during the week (difficulty going to sleep and staying asleep) and sleeps all day on Sunday. She currently takes temazepam (Restoril) 30 mg HS (recently increased from 15mg). She also experiences depression due to an abusive relationship with her boyfriend as well as her current lack of employment. She reports poor sleep hygiene (reads and watches TV in bed), drinks 6-8 cups of coffee throughout the day and does not pay attention to how late she eats or exercises. What non-pharmacological and pharmacological therapies would you recommend for JM? Post your initial response by Wednesday at midnight. Respond to one student by Sunday at midnight. ?Both responses should be a minimum of 150 words, scholarly written, APA formatted, and referenced. ?A minimum of 2 references are required (other than your text). Refer to the Grading Rubric for Online Discussion in the Course Resource section. Feedback 99 / 100 View Graded Rubric Start a New Thread Discussion Filter by: All Threads Sort by: Most Recent ActivityLeast Recent ActivityNewest ThreadOldest ThreadAuthor First Name A-ZAuthor First Name Z-AAuthor Last Name A-ZAuthor Last Name Z-ASubject A-ZSubject Z-A Module 4 Contains unread posts ? Pawn Johnson-Hunter posted Sep 24, 2020 12:01 AM Subscribe Generalized anxiety disorder is characterized by an excessive, persistent level of worry or consistent overwhelming feelings.?University and college students may be at higher risk of developing?Common mental health problems?(CMHP) because they are often under significant stress, are in a transitional period, and fall within the age range when CMHPs are at their developmental peak (Huang et al., 2018).?KT is experiencing an intolerant uncertainty, which may be increasing her anxiety. Her association with the failure of passing her classes and getting married after graduating are distorted thought processes. Brown and Tung (2018),?the key diagnostic feature of generalized anxiety disorder (GAD) is excessive anxiety and difficult to control worry about a number of events or activities, occurring more days than not for at least six months. Her worrying initially during spring break and has continued into late August, nearing six months without any foreseen resolve from the patient. In attempting to help her, one must consider her current lifestyle when deciding; the treatment may consist of medication, therapy, or both. Benzodiazepines are typical drug treatments for GAD and have high abuse with the patient due to their addictive nature. Furthermore, KT is a student, and the effect of a benzodiazepine would cause sedative effects that may negative outcomes as she is a student. Before prescribing medication, it may be useful to suggest other options such as exercise and therapy than have KT revisit to see how she has progressed. In the case of WD his depression should be treated with medication therapy due to his comorbidities.?Depression is associated with an increased risk of mortality in patients with coronary heart disease (Carney et al., 2016). Not treating WD depression could further exacerbate his heart condition. According to Schuster et al., (2016), ? American Heart Association (AHA) Science Advisory advocated that patients with coronary heart disease be systematically screened for depression to identify those who may require further assessment and treatment. Indeed, depression is present in 20?25% of patients with established heart disease, and effective treatment can improve health-related quality of life and adherence with recommended care, and lower mood symptoms and health care costs. JM has a combination of factors that contribute to her depression and insomnia. One of the non-pharmacological recommendations that could be suggested is individual and possibly group therapy. Her unhealthy relationship is likely the cause of her depression and insomnia. Engagement with others in similar situations could help her identify that her lifestyle plays a significant role in her mental health. She should also be offered social services for additional counseling immediately to see if she feels that she is in an unsafe environment. References Brown, T. A., & Tung, E. S. (2018). The contribution of worry behaviors to the diagnosis of generalized anxiety disorder.?Journal of Psychopathology and Behavioral Assessment,?40(4), 636-644.?http://dx.doi.org.wilkes.idm.oclc.org/10.1007/s10862-018-9683-5 