NURS 6630 Week 7 Therapy for Patients With Schizophrenia

Walden University NURS 6630 Week 7 Therapy for Patients With Schizophrenia-Step-By-Step Guide

This guide will demonstrate how to complete the Walden University NURS 6630 Week 7 Therapy for Patients With Schizophrenia assignment based on general principles of academic writing. Here, we will show you the A, B, Cs of completing an academic paper, irrespective of the instructions. After guiding you through what to do, the guide will leave one or two sample essays at the end to highlight the various sections discussed below.

How to Research and Prepare for NURS 6630 Week 7 Therapy for Patients With Schizophrenia                     

Whether one passes or fails an academic assignment such as the Walden University NURS 6630 Week 7 Therapy for Patients With Schizophrenia depends on the preparation done beforehand. The first thing to do once you receive an assignment is to quickly skim through the requirements. Once that is done, start going through the instructions one by one to clearly understand what the instructor wants. The most important thing here is to understand the required format—whether it is APA, MLA, Chicago, etc.

After understanding the requirements of the paper, the next phase is to gather relevant materials. The first place to start the research process is the weekly resources. Go through the resources provided in the instructions to determine which ones fit the assignment. After reviewing the provided resources, use the university library to search for additional resources. After gathering sufficient and necessary resources, you are now ready to start drafting your paper.

How to Write the Introduction for NURS 6630 Week 7 Therapy for Patients With Schizophrenia                     

The introduction for the Walden University NURS 6630 Week 7 Therapy for Patients With Schizophrenia is where you tell the instructor what your paper will encompass. In three to four statements, highlight the important points that will form the basis of your paper. Here, you can include statistics to show the importance of the topic you will be discussing. At the end of the introduction, write a clear purpose statement outlining what exactly will be contained in the paper. This statement will start with “The purpose of this paper…” and then proceed to outline the various sections of the instructions.

How to Write the Body for NURS 6630 Week 7 Therapy for Patients With Schizophrenia                     

After the introduction, move into the main part of the NURS 6630 Week 7 Therapy for Patients With Schizophrenia assignment, which is the body. Given that the paper you will be writing is not experimental, the way you organize the headings and subheadings of your paper is critically important. In some cases, you might have to use more subheadings to properly organize the assignment. The organization will depend on the rubric provided. Carefully examine the rubric, as it will contain all the detailed requirements of the assignment. Sometimes, the rubric will have information that the normal instructions lack.

Another important factor to consider at this point is how to do citations. In-text citations are fundamental as they support the arguments and points you make in the paper. At this point, the resources gathered at the beginning will come in handy. Integrating the ideas of the authors with your own will ensure that you produce a comprehensive paper. Also, follow the given citation format. In most cases, APA 7 is the preferred format for nursing assignments.

How to Write the Conclusion for NURS 6630 Week 7 Therapy for Patients With Schizophrenia                     

After completing the main sections, write the conclusion of your paper. The conclusion is a summary of the main points you made in your paper. However, you need to rewrite the points and not simply copy and paste them. By restating the points from each subheading, you will provide a nuanced overview of the assignment to the reader.

How to Format the References List for NURS 6630 Week 7 Therapy for Patients With Schizophrenia                     

The very last part of your paper involves listing the sources used in your paper. These sources should be listed in alphabetical order and double-spaced. Additionally, use a hanging indent for each source that appears in this list. Lastly, only the sources cited within the body of the paper should appear here.

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A Sample Answer For the Assignment: NURS 6630 Week 7 Therapy for Patients With Schizophrenia

Description Of the Psychopharmacological Medication Agent

Cariprazine is a psychopharmacological drug sold under the brand name Vraylar. It is an adult atypical antipsychotic drug of the second generation prescribed to treat schizophrenia and bipolar disorder. Cariprazine acts by altering dopamine and serotonin quantities in the brain, which alleviates symptoms including mania, hallucinations, and disordered thinking. The drug is offered as tablets and is typically ingested once daily.

