Week 4: Assessment of L.P. Complex Case Study Presentation Essay

Week 4: Assessment of L.P. Complex Case Study Presentation Essay

Week 4: Assessment of L.P. Complex Case Study Presentation Essay

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Describe clinical hours and patient encounters

Assess and diagnose patients in mental health settings*

Develop plans of care for patients in mental health settings*

Develop a case study presentation based on a clinical patient*

Analyze cases involving advanced practice care of patients in mental health settings

Advocate health promotion and patient education strategies across the lifespan

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Oladeji Ajani

College of Nursing-PMHNP, Walden University

PRAC 6675: PMHNP Care Across the Lifespan II

Erin Lutchkus

Introduction

Patients such as Ms. L.P. 63-year-old Female with Major depressive disorder, recurrent severe without psychotic features that do not respond to at least two trials of optimally dosed antidepressant monotherapy, can be declared to be having “treatment-resistant depression” typically refers to major depressive episodes that do not respond satisfactorily after two trials of antidepressant monotherapy (National Institute for Health & Clinical Excellence, 2022).

Diverse factors that may contribute to unipolar treatment-resistant major depression can include comorbid psychiatric disorders (e.g., anxiety, personality, and substance use disorders), adverse life events (e.g., childhood trauma or marital discord), and a history of drugs that can cause depression (e.g., glucocorticoids and interferons) and prior treatment history (McAllister-Williams, Arango, Blier, Demyttenaere, Falkai, Gorwood, Hopwood, Javed, Kasper, Malhi, Soares, Vieta, Young, Papadopoulos, & Rush, 2020).

Thus, the care of the patient recognizes as having unipolar treatment-resistant major depression starts with assessing the patient’s history and using an objective instrument such as the PHQ-9 depression questionnaire to evaluate the person objectively. The treatment strategies for the patient with unipolar major depression who do not respond to initial treatment with an antidepressant medication may include augmentation (adding a treatment) such as lithium, psychotherapy, the use of repetitive transcranial magnetic stimulation, or switching treatment to different antidepressants (National Institute for Health & Clinical Excellence, 2022).

For Ms. L.P.’s psychiatric evaluation, I will reassess the patient’s diagnosis since she is not responding to the initial treatment of antidepressants in other to confirm the diagnosis is major depressive disorder, I will also assess patient adherence to the use of antidepressants and develop a treatment strategy that can help give the patient the best clinical outcomes.

Subjective:

CC (chief complaint): “I’m most depressed most days and this interferes with my day-to-day functioning.”

HPI: Patient L.P. is a 63-year-old Caucasian female seen today at the clinic for routine management and ongoing evaluation of psychotropic medications, mental status, and level of function. Pt. reports concerns with medications, treatment, and changes in mental status and level of function since the last appointment. Pt reports anhedonia. The patient reports depression most days. Most days, the patient reports that mood and behaviors are labile, with up and down episodes that interfere with daily functions. Pt. reports that others have voiced concerns about mood and behaviors. Pt reports a decreased appetite. Pt is having difficulty both falling and staying asleep, waking tired and unrested. Pt reports increased isolation and withdrawal from daily activities and relationships. Pt. reports excessive worries and fears. Pt. reports memory problems and forgetfulness. Pt. denies thoughts or behaviors of self-harm or harm to others.

Substance Current Use:

Medical History:

Current Medications:

Arimidex 1 MG Oral Tablet 1 tablet (1 mg) orally daily

Clonazepam 1 MG Oral Tablet Take 1 tablet (1 mg) by mouth 2 times per day prn for

anxiety

Fluoxetine HCl 20 MG Oral Capsule TAKE 1 CAPSULE BY MOUTH ONCE DAILY.

Bupropion HCl ER (XL) 300 MG Oral Tablet Extended Release 24 Hour

Belsomra 10 MG Oral Tablet 1 tablet (10 mg) orally daily at bedtime as needed.

Omeprazole 40 MG Oral Capsule Delayed-Release 1 capsule (40 mg) orally 2 times.

per day 30 minutes before meals

Allergies: Penicillin

Reproductive Hx: Contraceptive use (none)

Past Medical Hx: Breast Cancer, history of hypertension, weaned herself off medications.

Family Psychiatric Hx: noncontributory

Past Psychiatric Hx: Depression, Anxiety

Social Hx: The client lives alone in a single-family home and is divorced. She admits to using alcohol 5-7 times per week, and 1-2 drinks per day.

Suicidal/Homicidal Ideation: Pt. has no known or vague history of h/o suicidal ideation, attempts, or other means to self-harm. Pt. has no h/o threats or aggression towards others.

ROS:

Physical exam/ROS: Pt. denies weakness, pain, tics, tremors, or movements. Pt. denies headaches, seizures, paraesthesia, ataxia, altered senses, or confusion. She reports 4 out of 10 pain from a fractured clavicle related to the motor vehicle accident.

ROS:

General

Constitutional Symptoms

No: Chills, Fatigue, Weakness

Integumentary

Hair

Yes: Within Normal Limits

Skin

Yes: Within Normal Limits

HEENT

Ears

Yes: Within Normal Limits

Eyes

No: Blurred Vision, Color Blindness, Inflammation, Pain

Head

Yes: Within Normal Limits

No: Headaches, Migraines, Trauma

Neck

Yes: Within Normal Limits

No: Enlargement of Lymph Nodes, Goiter, Pain

Nose

Yes: Within Normal Limits.