Carney, R. M., Freedland, K. E., Steinmeyer, B., Rubin, E. H., Mann, D. L., & Rich, M. W. (2016). Cardiac risk markers and response to depression treatment in patients with coronary heart disease.?Psychosomatic Medicine,?78(1), 49. Huang, J., Nigatu, Y. T., Smail-Crevier, R., Zhang, X., & Wang, J. (2018). Interventions for common mental health problems among university and college students: A systematic review and meta-analysis of randomized controlled trials.?Journal of Psychiatric Research,?107, 1-10. doi:10.1016/j.jpsychires.2018.09.018 Schuster, James M., MD, MBA, Belnap, B. H., Roth, L. H., MD, & Rollman, Bruce L., M.D., M.P.H. (2016). The checklist manifesto in action: Integrating depression treatment into routine cardiac care.?General Hospital Psychiatry,?40, 1-3. doi:10.1016/j.genhosppsych.2016.01.005 less 2 Unread 2 Unread 2 Replies 2 Replies 7 Views 7 Views View profile card for Pawn Johnson-Hunter Last post?Sep 27, 2020 9:54 PM?by Pawn Johnson-Hunter Week IV Initial Post Tomiko Edmonds Contains unread posts ? Tomiko Edmonds posted Sep 23, 2020 9:57 PM Subscribe When referring to Benzodiazepines, they are often prescribed however, they are recommended to be used for short term use for anxiety. They have a potential for dependence and abuse. They will have a sedative effect on the patient and can cause amnesia. While in an acute situation, a Benzodiazepine may be warranted but care must be taken to provide interventions that can be given long term if needed. In the elderly population, it should not be used long term as they may not be able to metabolize the medication hence it will stay in their system longer and can be detrimental. It can also cause safety risks by way of falls with the potential for fractures as well as skin breakdown due to the sedative effects that may not allow them to change positions on their own. Prolonged use is associated with the development of dependence, tolerance and adverse reactions, including cognitive impairment, dementia, falls and consequent fractures, (Fulone et al., 2018). Benzodiazepines act fast and can be effective for acute situations. Alprazolam, clonazepam, and lorazepam are among the 10 most commonly prescribed psychotropic medications in the United States, (Lembke et al., 2018). A common problem with this is that those who use illicit drugs combined with this are at greater risk for addiction and untoward events. Benzodiazepines have proven utility when they are used intermittently and for less than 1 month at a time. When they are used for extended periods, the benefits of benzodiazepines diminish and the risks associated with their use increase, (Lembke et al., 2018). When speaking with KT regarding her general anxiety disorder, it is important to assess her physically to determine if there are any physiological reasons or perhaps other medications that she is taking that could be the reason for her anxiety. After this is ruled out, it would be important to determine what, if any coping mechanisms she has to deal with the many concerns she has being a new student and coping with her various obligations. Therapy would be the initial course of action. If therapy is being utilized and it is not effective, then medications can be prescribed at its lowest dose. A selective serotonin reuptake inhibitor (SSRI) would be started in combination with therapy to treat her symptoms and coping mechanisms will be taught. She would be advised that the medication may take some time to have its greatest effect before she may see some improvement. WD may meet the criterion for Major Depressive Disorder as he had a major health event that one can consider life changing. Major depressive disorder is the most prevalent and disabling form of depression, affecting more than 32 million Americans. In any given year, nearly 7% of the American adult population has an episode of major depressive disorder, (Amick et al., 2015).? With his past medical history, the first course of treatment would be intensive counseling. A meta?analysis showed that patients who received psychosocial treatment had significant reductions in psychological distress and systolic BP (SBP), (Seyedhosseini et al., 2016). Refractory hypertension, being hard to treat may have caused his depression. The inherent complexity of psychological distress may in fact raise