Cariprazine has been given FDA approval for the management of schizophrenia and adult-onset bipolar disorder. Cariprazine is recommended for schizophrenia as a monotherapy or as an additional medication to lessen relapse frequency (Pinto et al., 2019). In individuals with bipolar I disorder who have responded to initial therapy, cariprazine is recommended for the acute management of manic or mixed episodes and for the maintenance of a calm mood.

Research for Non-FDA Uses

One area of research interest has been the use of cariprazine for the treatment of major depressive disorder (MDD). Several clinical trials have been conducted to evaluate the efficacy and safety of cariprazine as an adjunctive treatment for MDD, with some studies showing promising results. A study found that cariprazine as an adjunctive treatment to an antidepressant was effective in reducing depressive symptoms in patients with MDD who had not responded to prior antidepressant treatment (Pinto et al., 2019).

Another potential non-FDA use of cariprazine is for the treatment of substance use disorders. Preclinical studies have suggested that cariprazine may be effective in reducing drug-seeking behavior and reinstatement of drug use in animal models of addiction. Additionally, a pilot study published in the Journal of Dual Diagnosis in 2018 found that cariprazine may be useful for the treatment of cocaine use disorder in humans.

Drug Classification

Cariprazine is classified as a second-generation atypical antipsychotic medication. This class of drugs is used to treat various psychiatric disorders, including schizophrenia and bipolar disorder, by modulating the levels of dopamine and other neurotransmitters in the brain (Pinto et al., 2019). Second-generation atypical antipsychotics are considered to be a newer class of antipsychotic drugs compared to first-generation antipsychotics, and they have been developed to offer better efficacy and fewer side effects.

Cariprazine is structurally similar to aripiprazole, another atypical antipsychotic medication. Both medications are partial agonists at the dopamine D2 receptor and the serotonin 5-HT1A receptor, which means that they can stimulate or inhibit these receptors depending on the level of activity of the neurotransmitter. This unique pharmacological profile is thought to contribute to the efficacy and tolerability of cariprazine in the treatment of psychiatric disorders.

 Mechanism of Action

Cariprazine’s mechanism of action is complex and involves modulation of multiple neurotransmitter systems in the brain, including dopamine and serotonin. Specifically, cariprazine acts as a partial agonist at dopamine D2 and D3 receptors and a partial agonist at serotonin 5-HT1A receptors, while also acting as an antagonist at serotonin 5-HT2A receptors (Laszlovszky et al., 2021).

The partial agonist activity at dopamine D2 and D3 receptors allows cariprazine to modulate the dopaminergic pathways in the brain, which are known to be involved in the pathophysiology of schizophrenia and bipolar disorder. By acting as a partial agonist, cariprazine can both stimulate and inhibit these receptors, depending on the level of dopamine activity in the brain.

This unique pharmacological profile is thought to contribute to the medication’s ability to improve symptoms such as delusions, hallucinations, and disorganized thinking. In addition to its effects on dopamine, cariprazine also has partial agonist activity at serotonin 5-HT1A receptors, which are involved in the regulation of mood, anxiety, and cognition. By modulating the activity of these receptors, cariprazine may help to improve symptoms of depression and anxiety that are commonly associated with schizophrenia and bipolar disorder.

Pharmacokinetics and Pharmacodynamics

Cariprazine is an orally administered medication that is rapidly absorbed by the body, with peak plasma concentrations occurring within 3-4 hours of ingestion. The bioavailability of cariprazine is estimated to be approximately 52%, which means that about half of the medication reaches systemic circulation following oral administration (Laszlovszky et al., 2021).

Once absorbed, cariprazine is extensively metabolized in the liver by enzymes such as cytochrome P450 3A4 (CYP3A4) and cytochrome P450 2D6 (CYP2D6). The metabolites of cariprazine are primarily eliminated through urine and feces, with approximately 26% of the dose being eliminated in urine and 51% in feces.

Cariprazine acts as an antagonist at serotonin 5-HT2A receptors, which are involved in the regulation of sensory perception, cognition, and mood. By blocking the activity of these receptors, cariprazine may help to reduce the risk of side effects such as hallucinations and agitation that are associated with other antipsychotic medications.

