Case study 2

The 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

Begin zoloft 25 mg orally daily

RESULTS 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 Two

Add augmenting agent such as Wellbutrin IR 150 mg in morning 

RESULTS OF DECISION POINT TWO

• Client returns to clinic in four weeks
• Client stated that depressive symptoms have decreased      even more and his erectile dysfunction has abated
• Client reports that he has been feeling “jittery” and      sometimes “nervous”

Decision Point Three

Change Wellbutrin to XL 150 mg orally daily in AM 

Guidance to Student
The PMHNP should be aware that Zoloft or Wellbutrin could be responsible for the client complaints of Jitteriness. This feeling is usually temporary with SSRIs, however. The cause of the client’s complaint of “jitteriness” is most likely related to the Wellbutrin immediate release. As a result, the most appropriate answer would be to change the Wellbutrin to an extended release formulation. It would not be appropriate to add Ativan as the PMHNP should never add an additional medication to treat the side effect of another medication without first attempting to modify/change the medication causing the side effect.

Required Readings

Note: All Stahl resources can be accessed through this link provided.
 

Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (4th ed.). New York, NY: Cambridge University Press.

Note: To access the following chapters, click on the Essential Psychopharmacology, 4th ed tab on the Stahl Online website and select the appropriate chapter. Be sure to read all sections on the left navigation bar for each chapter.
Chapter 6, “Mood Disorders”

https://www.researchgate.net/profile/Marie_Asberg/publication/22697065_A_New_Depression_Scale_Designed_to_be_Sensitive_to_Change/links/09e41513f85c708fee000000.pdf

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?
• Also include how ethical considerations might impact your treatment plan and communication with clients.