Throat

Yes: Within Normal Limits

No: Dysphagia, Hoarseness, Tonsillitis

Cardiovascular

Arteries and Veins

Yes: Within Normal Limits

General

No: Angina, Cold Extremities, Cough

Pulmonary

Respiratory System

Yes: Within Normal Limits

GI

General

Yes: Within Normal Limits. There is no decreased appetite, nausea, or vomiting. There is no

reported diarrhea, or constipation.

No: Abdominal Pain or Colic, Weight Gain

GU

General

Yes: Within Normal Limits

Musculoskeletal

General

Yes: Within Normal Limits

No: Ankle Pain, Arthritis, no reported pain in muscles or joints, no limitation of range of motion,

no paresthesia or numbness.

Neurological

Autonomic System

Yes: Within Normal Limits

No: Syncope, Control of Urination, Facial Numbness

Cranial Nerves

Yes: Within Normal Limits

No: Disturbances in Hearing, Disturbances of Smell, Facial Weakness & Taste Disturbance.

No headache, dizziness, fainting, muscle spasm, loss of consciousness, sensitivity, or pain in the

hands and feet or memory loss

Motor System

Yes: Within Normal Limits

Sensory System

Yes: Within Normal Limits

Endocrine

General

Yes: Within Normal Limits

No: Excessive Sweating, Goiter, Hair Changes, Hx of Diabetes

Psychiatric

General

Yes: Mood Impaired, Mood-Down, Anxiety-Severe, Sleep Impaired, Sleep-Decreased, Appetite

Impaired, Appetite-Decreased, PHQ-9 screening completed (Score (0-27): 22)

No: Memory Impaired, Hallucinations, Hallucinations-Auditory, Hallucinations-Command,

Hallucinations[1]Visual, Hallucinations-Tactile, Hallucinations-Olfactory, Suicide/Self-Harm

Thoughts, Homicide/Other Harm Thoughts, History of Mental Abuse, History of Physical

Abuse, History of Sexual Abuse

Lymphatics

General

Yes: Within Normal Limits

Objective:

Vital signs: Height = 68in, Weight = 230lb, BMI= 34.97, Pulse =101bpm, Respiration=15 bpm

Exam:

General

Affect

Yes: Pleasant, Cooperative

Appearance

Yes: Alert and Oriented x 3, Alert & Oriented to Person, Alert & Oriented to Place, Alert &

Oriented to Time

Nutrition

Yes: Poor food intake

No: Within Normal Limits

Skin

General

Yes: Within Normal Limits, Dry, Skin Intact

Head

General

Yes: Symmetry of Motor Function, Atraumatic/Normocephalic

Temporal Mandibular Joint

Yes: Normal Exam, Full Range of Motion, Symmetric

Eyes

General

Yes: PERRLA, Extraocular Movements Intact

Iris

Yes: Normal Appearing

Pupils

Yes: Normal Appearing, PERRLA, Normal Consensual Reaction, Normal Near Reaction

Ears

Tympanic Membrane

Yes: Within Normal Limits

External Ear

Yes: Within Normal Limits

Nose

General

Yes: Nares Patent, Turbinates Normal

Mouth

General

Yes: Within Normal Limits

Teeth

Yes: Within Normal Limits

Gums

Yes: Within Normal Limits

Tongue

Yes: Within Normal Limits

Pharynx

Yes: Within Normal Limit

Pulmonary

Observation/Inspection

Yes: Within Normal Limits

Auscultation

Yes: Clear to Auscultation

Abdomen

Inspection

Yes: Within Normal Limits

Auscultation

Yes: Normo-Active Bowel Sounds

Gastrointestinal

General

Yes: Within Normal Limits

No: Diarrhea, Vomiting

Genitourinary

General

Yes: Within Normal Limits

Musculoskeletal

Shoulder

Yes: Normal Exam, Full Range of Motion

Gait

Yes: Normal Gait, Stance Phase Normal

Neurologic

Cranial Nerves (CN)

Yes: Within Normal Limits, CN 2-12 Intact Grossly

Motor System-General

Yes: Normal Exam

Motor System-Involuntary

No: Oral-Facial Dyskinesias, Tics, Dystonia

Motor System-Strength

Yes: Normal Muscular Strength

No: Weakness

Mental Health

Posture

Yes: Within Normal Limits, Upright, Attentive

Grooming/Hygiene

Yes: Within Normal Limits, Appropriate Grooming

Facial Expressions

Yes: Within Normal Limits, Appropriate Expression

Affect

Yes: Flat, Labile, Sad

No: Within Normal Limits

Speech/Language

Yes: Within Normal Limits, Appropriate, Normal Rate

Mood

Yes: Sadness, Anxiety, Worry

No: Within Normal Limits

Thought Process

Yes: Within Normal Limits, Appropriate

Thought Content

Yes: Within Normal Limits, Appropriate

Orientation

Yes: Alert and Oriented x 3

Attention

Yes: Within Normal Limits, Appropriate

Remote Memory

Yes: Impaired

Learning Ability

Yes: Within Normal Limits

Diagnostic results:

Assessment:

Mental Status Exam: Pt. arrived on time. Pt provided information that appeared to be reliable. Pt. is alert and well nourished. Pt dress and grooming are appropriate for weather, setting, culture, and age. Pt. displayed amotivation. The mood is depressed and anhedonia. The affect is blunted and defeated. Speech is soft, brief, and delayed responses to questions. Pt maintained intermittent eye contact. Thought processes are slow, dull, and somewhat indecisive. Content is superficial and vague. Pt attention span is short. Pt able to follow simple directions and make independent treatment decisions. Pt did not report or display side effects to medications.

Patient Health Questionnaire (PHQ-9).

PHQ- 9 SCORE = REMISSION <5.

PHQ- 9 SCORE = 0-4 MINIMAL Depression.