the blood pressure. The most common cardiovascular-related side effects of SSRIs include mild bradycardia and hypotension, mild QRS prolongation, and first-degree cardiac block, (Nezafati et al., 2016). Behavioral modification would be the first line of defense however, if this is not sufficient, medications would be introduced. The provider must assess the willingness of the patient to be compliant with the prescribed medications as all medications have some sort of side effects. Regardless of which treatment patients prefer, some evidence suggests that patients who receive their treatment of choice fare better than those whose treatment is incongruous with their preferences, (Amick et al., 2015). When starting medications, again the use of SSRIs is considered. To initiate antidepressant treatment, modern guidelines recommend new generation antidepressants and in particular (SSRIs), (Kato et al., 2018). When prescribing medication for WD, it is important to note that SSRIs are thought to contribute to glaucoma so care must be taken in his circumstance. It has been hypothesized that SSRIs may increase intraocular pressure via serotonergic effects on ciliary body muscle activation and pupil dilation, (Chen et al., 2017). Serotonin has been shown to play a critical role in lens transparency, and, thus, it is postulated that increased levels of serotonin may be associated with lens opacity in human eyes, (Karaküçük et al., 2019). The effect on the body may make their eyes dry and gritty so this should be considered when prescribing medications. In addition to the above, SSRIs can potentially induce Diabetes. SSRIs are potential inducers of insulin resistance, and its role may be to act as a direct inhibitor of the insulin signaling cascade in β-cells, (Yao et al., 2018). The effect of comorbid diabetes and depression on decrements in health has been shown to be interactive, suggesting a negative effect on health beyond that expected by adding the effect of the two disorders, (Berge & Riise, 2015). When assessing JW, it is important to note that she has significant concerns that are causing her to have anxiety and depression based on her situation. Her immediate safety needs to be addressed wherever possible and resources for job preparedness and training should be referred. Again, counseling should be incorporated first in her treatment plan and coping mechanisms should be taught prior to medication administration.?In patients with conditions such as pain, cancer or depression, treatment focused on relieving the primary disorder, (Geiger-Brown et al., 2015). Her primary disorder are the burdens that she deals with on a daily basis. Most likely she is thinking too much of her current situation which is leading to her insomnia. At some point, the body is forcing her to sleep and she finds herself sleeping for extended periods of time on Sunday. Sleep is an important aspect of health and is restorative in nature. The lack of sleep can cause numerous problems both psychologically and physiologically. Sleep problems can be addressed through simple precautions, such as sleep hygiene, relaxation techniques, and behavioral therapy, before recommending medication, (Duman & Timur Taşhan, 2018). Alternative, nonpharmacological approaches should be explored such as warm milk, providing a warm quiet environment absent of television or other stimulants prior to the hour of sleep. Late night exercising may prevent her from sleeping as her energy levels may increase however, for some, it can help them sleep better so it advisable to discuss with JW how she feels after exercise. Listening to white noise and calming sounds may prove to be effective. Additionally, avoiding the use of anything that contains caffeine would be advisable. JW is noted to be taking a benzodiazepine for sleep. While effective for sleep, it does not have an effect on the reason why she is not getting enough sleep. Temazepam has a longer half life than other benzodiazepines and with continued use will not be effective at the same dose. I would opt to try a more natural approach in addition to nonpharmacological treatments for her insomnia. ? References Amick, H. R., Gartlehner, G., Gaynes, B. N., Forneris, C., Asher, G. N., Morgan, L. C., Coker-Schwimmer, E., Boland, E., Lux, L. J., Gaylord, S., Bann, C., Pierl, C., & Lohr, K. N. (2015). Comparative benefits and harms of second generation antidepressants and cognitive behavioral therapies in initial treatment of major depressive disorder: Systematic review and meta-analysis.?BMJ, h6019.?https://doi.org/10.1136/bmj.h6019 Berge, L., & Riise, T. (2015). Comorbidity between type 2 diabetes and depression in the adult population: Directions of the association and its possible pathophysiological mechanisms.?International Journal of Endocrinology,?2015, 1?7.?https://doi.org/10.1155/2015/164760 Chen, V.