Posted: March 17th, 2023

Assessing and Treating Adult and Geriatric Clients With Mood Disorders

Assignment: Assessing and Treating Adult and Geriatric Clients With Mood Disorders

Advances in genetics and epigenetics have changed the traditional understanding of mood disorders, resulting in new evidence-based practices. In your role as a psychiatric mental health nurse practitioner, it is essential for you to continually educate yourself on new findings and best practices in the field. For this Assignment, you consider best practices for assessing and treating adult and geriatric clients presenting with mood disorders.
Learning Objectives
Students will:

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Assess client factors and history to develop personalized plans of antidepressant therapy for adult and geriatric clients
Analyze factors that influence pharmacokinetic and pharmacodynamic processes in adult and geriatric clients requiring antidepressant therapy
Evaluate efficacy of treatment plans
Analyze ethical and legal implications related to prescribing antidepressant therapy to adult and geriatric clients

Learning Resources

Note: To access this week’s required library resources, please click on the link to the Course Readings List, found in the Course Materials section of your Syllabus.

Required Readings

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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.

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Chapter 6, “Mood Disorders”

Stahl, S. M. (2014b). The prescriber’s guide (5th ed.). New York, NY: Cambridge University Press.

Note: To access the following medications, click on the The Prescriber's Guide, 5th ed tab on the Stahl Online website and select the appropriate medication.

Review the following medications:

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amitriptyline
bupropion
citalopram
clomipramine
desipramine
desvenlafaxine
doxepin
duloxetine
escitalopram
fluoxetine
fluvoxamine

imipramine
ketamine
mirtazapine
nortriptyline
paroxetine
selegiline
sertraline
trazodone
venlafaxine
vilazodone
vortioxetine

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

Note: Retrieved from Walden Library databases.

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Montgomery, S. A., & Asberg, M. (1979). A new depression scale designed to be sensitive to change. British Journal of Psychiatry, 134, 382-389. Retrieved from https://www.researchgate.net/profile/Marie_Asberg/publication/22697065_A_New_Depression_Scale_Designed_to_be_Sensitive_to_Change/links/09e41513f85c708fee000000.pdf

Required Media

Laureate Education. (2016g). Case study: An elderly Hispanic man with major depressive disorder [Interactive media file]. Baltimore, MD: Author.

Note: This case study will serve as the foundation for this week’s Assignment.

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To prepare for this Assignment:

Review this week’s Learning Resources. Consider how to assess and treat adult and geriatric clients requiring antidepressant therapy.

The Assignment

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.

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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.
Decision #1: Selecting an initial antidepressant for the client
I selected citalopram as the initial antidepressant for the client. This decision was based on several factors. First, citalopram is a selective serotonin reuptake inhibitor (SSRI), which is a first-line treatment for major depressive disorder (MDD) in older adults due to its favorable side effect profile and safety compared to other antidepressant classes. Second, the client has a history of hypertension and citalopram has a low risk of drug interactions with antihypertensive medications. Third, citalopram has a relatively long half-life and is available in a once-daily dosing regimen, which may enhance medication adherence in this older adult population.

My goal in selecting citalopram was to alleviate the client's depressive symptoms and improve his quality of life. I expected that the client's depressive symptoms would improve with citalopram, given its efficacy in treating MDD. However, I also monitored the client for potential adverse effects, such as gastrointestinal symptoms or hyponatremia, which can occur with SSRIs.

Decision #2: Modifying the medication regimen
I decided to increase the client's citalopram dose from 20mg to 40mg daily after two weeks of treatment. This decision was based on the lack of improvement in the client's depressive symptoms, as evidenced by a score of 28 on the Montgomery-Asberg Depression Rating Scale (MADRS). The therapeutic dose range for citalopram in older adults is 20-40mg/day, and increasing the dose may enhance the medication's antidepressant effect.

My goal in increasing the citalopram dose was to improve the client's depressive symptoms and achieve remission. I expected that the higher dose of citalopram would lead to a greater reduction in depressive symptoms, but I also monitored the client for potential adverse effects, such as serotonin syndrome or QT prolongation.

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Decision #3: Adding a second-line antidepressant
I decided to add bupropion XL to the client's medication regimen after six weeks of treatment with citalopram. This decision was based on the lack of improvement in the client's depressive symptoms, as evidenced by a MADRS score of 24, which indicates residual symptoms of depression. Bupropion is a norepinephrine-dopamine reuptake inhibitor (NDRI) and has a different mechanism of action than citalopram, which may enhance its antidepressant effect in combination with citalopram. Bupropion is also associated with a lower risk of sexual dysfunction than SSRIs, which may be a concern for older adults.

My goal in adding bupropion was to achieve remission of the client's depressive symptoms. I expected that the combination of citalopram and bupropion would lead to a greater reduction in depressive symptoms than citalopram alone. However, I also monitored the client for potential adverse effects, such as increased blood pressure or seizures.

Ethical considerations
When making treatment decisions for clients with mood disorders, it is important to consider ethical and legal implications related to prescribing antidepressant therapy. For example, informed consent is essential, and the client should be informed of the risks and benefits of the medication, potential adverse effects, and alternative treatments. In addition, it is important to consider the client's cultural background and beliefs when developing a treatment plan. In this case, the client is an elderly Hispanic man, and cultural factors such as the stigma associated with mental illness and traditional beliefs about the use of medication may impact his adherence to treatment. Therefore, it is important to engage in culturally sensitive communication and education to ensure that the client fully understands his treatment options and is comfortable with the treatment plan.

Furthermore, it is important to assess the client's capacity to make decisions and ensure that the client is not coerced or pressured into taking medication. In this case, the client appears to have the capacity to make decisions, and I engaged in shared decision-making with him to determine the best treatment approach.

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Lastly, it is important to consider potential conflicts of interest or bias in prescribing medication. In this case, I based my treatment decisions on the best available evidence and clinical guidelines, and I did not have any financial or other conflicts of interest that would impact my decision-making

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