PHQ- 9 SCORE = 5- 9 MILD Depression.

PHQ- 9 SCORE = 10- 14 MOD Depression.

PHQ- 9 SCORE = 15- 19 MOD SEVERE Depression.

PHQ- 9 SCORE >20 SEVERE Depression.

DURING PAST 2 WEEKS, HOW OFTEN WERE YOU BOTHERED BY;

1)Little interest or pleasure in doing things = 3

2) Feeling down depressed hopeless = 3

3)Trouble falling asleep or staying asleep=3

4) Feeling tired or having little energy = 3

5) Poor appetite or overeating = 2.

6) Feeling bad about yourself or that you are a failure, or you have let yourself or your family down = 3

7) Trouble concentrating on things such as reading newspaper or watching TV = 3

8) Moving or speaking so slowly that other people could have noticed= 2

9) Thoughts about being dead = 0

Total score = 22.

PHQ- 9 SCORE >20 = SEVERE Depression.

Labs:

Lithium serum or plasma = 1.880u/U/ml

Creatinine =0.73mg/dl

BUN = 18mg/dl

Urea nitrogen = 18mg/dl

Assessment:

Assessment note

PROBLEM 1. Routine and ongoing medication management with mental status evaluation.

PROBLEM 2. Schedule Drug: C-II-IV review and monitoring. No reported issues.

PROBLEM 3. The patient reports an exacerbation of depression over the last 12 weeks that has interfered with her ability to function at home and in the community.

PROBLEM 4. Insomnia is ongoing.

Differential Diagnosis:

(F33.2) Major depressive disorder, recurrent severe without psychotic features

(F41.1) Generalized anxiety disorder.

(F06.31) Mood disorder due to known physiological condition with depressive features.

Provision of evidence from literature to support the patient’s clinical differential diagnosis.

Based on the patient’s History, the presumptive diagnosis for the 63-year-old female L.P. is Major depressive disorder, recurrent severe without psychotic features (American Psychiatric Association, 2022). The patient has the following symptoms present during the same 2-weeks, representing a change from previous functioning. Her symptoms include a depressed mood most of the day, nearly every day, as indicated by her complaint of feeling sad.

Besides, Ms. L.P. has markedly diminished interest in the activities of the day, nearly every day, as evidenced by her report of increased isolation and withdrawal from daily activities and relationships. The patient reports labile mood and behaviors, with up and down episodes that interfere with daily functions. She voiced concerns about mood and behaviors. Pt reports a decreased appetite. Pt is having difficulty both falling and staying asleep, waking tired and unrested.

Research shows that individuals suffering from the major depressive disorder can be associated with a premature loss of deep (slow-wave) sleep and increased nocturnal arousal (Rantamaki & Kohtala, 2020)—patients such as L.P. that manifest abnormal sleep profile is less responsive to psychotherapy and have a greater risk of relapse or recurrence and may benefit preferentially from treatment such as the use of pharmacotherapy or use of transcranial magnetic stimulation ( Rantamaki & Kohtala, 2020; Sadock et al., 2015, p.351).

Moreover, Ms. L.P. also experiences a diminished ability to think or concentrate, as evidenced by her reporting that she has memory problems and forgetfulness, which interfere with her daily functioning at work, leading to increased isolation of herself and withdrawal from daily activities and relationships.

Furthermore, based on the patient’s History, her depression episode cannot be attributable to the physiological effects of a substance or another medical condition, nor does she has any symptoms or History of psychotic disorders (APA, 2020).

Therefore, based on Ms. L.P.’s History and persistent symptoms, she is experiencing the patient met criteria for Major depressive disorder, recurrent severe without psychotic features (APA, 2022). The patient number of symptoms is substantially in excess to make the diagnosis, and the intensity of her symptoms is seriously distressing and unmanageable presently using psychopharmacotherapy and psychotherapy thus far with her treatment.

The 63-year-old Ms. L.P., based on her current treatment of the use of more than two trials of psychopharmacological interventions, continues to experience persistent symptoms which have not abated, possibly pointing to individual experiencing treatment-resistant depression (TRD) (Stern, Fava, Wilens & Rosenbaum, 2016). Treatment-resistant depression often refers to major depressive episodes that do not respond satisfactorily to at least two trials of optimally dosed antidepressant monotherapy and may probably benefit from adding to her treatment repetitive transcranial magnetic stimulation (TMS) (Bennabi et al., … & Haffen, 2019).

The second differential diagnosis for the patient is generalized anxiety disorder (APA, 2022). Generalized anxiety disorder is defined as excessive anxiety and worries about several events or activities for most days for at least 6 months (Sadock et al., 2015). The patient’s worry is difficult to control and is associated with somatic symptoms, such as difficulty sleeping, restlessness, muscle tension, and irritability, that point to increased anxiety.

In addition, the patient’s experience of anxiety is not caused by substance use or general medical condition (APA, 2022). However, her anxiety is pervasive and does occur even when she is not depressed. Furthermore, she reports excessive worries and fears that s difficult to control and subjectively distressing, leading to her increasing isolation and withdrawal from daily activities and relationships.

Evidence from the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study demonstrates comorbidity that 53% of the patients with major depression had significant anxiety and were considered to have anxious depression (Kalin, 2020). Ms. L.P.’s anxiety exists simultaneously with her depression but not majorly debilitating compared to the depression symptoms. I chose to rule out generalized anxiety disorder as her presumptive diagnosis. Her presumptive diagnosis is Major depressive disorder, recurrent severe without psychotic features (APA, 2022).