-H., Ng, M.-H., Chiu, W.-C., McIntyre, R. S., Lee, Y., Lin, T.-Y., Weng, J.-C., Chen, P.-C., & Hsu, C.-Y. (2017). Effects of selective serotonin reuptake inhibitors on glaucoma: A nationwide population-based study.?PLOS ONE,?12(3), e0173005.?https://doi.org/10.1371/journal.pone.0173005 Duman, M., & Timur Taşhan, S. (2018). The effect of sleep hygiene education and relaxation exercises on insomnia among postmenopausal women: A randomized clinical trial.?International Journal of Nursing Practice,?24(4), e12650.?https://doi.org/10.1111/ijn.12650 Fulone, I., Silva, M., & Lopes, L. (2018). Long-term benzodiazepine use in patients taking antidepressants in a public health setting in brazil: A cross-sectional study.?BMJ Open,?8(4), e018956.?https://doi.org/10.1136/bmjopen-2017-018956 Geiger-Brown, J. M., Rogers, V. E., Liu, W., Ludeman, E. M., Downton, K. D., & Diaz-Abad, M. (2015). Cognitive behavioral therapy in persons with comorbid insomnia: A meta-analysis.?Sleep Medicine Reviews,?23, 54?67.?https://doi.org/10.1016/j.smrv.2014.11.007 Karaküçük, Y., Beyoglu, A., Çömez, A., Orhan, F., & Demir, M. (2019). Early effects of selective serotonin reuptake inhibitors (ssris) on cornea and lens density in patients with depression.?Psychiatry and Clinical Psychopharmacology,?29(4), 387?393.?https://doi.org/10.1080/24750573.2019.1673944 Kato, T., Furukawa, T. A., Mantani, A., Kurata, K., Kubouchi, H., Hirota, S., Sato, H., Sugishita, K., Chino, B., Itoh, K., Ikeda, Y., Shinagawa, Y., Kondo, M., Okamoto, Y., Fujita, H., Suga, M., Yasumoto, S., Tsujino, N., Inoue, T.,?Guyatt, G. H. (2018). Optimising first- and second-line treatment strategies for untreated major depressive disorder ? the sun??d study: A pragmatic, multi-centre, assessor-blinded randomised controlled trial.?BMC Medicine,?16(1).?https://doi.org/10.1186/s12916-018-1096-5 Lembke, A., Papac, J., & Humphreys, K. (2018). Our other prescription drug problem.?New England Journal of Medicine,?378(8), 693?695.?https://doi.org/10.1056/nejmp1715050 Nezafati, P., Nezafati, M., Eshraghi, A., Vojdanparast, M., & Abtahi, S. (2016). Selective serotonin reuptake inhibitors and cardiovascular events: A systematic review.?Journal of Research in Medical Sciences,?21(1), 66.?https://doi.org/10.4103/1735-1995.189647 Seyedhosseini, S., Razavi Ratki, S., Valizadeh, A., Rastgoo, T., Tavakkoli, R., Golabchi, A., Ghashghaei, F., Nemayandeh, S., Boroomand, A., & Shirinzade, A. (2016). Can antidepressant drug impact on blood pressure level in patients with psychiatric disorder and hypertension? a randomized trial.?International Journal of Preventive Medicine,?7(1), 26.?https://doi.org/10.4103/2008-7802.174891 Yao, S., Li, J., Fan, X., Liu, Q., & Lian, J. (2018). The effect of selective serotonin re-uptake inhibitors on risk of type ii diabetes mellitus and acute pancreatitis: A meta-analysis.?Bioscience Reports,?38(5).?https://doi.org/10.1042/bsr20180967 ? ? less 2 Unread 2 Unread 2 Replies 2 Replies 8 Views 8 Views View profile card for Tomiko Edmonds Last post?Sep 27, 2020 6:27 PM?by Tomiko Edmonds Module IV: Psychiatric Disorders Contains unread posts ? Shante Hunt posted Sep 23, 2020 6:45 PM Subscribe KT is a 24 year old female who is exhibiting symptoms of generalized anxiety disorder resulting from worries related to her personal, professional, and academic life.??Treatment of generalized anxiety disorder can begin with cognitive behavioral therapy, pharmacotherapy, or a combination of both methods.??Assessment of her symptoms would include questions related to severity and duration of anxiety, impact on her daily life, assessment of her sleep habits, and whether or not she has other diagnoses such as major depressive disorder.??I would begin KT?s treatment with an SSRI such as Escitalopram 5 mg daily (Stein and Sereen, 2015) and refer her to a psychologist for