Appropriate Dosing, Administration Route, and any Considerations for Dosing Alterations

The recommended starting dose for cariprazine in the treatment of schizophrenia is 1.5 mg/day, taken orally with or without food. The dose may be increased gradually over several days to a target dose of 4.5 mg/day, based on the patient’s response and tolerability. The maximum recommended dose is 6 mg/day.

For the treatment of bipolar disorder, the recommended starting dose is 1.5 mg/day, taken orally with or without food (Fagiolini et al., 2020). The dose may be increased gradually over several days to a target dose of 3 mg/day, based on the patient’s response and tolerability. The maximum recommended dose is 6 mg/day.

Cariprazine is available in tablet form and should be taken orally once daily, before or after meals. The tablets should be swallowed whole and should not be crushed or chewed (Fagiolini et al., 2020). Cariprazine may interact with other medications that affect the metabolism of the medication, such as CYP3A4 and CYP2D6 inhibitors or inducers. Patients taking these medications may require a dose adjustment of cariprazine to ensure optimal efficacy and tolerability.

Considerations Of Use and Dosing in Specific Specialty Populations

Children and adolescents

Not approved for use in children and adolescents under the age of 18 years old.

Elderly

Elderly patients may be more sensitive to the effects of cariprazine due to changes in metabolism and clearance of the medication (Fagiolini et al., 2020). Therefore, the dose may need to be adjusted in elderly patients to avoid adverse effects such as sedation, orthostatic hypotension, or extrapyramidal symptoms.

Pregnancy and breastfeeding

Cariprazine should only be used during pregnancy or breastfeeding if the potential benefits to the mother outweigh the potential risks to the fetus or infant.

Suicidal behaviors

May increase the risk of suicidal thoughts or behaviors, especially in children and young adults. Patients should be closely monitored for signs of suicidal ideation, especially during the first few months of treatment or after a change in dose.

Half-life

Half-life is the amount of time it takes for half of the initial dose of a drug to be eliminated from the body.  The half-life of a medication is important because it determines the frequency and timing of dosing and can affect the drug’s efficacy and potential for adverse effects (Fagiolini et al., 2020).  The half-life of cariprazine is approximately 2-4 days, meaning it takes 2-4 days for half of the initial dose of cariprazine to be eliminated from the body.

This relatively long half-life suggests that cariprazine may be suitable for once-daily dosing, but it may take longer to reach a steady state and may require a longer time to clear from the body if dosing is discontinued. The half-life of cariprazine should be taken into account when determining appropriate dosing regimens and monitoring for potential adverse effects.

Side effects

Common side effects of cariprazine include:

• Restlessness
• Extrapyramidal symptoms (such as tremors or muscle stiffness)
• Sedation
• Nausea
• Vomiting
• Constipation
• Headache
• Weight gain

Contraindications for use including significant drug to drug interactions

Contraindications for the use of cariprazine include:

• Hypersensitivity to cariprazine or any component of the formulation
• Unstable heart disease
• QTc prolongation
• Severe hepatic impairment
• Severe renal impairment
• Known history of prolonged QT syndrome

Significant drug-to-drug interactions include:

• Strong CYP3A4 inhibitors can increase the concentration of cariprazine in the body, potentially leading to increased side effects (Edinoff et al., 2020).
• Strong CYP3A4 inducers (such as rifampin and phenytoin) can decrease the concentration of cariprazine in the body, potentially reducing its efficacy.

Overdose Considerations

An overdose of cariprazine can be dangerous and potentially life-threatening. Symptoms of an overdose may include severe sedation, seizures, confusion, cardiac arrhythmias, and respiratory depression (Edinoff et al., 2020). In the event of an overdose, immediate medical attention should be sought.

Diagnostics and labs monitoring

• Complete blood count
• Liver function tests
• Electrolyte levels

Comorbidities Considerations

Cardiovascular disease: Cariprazine can cause changes in blood pressure and heart rate, so caution is advised in patients with cardiovascular disease. Blood pressure and heart rate should be monitored regularly during treatment.