The third differential diagnosis is Mood disorder due to known physiological condition with depressive features (APA, 2022). A major depressive episode can be considered an appropriate diagnosis for the patient if the mood disturbance is a direct pathophysiological consequence of a specific medical condition (e.g., multiple sclerosis, stroke, hypothyroidism) (APA, 2022).

Based on her past medical History of Breast Cancer, the patient’s breast cancer is now in remission. She has hypertension, which she continues to be treated with high blood pressure medication, and her blood pressure is fully stabilized.

Therefore, based on her objective vital signs, which are stable without having related symptoms of cancer and high blood pressure can be ruled out that any of these pathophysiological diseases not physiologically induce her depression symptoms. Thus, for the above reasons, the patient’s depressive episode can be ruled out from having a physiological origin. Overall, the patient’s presumptive diagnosis met the diagnostic criteria for Major depressive disorder, recurrent severe without psychotic features (APA, 2022).

Diagnostic Impression:

The patient’s History, together with a mental status examination, was consistent with Major depressive disorder. The patient’s History shows she had tried many antidepressants without getting evident relief from these multiple medication trials in conjunction with outpatient psychotherapy. At this time, we have agreed to add repetitive transcranial magnetic stimulation (TMS) to her treatment, which may prove beneficial in relieving the patient’s depressive symptoms (National Institute for Health & Clinical Excellence, 2022).

Plan -6/7/23

Plan note.

-Continue medications as prescribed.

– recommended transcranial magnetic stimulation to relieve the patient’s depressive symptoms due to the level of incapacitation, as well as multiple medication trials in conjunction with outpatient therapy with limited efficacy and significant side effects. We discussed the risks and benefits, and the patient expressed understanding of all instructions.

-reports chronic and persistent sleep disturbance that has responded to nightly use of sleep aids and benzodiazepines. Pt. does not demonstrate behaviors of misuse or abuse.

-Reviewed previous psychiatric progress notes, medications, allergies, and potential drug-to-drug interactions.

-Additional time spent discussing with the patient non-pharmacological strategies for the management of symptoms, including nutrition, diet, hydration, sleep hygiene, regular exercise, relaxation, time for self, “dial-down,” and opening senses.

-Additionally discussed with Pt: Benzodiazepine. Pt. was instructed on the risks of dependence and misuse. Clinical research and information provided long-term use.

-A follow-up visit is scheduled in 4 weeks to review progress on the current treatment plan and to consider changes in medication or dosage based on the client’s progress at that time.

Plan:

First, since the partial trial on multiple antidepressants medication was not entirely successful, the plan is to augment the current treatment of Fluoxetine HCl 20 MG Oral Capsule and Bupropion HCl ER (XL) 300 MG Oral Tablet Extended Release 24 Hour by adding repetitive transcranial magnetic stimulation (TMS) to her treatment (National Institute for Health & Clinical Excellence, 2022).

Transcranial Magnetic stimulation (TMS) is used for depression treatment. It involves using very short pulses of magnetic energy to stimulate nerve cells in the brain (Sadock et al., 2015, p.373). It is specifically indicated for the treatment of depression in adult patients who have failed to achieve satisfactory improvement from one prior antidepressant medication at or above the minimal effective dose and duration in the current episode (Sadock et al., 2015, p.373).

Repetitive transcranial magnetic stimulation (rTMS) produces focal secondary electrical stimulation of targeted cortical regions. It is nonconvulsive, requires no anesthesia, has a safe side effects profile, and is not associated with cognitive side effects (Mann & Malhi, 2023; National Institute for Health & Clinical Excellence, 2022).

Brain stimulation techniques such as rTMS is reserved for treatment resistance and recommended only after the failure of an adequately conducted trial of antidepressant treatment (National Institute for Health & Clinical Excellence, 2022).

Second, we also agreed for the patient to continue psychotherapy to treat depression. According to her social History, the patient experiences a difficult relationship in her marriage and has recently divorced may have developed into complex trauma that has taken deep root, which the application of interpersonal psychotherapy intervention will help to address.

Research evidence also supports psychotherapy for severe episodes of treatment-resistant depression, including randomized trials in patients with mild to moderate episodes of treatment-resistant depression.

As an example, four-month trial enrolled patients of 64 patients who had not responded to an average of three antidepressants and were acutely depressed on average for approximately 26 months and randomized them to an intervention consisting of interpersonal psychotherapy and pharmacotherapy or to treatment as usual (pharmacotherapy or psychotherapy) (Miniati et al., 2023). Remission occurred in more patients who received interpersonal psychotherapy (35 versus 13 percent). (Miniati et al., 2023).

In addition, if the patient responds to treatment with rTMS, she will generally require continuation and maintenance treatment with antidepressants, psychotherapy, or both.

Third, we also provide teaching on adding nonpharmacological treatment strategies for depression, such as management of symptoms through nutrition, diet, hydration, sleep hygiene, regular exercise, relaxation, time for self, “dial-down,” and opening senses.

Case Formulation and Treatment Plan:

Treatment Plan

Objective #1: Ms. L.P. will complete psychological testing to assess the depth of the depression, the need for antidepressant medication, and suicide prevention measures.

Goal#1: Provide History and status of depression symptoms.

Intervention #1: Arrange for the administration of an objective assessment instrument for evaluating the patient’s depression and suicide risk (e.g., Patient Health Questionnaire (PHQ-9); evaluate the results and give feedback to the patient; readminister as indicated to assess treatment progress.

Objective #2: Ms. L.P. will complete a medical evaluation to assess the possible contribution of medical or substance-related conditions to depression.

Goal#2: Participate in a medical evaluation to help increase understanding of the condition.