cognitive behavioral therapy.??In addition to pharmacotherapy, I would suggest lifestyle modifications to avoid stimulants like caffeine. ? WD is a 49 year old male with a recent history of MI one week ago.??He presents with symptoms of major depressive disorder on follow up and has a history of uncontrolled hypertension, diabetes type II, and uncontrolled narrow angle glaucoma.??My first recommendation for WD would be psychotherapy to help him explore his feelings of depression.??If psychotherapy is either ineffective or not reaching an optimal effect, I would start him on an SSRI like Paroxetine since this class of drug is considered first line treatment and Paroxetine does not have the anticholinergic effects of other SSRIs that would be contraindicated for him due to his history of HTN and glaucoma (Citrome, 2018). ? JM is a 42 year old female reporting symptoms of insomnia and additive depression due to personal difficulties in her relationship and lack of employment.??She reports that she has trouble achieving and maintaining sleep despite taking Restoril 30 mg at bedtime.??She also reports poor sleep hygiene and high caffeine intake so treatment would begin with instructing her to limit her caffeine intake and not consume coffee close to bedtime; we would select a time that is agreeable to her.??Additional non-pharmacological recommendations would include eliminating the use of her cell phone for at least 30 minutes before bedtime to allow her brain to prepare for sleep (Lie et al, 2015).??Pharmacological intervention would include a medication such as Suvorexant 10 mg at bedtime(Belsomra) which is approved for insomnia characterized by difficulty falling asleep and maintaining sleep and has??(Lie et al, 2015).??If Suvoxerant is too expensive for her due to her lack of employment and because she reports depressive symptoms I may recommend Doxepin which is a TCA but does not demonstrate the common side effects of other TCAs due to the lower dose appropriate for insomnia (Lie et al, 2015). ? References: ? Citrome, L. (2018). Improving diagnosis and treatment strategies for major depressive disorder.?Journal of Managed Care Medicine, 21(1), 24-28.?http://web.a.ebscohost.com.wilkes.idm.oclc.org/ehost/pdfviewer/pdfviewer?vid=5&sid=140a33b2-ea8d-4391-9cc4-df4e0b1f96a8%40sdc-v-sessmgr02 ? Lie, J., Tu, K., Shen, D., & Wong, B. (2015). Pharmacological treatment of insomnia.?P&T: A Peer-Reviewed Journal for Managed Care and Formulary Management, 40(11), 759-771.?http://web.a.ebscohost.com.wilkes.idm.oclc.org/ehost/pdfviewer/pdfviewer?vid=8&sid=140a33b2-ea8d-4391-9cc4-df4e0b1f96a8%40sdc-v-sessmgr02 ? Stein, M., & Sareen, J. (2015). Clinical practice. Generalized anxiety disorder.?New England Journal of Medicine, 373(21), 2059-2068. Doi:?http://dx.doi.org.wilkes.idm.oclc.org/10.1056/NEJMcp1502514 ? less 1 Unread 1 Unread 1 Replies 1 Replies 9 Views 9 Views View profile card for Tomiko Edmonds Last post?Sep 27, 2020 6:09 PM?by Tomiko Edmonds Module IV Candace Whitman-Workman Contains unread posts ? Candace Whitman-Workman posted Sep 23, 2020 9:51 PM Subscribe KT I would begin by having an open and frank conversation with KT.? I would inquire as to how her studies are going and about life goals.? I would complete the GAD-7 assessment to establish if she met the conditions for a diagnosis of GAD.? I also would want to glean a better understanding of her treatment goals.? Is she requesting an anxiolytic medication?? Has she tried medications whether her prescriptions or those obtained from friends or acquaintances?? I would want to know what type of social supports she has both at home and at school and if local family and friends continue their support while she?s away at school.? I would continue to explore and do a PHQ-9 to further evaluate depression and the potential for self-harm. I would highly encourage her to see a therapist and attempt to link her with campus mental health assistance.? I would speak with her in an accepting, destigmatizing way in order to get her buy in for therapy.? My personal opinion is that medications, without changing thinking or thought patterns, are only partially treating the anxiety issue. Working in addictions, I see all too much that people want a pill to fix everything and do not necessarily want to do the personal work behind the situation or symptoms.? I would not, unless