Diabetes: Cariprazine can cause changes in blood glucose levels, so caution is advised in patients with diabetes. Blood glucose levels should be monitored regularly during treatment.

Seizure disorder: Cariprazine can lower the seizure threshold, so caution is advised in patients with a history of seizures or epilepsy (Edinoff et al., 2020).

Renal or hepatic impairment: Cariprazine is metabolized in the liver and excreted in the kidneys, so caution is advised in patients with renal or hepatic impairment. Dose adjustments may be necessary.

Substance use disorder: Cariprazine may have potential for abuse or dependence, so caution is advised in patients with a history of substance use disorder.

Pregnancy or breastfeeding: The safety of cariprazine during pregnancy and breastfeeding is not well-established, and the potential risks and benefits should be carefully considered before prescribing to women who are pregnant or breastfeeding.

Legal and Ethical Considerations

One of the most critical legal considerations is obtaining informed consent from patients. Healthcare providers must explain the potential benefits and risks of cariprazine, as well as any alternative treatments that may be available. Informed consent is critical to ensuring that patients understand the implications of taking medication, and that they are fully informed about their treatment options.

Another legal consideration is the off-label use of cariprazine. While cariprazine is approved by the

FDA for the treatment of schizophrenia and bipolar disorder, healthcare providers may also prescribe it for off-label uses (Rancans et al., 2021). Off-label use is legal, but it must be based on clinical judgment and the best available evidence. Providers should also be aware of any potential legal risks associated with off-label use.

Prescribing practices are also essential legal and ethical considerations. Healthcare providers must prescribe cariprazine at the appropriate dosage and monitor patients for side effects or adverse reactions. Providers should also follow established medical guidelines and best practices when prescribing cariprazine or any other medication.

Healthcare providers must protect patient privacy by following all relevant privacy laws and regulations, such as HIPAA. This includes keeping patient medical records confidential and only sharing information with other healthcare providers on a need-to-know basis. Finally, healthcare providers may be held liable for any harm that their patients experience as a result of medication errors or other negligent actions.

Pertinent Patient Education Considerations

Dosing and administration

Patients should be educated on how to take cariprazine, including the appropriate dosage and administration route. Patients should also be advised to take the medication as directed by their healthcare provider and not to adjust their dose or stop taking the medication without consulting their provider.

Side effects and adverse reactions

Patients should be informed about the potential side effects and adverse reactions of cariprazine. They should be advised to contact their healthcare provider immediately if they experience any side effects, such as dizziness, nausea, or constipation.

Drug interactions

Patients should be informed of potential drug interactions with cariprazine, including over-the-counter medications, herbal supplements, and other prescription drugs. Patients should be advised to consult their healthcare provider before taking any new medications (Rancans et al., 2021).

Importance of compliance

Patients should be educated on the importance of compliance with their cariprazine treatment regimen. Skipping doses or discontinuing treatment without consulting their healthcare provider can lead to a worsening of their condition.

Pregnancy and breastfeeding

Patients should be informed about the potential risks of taking cariprazine during pregnancy or while breastfeeding. Patients who are pregnant or breastfeeding should consult their healthcare provider before taking cariprazine.

Suicide risk

Patients should be advised of the potential risk of suicide associated with cariprazine and other medications used to treat mental illness. Patients should be advised to contact their healthcare provider immediately if they experience any suicidal thoughts or behaviors.

References

Correll, C. U., & Schooler, N. R. (2020). Negative symptoms in schizophrenia: a review and clinical guide for recognition, assessment, and treatment. Neuropsychiatric Disease and Treatment, 519-534. Doi: 10.2147/NDT.S225643

Edinoff, A., Ruoff, M. T., Ghaffar, Y. T., Rezayev, A., Jani, D., Kaye, A. M., … & Urits, I. (2020). Cariprazine to treat schizophrenia and bipolar disorder in adults. Psychopharmacology Bulletin, 50(4), 83. https://doi.org/10.1211/pj.2015.20069435