Intervention#2: Refers the patient to a physician for a medical evaluation to rule out general medical or substance-induced causes of the depressive symptoms.

Objective#3: Ms. L.P. will verbalize an understanding of the rationale for the treatment of depression

Goal#3: Recognize, accept, and cope with feelings of depression

Intervention#3: Consistent with the treatment model, discuss with Ms. L.P. how changes in cognitive, behavioral, interpersonal, and other factors can help the patient alleviate depression and return to the previous level of effective functioning.

Objective#4: Ms. L.P. will learn and implement behavioral strategies to overcome depression.

Goal #4: Alleviate depressive symptoms and return to the previous level of effective functioning.

Intervention#4:
Assist Ms. L.P. in developing skills that increase the likelihood of deriving pleasure and meaning from behavioral activation (e.g., assertiveness skills, developing an exercise plan, less internal/more external focus, and increasing social involvement).

Reinforce success.

Problem-solve obstacles toward sustained, rewarding activation.

Objective#5: Ms. L.P. will learn to identify important people in life, past and present, and describe the quality, good and poor, of those relationships.

Goal#5: Develop healthy interpersonal relationships that lead to alleviation and help prevent the relapse of depression.

Intervention#5: Conduct interpersonal therapy, beginning with assessing Ms. L.P.’s “interpersonal role disputes, role transitions, and interpersonal deficits).

Objective #6: Implement mindfulness techniques for relapse prevention.

Goal#6: Develop healthy thinking patterns and beliefs about self, others, and the world that lead to alleviation and help prevent the relapse of depression.

Intervention#6: Use mindfulness meditation and cognitive therapy techniques to help Ms.L.P. learn to recognize and regulate the negative thought associated with depression and to change her relationship with these thoughts.

Objective#7: Ms. L.P. will read on overcoming depression.

Goal#7: Elevate self-esteem.

Intervention #7: As adjunctive bibliotherapy, recommend that Ms.L.P. read self-help books consistent with the therapeutic approach used in therapy to help supplement and foster a better understanding of key concepts (e.g., The Interpersonal Solution to Depression by Pettit and Joiner; The Mindfulness and Acceptance Workbook for Depression by Strosahl and Robinson; The 10 Step Depression Relief Workbook by Rego and Fader); process material read.

Reflections:

The patient is a 63-year-old Female, Ms. L.P., diagnosed with Major depressive disorder, recurrent severe without psychotic features (APA, 2022). Due to the nature of her illness and history of chronic depression, and the partial trial on multiple antidepressants medication was not entirely successful, the plan is to augment the current treatment of Fluoxetine HCl 20 M.G. Oral Capsule by adding repetitive transcranial magnetic stimulation (TMS) to her treatment (National Institute for Health & Clinical Excellence, 2022).

Currently, Ms. L.P. has yet to start the treatment with repetitive transcranial magnetic stimulation (TMS) because we are awaiting insurance approval, and she also needs to get time off from her workplace to start and complete the treatment.

If allowed to conduct Ms. L.P.’s routine management and ongoing evaluation of psychotropic medications again, the following are steps that I will take to improve her health outcomes better. Since she has treatment-resistant depression, instead of the treatment recommendation with repetitive transcranial magnetic stimulation (TMS), I may consider first augmenting her present antidepressant medication with Lithium (Stern, Fava, Wilens & Rosenbaum, 2016).

Lithium is one of the most common augmenting agents for treatment-resistant depression ( Stern et al., 2016). A minimum daily dose of 900mg is generally recommended (Stern et al., 2016). The efficacy of lithium augmentation (with an SSRI such as Fluoxetine) has been supported by randomized, placebo-controlled, double-blind studies. In a meta-analysis, lithium augmentation was significantly more effective than placebo (95% confidence interval [CI 1.8-5.4) (Crossley & Bauer, 2007).

Second, if I can conduct the patient’s routine management and ongoing evaluation of psychotropic medications again, I will refer her to a psychodynamic therapist. The conduct of brief psychodynamic therapy for depression will help her to increase her insight into how past relational patterns may be influencing current vulnerabilities to depression, identify core conflictual themes, and process with her toward making changes in current relational patterns.

The third step I will take if I need to conduct the patient’s routine management and ongoing evaluation of psychotropic medications again will be to continue to assess and monitor the patient’s suicide risk.

Identifying and explaining social determinants of health may impact on Ms. L.P.’s recurrent depressive episodes.

Social determinants of health (SDOH) are the conditions in the environments where people are born, live, learn, work, play, worship, and age that affects a wide range of health, functioning, and quality-of-life outcomes and risks (Office of Disease Prevention and Health Promotion, 2020). An identifiable social determinant of health relevant to Ms. L.P. with chronic depression will be access to timely comprehensive healthcare services with affordable health insurance coverage (Office of Disease Prevention and Health Promotion, 2020).

Ms. L.P., due to the nature of her condition with chronic depression, will need increased access to specialized care with a referral from her primary care provider to a psychiatric nurse practitioner, psychotherapist, and neurologist. Thus, she needs health insurance coverage that will help provide access to health care services and medications she will need.

Research shows that Chronic and multiple chronic diseases are important determinants of depression in middle-aged and older adults (Li, Su, Guo, Liu & Zhang, 2023). Health insurance and health service quality were the key factors in relieving the depression of chronic disease patients (Li et al., 2023).

Suitable interventions that can help individuals such as Ms. L.P. with chronic depression will be to have good health insurance coverage through which she will get good health care services that can help to pay attention to her mental health care and improve the quality of health service she is getting, and alleviate the psychological harm caused by chronic disease (Li et al., 2023). Also, getting good healthcare insurance coverage will help increase her access to the healthcare professional and help her get the care she needs.