there was some significant information uncovered in the interview that is not obvious in the case scenario, start a benzodiazepine.? I would, however, opt for starting an SSRI in conjunction with therapy.? Given that the SSRI would not have effect for two (2) to four (4) weeks, I would also use Vistaril and or a beta-blocker on an as needed basis until the SSRI is more fully effective; longer if breakthrough symptoms continue to occur. I would provide education that in young people, such as herself, antidepressants can potentiate the thoughts of suicide and encourage her to reach out to her local provider should she experience any type of suicidal thinking.? I would encourage her to continue follow up on campus in her school?s city with a collaborative provider to help to manage her symptoms.? I would want her to continue to follow up with me. WD WD?s depression must have been occurring long before his cardiac symptoms or event to meet the guidelines for MDD.? As Chisholm-Burns et al. (2019) explains, untreated anxiety disorders can lead to MDD.? Also, anxiety producing hormones lead to tissue and organ damage, very likely contributing to WD?s cardiac event.? ?I would evaluate WD and treating much like KT further evaluate symptoms and encouraging him to see a therapist.? While it is not clear in this case scenario whether WD has any psychotic symptoms, I would fully evaluate for them.? I would start an antidepressant only if his symptoms were moderate to severe.? With his recent cardiac event, he will be on many medications and I would rather not add another unless absolutely necessary.? However, if WD does have symptoms of psychosis, I would start an antipsychotic.? I would also begin folic acid as this drug has little drug to drug interactions and aids in depression.? I would also add Omega 3s since it would have dual benefit on mood and cardiac issues.? Appleton et al. (2016) reviews the benefits of Omega 3 fatty acids for the treatment of depression.? I would re-evaluate in 4-8 weeks and per Chisholm-Burns et al. (2019) and if no symptom improvement, reassess the diagnosis and treatment. JM For JM, non-pharmalogical approaches would include patient education regarding sleep hygiene, stimulus reduction, and caffeine reduction.? I would also educate JM on the importance of getting regular exercise and engaging herself in something on Sunday to avoid day time sleep.? It?s important to re-establish the circadian rhythm.? I would complete a NPSG to fully evaluate the potential sleep disturbance.? Prior to making pharmacologic changes, I would want to further evaluate how her sleep changed since instituting the Restoril.? It is possible that a paradoxical effect could be occurring and if this is suspected, I would immediately discontinue the Restoril.? Given JM?s abusive environment, it is possible she is experiencing PTSD and or depression.? Rather than using Restoril, I would tend to prescribe something such as Trazadone or Seroquel at HS.? I would also encourage JM to get involved with a therapist to work through some of her other issues that are most likely contributing factors.? I would also start Melatonin and as recommended by Madsen, et al. (2017), would initiate a sleep diary.? Through the use of a sleep diary, JM can drill down on sleep cycle, diet and environmental factors precipitating sleep. References Appleton, K. M., Sallis, H. M., Perry, R., Ness, A. R., & Churchill, R. (2015). Omega-3 fatty acids for depression in adults.?Cochrane Library,?2016(12), CD004692. doi:10.1002/14651858.cd004692.pub4 Chisolm-Burns, M. A., S, Schwinghammer, T. L., Malone, P. M., Kolesar, J. M., Lee, J. M., & Bookstaver, P. B. (2019).?Pharmacotherapy Principles & Practice?(Fifth ed.). McGrraw-Hill Education. Madsen, M. T., Isbrand, A., Andersen, U. O., Andersen, L. J., Taskiran, M., Simonsen, E., & Gögenur, I. (2017). The effect of MElatonin on depressive symptoms, anxiety, CIrcadian and sleep disturbances in patients after acute coronary syndrome (MEDACIS): Study protocol for a randomized controlled trial.?Trials,?18(1), 81. doi:10.1186/s13063-017-1806-x ? more 2 Unread 2 Unread 2 Replies 2 Replies 9 Views 9 Views View profile card for Kathryn Mosholder Last post?Sep 27, 2020 5:26 PM?by Kathryn Mosholder Module 4: Psychiatric Disorders ? Anna McMullen posted Sep 21, 2020 4:47 PM Subscribe Benzodiazepines (BZDs) are useful medications for the acute treatment of seizures, severe muscle spasms, tremors, alcohol withdrawal syndrome, anxiety, and?insomnia?