Provision of recommendation for a referral to assist Ms. L.P. with alcohol usage treatment.

During her psychiatric evaluation, the patient admits to using alcohol 5-7 times weekly and 1-2 drinks daily. In studies of adults, alcohol use disorder (AUD) was associated with a risk for the onset of major depressive disorder and dysthymia (Fergusson, Boden & Horwood, 2009).

The use of alcohol at the present consumption can worsen Ms. L.P.’s depression which will be very detrimental to her mental health. The psychiatric nurse practitioner must refer the patient to a substance use disorder counselor or chemical dependency professional for addiction treatment.

Besides, increased alcohol use is also associated with the risk of independent depressive disorders (McHugh & Weiss, 2019). Thus, treatment of depression should be considered, along with close monitoring of mood, for a person like Ms. L.P., who has chronic depression and drinks alcohol (McHugh & Weiss, 2019).

Conclusion:

Major depressive disorder is among the most treatable of mental disorders. Most people respond well to treatment, and almost all gain some relief from symptoms. Ms. L.P.’s condition is a severe case of major depressive disorder because she is not responding to the antidepressants prescribed for her treatment. This type of depressive disorder is called unipolar treatment-resistant major depression (National Institute for Health & Clinical Excellence, 2022).

Before a psychiatric nurse practitioner suggests a specific treatment, they will thoroughly assess the problem and symptoms of the person. A physical exam or discussion with the person’s primary care physician may also occur. Psychotherapy, medication (e.g., second-generation antipsychotic, lithium, a second antidepressant, or triiodothyronine), electroconvulsive therapy, repetitive transcranial magnetic stimulation, or supplementary and supportive interventions such as exercise help treat unipolar treatment-resistant major depression (National Institute for Health & Clinical Excellence, 2022).

Alternative treatment approaches the psychiatric nurse practitioner can adopt for the treatment of unipolar treatment-resistant major depression may involve switching to different antidepressants, Psychotherapy, electroconvulsive therapy, or repetitive transcranial magnetic stimulation (Mann & Malhi, 2023).

References
American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorder (5th ed.,text rev.), Retrieved June 16th, 2023, from https://go.openathens.net/redirector/waldenu.edu?url Links to an external site.

Bennabi, D., Charpeaud, T., Yrondi, A., Genty, J.B., Destouches, S., Lancrenon, S., Alaïli, N., Bellivier, F., Bougerol, T., Camus, V., Dorey, J.M., Doumy, O., Haesebaert, F., Holtzmann, J., Lançon, C., Lefebvre, M., Moliere. F., Nieto, I., … & Haffen, E. (2019). Clinical guidelines for the management of treatment-resistant depression: French recommendations from experts, the French Association for Biological Psychiatry and Neuropsychopharmacology and the fondation FondaMental. BMC Psychiatry. 19(1):262.

Crossley, N.A., & Bauer, M. (2007). Acceleration and augmentation of antidepressants with lithium for disorders: Two meta-analyses of randomized, placebo-controlled trials. J Clin Psychiatry, 68:935-940.

Fergusson, D.M., Boden, J.M., & Horwood, L.J. (2009). Tests of causal links between alcohol abuse or dependence and major depression. Arch Gen Psychiatry, 66(3):260–266.

Kalin, N.H. (2020). The critical relationship between anxiety and depression. Am J Psychiatry, 177(5):365-367.

Kroenke, K., & Spitzer, R. L. (2002). The PHQ-9: A new depression diagnostic and severity measure.Psychiatric Annals, 32(9): 509–515

Li, D., Su, M., Guo, X., Liu, B., & Zhang, T. (2023). The association between chronic disease and depression in middle-aged and elderly people: The moderating effect of health insurance andhealth service quality. Front Public Health, 11:935969.

Mann, S.K., & Malhi, N.K. (2023). Repetitive Transcranial Magnetic Stimulation. In: StatPearls[Internet]. Treasure Island (FL): StatPearls Publishing Retrieved June 16th, 2023, from https://www.ncbi.nlm.nih.gov/books/NBK568715/Links to an external site.

McAllister-Williams, R. H., Arango, C., Blier, P., Demyttenaere, K., Falkai, P., Gorwood, P., Hopwood, M., Javed, A., Kasper, S., Malhi, G. S., Soares, J. C., Vieta, E., Young, A. H., Papadopoulos, A., & Rush, A. J. (2020). The identification, assessment, and management of difficult-to-treat depression: An international consensus statement. Journal of Affective Disorders, 267, 264–282

McHugh, R.K., & Weiss, R.D. (2019). Alcohol use disorder and depressive disorders. Alcohol Res,40(1): 40.1.01.

National Institute for Health & Clinical Excellence. (2022). The Treatment and Management of Depression in Adults (updated edition). National Clinical Practice Guideline. Retrieved June 16th, 2023 from http://www.nice.org.uk/Links to an external site.

Office of Disease Prevention and Health Promotion. (2020). Health care access and quality. RetrievedJune 17th, 2023, from httLinks to an external site.ps://health.gov/healthypeople/objectives-and-data/browse-objectives/health-care-access-and-qualityLinks to an external site./

Rantamäki, T., & Kohtala, S. (2020). Encoding, consolidation, and renormalization in depression: Synaptic homeostasis, plasticity, and sleep integrate rapid antidepressant effects. Pharmacological Review, 72 (2) 439-465

Rush, A.J., Trivedi, M.H., Wisniewski, S.R., Nierenberg, A.A., Stewart, J.W., Warden, D., Niederehe, G., Thase, M.E., Lavori, P.W., Lebowitz, B.D., McGrath, P.J., Rosenbaum, J.F., Sackeim, H.A., Kupfer, D.J., Luther, J., Fava, M. (2006). Acute and longer-term outcomes in depressed outpatients requiring one or several treatment steps: a STAR*D report. Am J Psychiatry, 163(11):1905-17.

Sadock, B. J., Sadock, V. A., & Ruiz, P. (2015). Kaplan & Sadock’s synopsis of psychiatry (11th ed.). Wolters Kluwer.

Stahl, S.M. (2021). Stahl’s essential psychopharmacology prescriber’s guide (7th ed). Cambridge Press.

Stern, T.A., Fava, M., Wilens, T.E., & Rosenbaum, J.F. (2016). Massachusetts general hospital psychopharmacology and neurotherapy (1st ed.). Elsevier.

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C_6675_Week4_Discussion_Presenter_Rubric

PRAC_6675_Week4_Discussion_Presenter_Rubric

Criteria Ratings Pts

This criterion is linked to a Learning OutcomePhoto ID Display and Professional Attire

5 to >0.0 pts

Excellent

Photo ID is displayed. The student is dressed professionally with a lab coat.

0 pts

Fair

0 pts

Good

0 pts

Poor

Photo ID is not displayed. Student must remedy this before grade is posted. The student is not dressed professionally with a lab coat.

5 pts

This criterion is linked to a Learning OutcomeTime

5 to >0.0 pts

Excellent

The video does not exceed the 8-minute time limit.

0 pts

Fair

0 pts

Good

0 pts

Poor

The video exceeds the 8-minute time limit. (Note: Information presented after the 8 minutes will not be evaluated for grade inclusion.)

5 pts

This criterion is linked to a Learning OutcomeObjectives for the Presentation

5 to >4.0 pts

Excellent

3–4 objectives provided and written in terms of what the audience will know or be able to do after viewing. Appropriate Bloom’s verbs are used. Objectives are targeted and clear.

4 to >3.5 pts

Good

3–4 objectives provided and written in terms of what the audience will know or be able to do after viewing. Appropriate Bloom’s verbs are used.

3.5 to >3.0 pts

Fair

At least 3 objectives provided and written in terms of what the audience will know or be able to do after viewing, but are somewhat vague or unclear. Appropriate Bloom’s verbs may be missing.

3 to >0 pts

Poor

Fewer than 3 objectives provided. Objectives for the presentation are vague, unclear, or missing.

5 pts

This criterion is linked to a Learning OutcomeDiscuss subjective data:• Chief complaint• History of present illness (HPI)• Medications• Psychotherapy or previous psychiatric diagnosis• Pertinent histories and/or ROS

5 to >4.0 pts

Excellent

The video is a Kaltura video and accurately and concisely presents the patient’s subjective complaint, history of present illness, medications, psychotherapy or previous psychiatric diagnosis, and pertinent histories and/or review of systems that would inform a differential diagnosis.

4 to >3.5 pts

Good

The video is not a Kaltura video but easily opened and accurately presents the patient’s subjective complaint, history of present illness, medications, psychotherapy or previous psychiatric diagnosis, and pertinent histories and/or review of systems that would inform a differential diagnosis.

3.5 to >3.0 pts

Fair

The video is not a Kaltura video and did not open without needing to reach the student. The 2nd attempt video presents the patient’s subjective complaint, history of present illness, medications, psychotherapy or previous psychiatric diagnosis, and pertinent histories and/or review of systems that would inform a differential diagnosis but is somewhat vague or contains minor inaccuracies.

3 to >0 pts

Poor

There is no video submission or video presents an incomplete, inaccurate, or unnecessarily detailed/verbose description of the patient’s subjective complaint, history of present illness, medications, psychotherapy or previous psychiatric diagnosis, and pertinent histories and/or review of systems that would inform a differential diagnosis. Or subjective documentation is missing.

5 pts

This criterion is linked to a Learning OutcomeDiscuss objective data:• Physical exam documentation of systems pertinent to the chief complaint, HPI, and history• Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses

10 to >8.0 pts

Excellent

The video accurately and concisely documents the patient’s physical exam for pertinent systems. Pertinent diagnostic tests and their results are documented, as applicable.

8 to >7.0 pts

Good

The response accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are documented, as applicable.

7 to >6.0 pts

Fair

Documentation of the patient’s physical exam is somewhat vague or contains minor inaccuracies. Diagnostic tests and their results are documented but contain inaccuracies.

6 to >0 pts

Poor

The response provides incomplete, inaccurate, or unnecessarily detailed/verbose documentation of the patient’s physical exam. Systems may have been unnecessarily reviewed, or objective documentation is missing.
10 pts

This criterion is linked to a Learning OutcomeDiscuss results of assessment:• Results of the mental status examination• Provide a minimum of three possible diagnoses in order of highest to lowest priority and explain why you chose them. What was your primary diagnosis and why? Describe how your primary diagnosis aligns with DSM-5 diagnostic criteria and is supported by the patient’s symptoms.

20 to >17.0 pts

Excellent

The video accurately documents the results of the mental status exam. Video presents at least 3 differentials in order of priority for a differential diagnosis of the patient, and a rationale for their selection…. Response justifies the primary diagnosis and how it aligns with DSM-5-TR criteria.

17 to >15.0 pts

Good

The video adequately documents the results of the mental status exam…. Video presents 3 differentials for the patient and a rationale for their selection. Response adequately justifies the primary diagnosis and how it aligns with DSM-5-TR criteria.