(Harvard Health Publishing, 2019).?Though short-term administration can be efficacious and pose minimal risk, long-term administration causes physical dependence, resulting in withdrawal syndrome when abruptly discontinued. BZDs are generally recommended as a short-term option for acute anxiety or while pending a response towards antidepressants, since they have a rapid anxiolytic and sedative/hypnotic effect (Tanguay Bernard et al., 2018). Assuming that KT meets the criteria for GAD, first-line therapy to recommend would be cognitive behavioral therapy (CBT)/ cognitive therapy (CT) to help her evaluate and cope with her anxious thoughts through cognitive restructuring, problem solving, worry exposure, and applied relaxation (Powers et al., 2015). KT might also want to consider pharmacologic therapy along with CBT/CT, such either an SNRI or an SSRI, approved therapies including Venlafaxine XR, Paroxetine, or Escitalopram (Powers et al., 2015). These medications are as effective and safer for long-term administration than benzodiazepines for GAD, while also reducing the risk of dependence (Harvard Health Publishing, 2019). Assuming WD meets the criteria for MDD, recommendations to help him cope with his recent life-alternating event (suffering from an MI) and resolve his depressive symptoms to return to a euthymic state is the goal. Interpersonal and CBT would be recommended for first-line therapy, along with pharmacotherapy, as combination therapy is helpful for patients with psychosocial stressors such as WD?(Chisholm-Burns et al., 2019).?SSRI?s would be most appropriate for first-line pharmacotherapy, however, precautions on which medication to prescribe must be taken considering WD?s past medical history. A dose related elevation in BP can occur with the SNRI?s venlafaxine and desvenlafaxine, and due to WD?s HTN, these would not be recommended?(Chisholm-Burns et al., 2019). Additionally, the SSRI paroxetine has mild anticholinergic effects, and with WD?s severe uncontrolled narrow angle glaucoma, this medication would also not be recommended. According to the Cleveland Clinic (2019) there is a link between and heart disease and depression; these patients should adopt a healthy lifestyle including regular exercise, proper sleep, a healthy diet, and may also benefit from the SSRIs sertraline (Zoloft) and citalopram (Celexa) which have been deemed effective and safe in patients with heart disease. Given JM?s current circumstances, I would first recommend that she improve her sleep hygiene. Ways that she can improve her sleep hygiene include: keeping a consistent routine before bedtime, allowing 30 minutes for winding down before sleep, dimming the lights in the room, unplugging from electronics 30-60 minutes before bed, cut down on caffeine, don?t eat late in the evening, get daylight exposure to help with circadian rhythm, exercise but not within a few hours of going to sleep, and restrict in bed activity (such as reading and watching TV)?(Vyas & Suni, 2020).?JM is also suffering from psychosocial issues, her abusive relationship with her boyfriend and unemployment. CBT/CT would be helpful and aid in coping with these recent life stressors. Moving on from an abusive relationship and gaining employment may help reduce the stress she is currently experiencing. JM is currently taking a benzodiazepine, Restoril 30mg HS, and this dose was recently increased. The increased dose may be helpful while JM is working on improving her sleep hygiene and her psychosocial stressors, but it is not recommended for long-term use. Though JM would benefit from antidepressant therapy, SSRI?s and SNRI?s may cause insomnia and worsen sleep quality, and since JM is already experiencing poor sleep, other options may want to be considered?(Aiken, 2019).?Although quetiapine (Seroquel) should not be used for primary insomnia, it is appropriate to be used for antidepressant augmentation, as it is not just sedating, it also improves the deep, restorative phase of sleep (Aiken, 2019). Another drug that may be considered for JM is buproprion; though it can increase daytime energy, it causes no more insomnia than SSRIs and
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