15 to >13.0 pts

Fair

The video presents the results of the mental status exam, with some vagueness or inaccuracy…. Video presents 3 differentials for the patient and a rationale for their selection. Response somewhat vaguely justifies the primary diagnosis and how it aligns with DSM-5-TR criteria.

13 to >0 pts

Poor

The response provides an incomplete, inaccurate, or unnecessarily detailed/verbose description of the results of the mental status exam and explanation of the differential diagnoses. Or assessment documentation is missing.

20 pts

This criterion is linked to a Learning OutcomeDiscuss treatment plan: • A treatment plan for the patient that addresses psychotherapy; one health promotion activity and one patient education strategy; plan for treatment and management, including alternative therapies; pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters; and a rationale for the approaches selected. Discusses an identified social determinate of health impacting this patient’s mental health status and provide your recommendation for a referral to assist this patient in meeting this identified need

20 to >17.0 pts

Excellent

The video clearly and concisely outlines an evidence-based treatment plan for the patient that addresses psychotherapy, health promotion and patient education, treatment and management, pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters. A clear and concise rationale for the treatment approaches recommended is provided. Discussion includes a social determinate of health need impacting mental health status with referral recommendation and evidence of researching literature and incorporating local community resources

17 to >15.0 pts

Good

The video clearly outlines an appropriate treatment plan for the patient that addresses psychotherapy, health promotion and patient education, treatment and management, pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters. A clear rationale for the treatment approaches recommended is provided. Discussion includes a social determinate of health need impacting mental health status with referral recommendation but no evidence of researching literature and incorporating local community resources

15 to >13.0 pts

Fair

The response somewhat vaguely or inaccurately outlines a treatment plan for the patient and provides a rationale for the treatment approaches recommended. Discussion includes a social determinate of health need impacting mental health status with no referral recommendation or evidence of researching literature and incorporating local community resources

13 to >0 pts

Poor

The response does not address the diagnosis or is missing several elements of the treatment plan.

20 pts

This criterion is linked to a Learning OutcomeReflect on this case. Discuss what you learned and what you might do differently. Pose 3 questions or discussion prompts, based on your presentation, that your colleagues can respond to after viewing your video.

5 to >4.0 pts

Excellent

Reflections are thorough, thoughtful, and demonstrate critical thinking…. Questions or prompts for colleagues are thought-provoking and will require substantive responses and critical thinking.

4 to >3.5 pts

Good

Reflections demonstrate critical thinking. Questions or prompts for colleagues are appropriate and will require substantive responses.

3.5 to >3.0 pts

Fair

Reflections are somewhat general or do not demonstrate critical thinking. Questions or prompts for colleagues are somewhat general and may not require substantive responses.

3 to >0 pts

Poor

Reflections are incomplete, inaccurate, or missing. Questions or prompts for colleagues are general, inappropriate, or missing.

5 pts

This criterion is linked to a Learning OutcomeFocused SOAP Note

10 to >8.0 pts

Excellent

The response clearly, accurately, and thoroughly follows the SOAP format to document the selected patient case. Preceptor signature and date pdf/image is uploaded on the completed assignment (not an electronic signature).

8 to >7.0 pts

Good

The response accurately follows the SOAP format to document the selected patient case. Preceptor signature and date pdf/image is uploaded on the completed assignment but is an electronic signature.

7 to >6.0 pts

Fair

The response follows the SOAP format to document the selected patient case, with some vagueness and inaccuracy. Preceptor signature and date pdf/image is uploaded on the completed assignment but is an electronic signature.

6 to >0 pts

Poor

The response incompletely and inaccurately follows the SOAP format to document the selected patient case. No preceptor signature submitted.

10 pts

This criterion is linked to a Learning OutcomePresentation Style

5 to >4.0 pts

Excellent

Presentation style is exceptionally clear, professional, and focused.

4 to >3.5 pts

Good

Presentation syle is clear, professional, and focused.

3.5 to >3.0 pts

Fair

3 to >0 pts

Poor

Presentation style is unclear, unprofessional, and/or unfocused.

5 pts

This criterion is linked to a Learning OutcomeDiscussion Facilitation

10 to >8.0 pts

Excellent

Presenters effectively lead, sustain, and engage the discussion from Day 4 through Day 7.

8 to >7.0 pts

Good

Presenters lead, sustain, and engage the discussion from Day 4 through Day 7.

7 to >6.0 pts

Fair

presenters lead, sustain, and engage the discussion at least three out of four days between Days 4 and 7.

6 to >0 pts

Poor

Presenters did not sustain and engage the discussion through Day 7.

10 pts

Total Points: 100 Respond to the focus note

Carlat, D. J. (2017). The psychiatric interview (4th ed.). Wolters Kluwer.

Chapter 26, “Assessing Alcohol Use Disorder”

MeditrekLinks to an external site.

https://edu.meditrek.com/Default.html

Note: Use this website to log into Meditrek to report your clinical hours and patient encounters.to an external site.

Document: Focused SOAP Note Template (Word document)Download Focused SOAP Note Template (Word document)

Document: Focused SOAP Note Exemplar (Word document)Download Focused SOAP Note Exemplar (Word document)

Stern, T. A., Fava, M., Wilens, T. E., & Rosenbaum, J. F. (2016). Massachusetts General Hospital psychopharmacology and neurotherapeutics. Elsevier.

Chapter 15, “Alcohol-Related Disorders”

Chapter 16, “Drug Addiction”

Office of Disease Prevention and Health Promotion. (n.d.). Social Determinates of Health.Links to an external site. Healthy People 2030. U.S. Department of Health and Human Services. https://health.gov/healthypeople/priority-areas/social-determinants-health

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