Fagiolini, A., Alcalá, J. Á., Aubel, T., Bienkiewicz, W., Bogren, M. M., Gago, J., Cerveri, G., Colla, M., Sanchez, F. C., Cuomo, A., Helge, F., Iacoponi, E., Karlsson, P., Peddu, P., Pettorruso, M., Pereira, H. J., Schölin, J. S., & Vernaleken, I. B. (2020). Treating schizophrenia with cariprazine: From clinical research to clinical practice. Real world experiences and recommendations from an international panel. Annals of General Psychiatry, 19(1). https://doi.org/10.1186/s12991-020-00305-3

Laszlovszky, I., Barabássy, Á., & Németh, G. (2021). Cariprazine, a broad-spectrum antipsychotic for the treatment of schizophrenia: Pharmacology, efficacy, and safety. Advances in Therapy, 38(7), 3652-3673. https://doi.org/10.1007/s12325-021-01797-5

Pinto, J. V., Saraf, G., Vigo, D., Keramatian, K., Chakrabarty, T., & Yatham, L. N. (2019). Cariprazine in the treatment of bipolar disorder: A systematic review and meta‐analysis. Bipolar Disorders, 22(4), 360-371. https://doi.org/10.1111/bdi.12850

Rancans, E., Dombi, Z. B., Mátrai, P., Barabássy, Á., Sebe, B., Skrivele, I., & Németh, G. (2021). The effectiveness and safety of cariprazine in schizophrenia patients with negative symptoms and insufficient effectiveness of previous antipsychotic therapy: An observational study. International Clinical Psychopharmacology, 36(3), 154-161. https://doi.org/10.1097/yic.0000000000000351

Study Guide for Medication Treatment Schizophrenia Spectrum and Other Psychosis Disorders

Antipsychotic medication has been the common and standard method of treatment patients with Schizophrenia. These medications provide the patients with a therapeutic and safe environment effective in controlling symptoms (Chang et al., 2021). Schizophrenia is a disorder affecting the sensory nerves and also creating a great disturbance in the thinking process.

Both generic and non-generic drugs have been important in the treatment of Schizophrenia and other disorders. These antipsychotic drugs are commonly used because of the wide spectrum of receptor activity, especially in stabilizing dopamine and serotine levels in the brain. Again, they are effective in controlling symptoms. Therefore, the purpose of this write-up is to develop a study guide for an antipsychotic drug.

Drug Description

Paliperidone Palmitate is a drug used in treating Schizophrenia. Its brand name is Invega Sustenna. This drug is approved by the FDA to treat Schizophrenia and other psychosis disorders. The drug is approved to treat the schizoaffective disorder as either adjunctive therapy or monotherapy.

Non-FDA uses

Invega Sustenna belongs to the general class of antipsychotics, and its non-FDA uses include the treatment of depression and treating hallucinations.

• According to Kverno & Rozenberg (2021), Invega Sustenna is used in treating depression despite the reviews showing that it has been given a rating of 3.9 out of 10 in treating depression. Lower doses of Invega Sustenna are advised when a patient is suffering from mild depression.
• Invega Sustenna has been found to reduce hallucinations and help patients better think of themselves (Kverno & Rozenberg, 2021).

According to the Schizophrenia and Related Disorders Alliance of America, approximately 3.5 million people in the United States are diagnosed with schizophrenia (n.d.), and it is one of the leading causes of disability. In practice, patients may present with delusions, hallucinations, disorganized thinking, disorganized or abnormal motor behavior, as well as other negative symptoms that can be disabling for these individuals.

Not only are these symptoms one of the most challenging symptom clusters you will encounter, many are associated with other disorders, such as depression, bipolar disorder, and disorders on the schizophrenia spectrum. As a psychiatric nurse practitioner, you must understand the underlying neurobiology of these symptoms to select appropriate therapies and improve outcomes for patients.
This week, as you examine antipsychotic therapies, you explore the assessment and treatment of patients with psychosis and schizophrenia. You also consider ethical and legal implications of these therapies.

Reference:

Schizophrenia and Related Disorders Alliance of America. (n.d.). About schizophrenia.https://sardaa.org/resources/about-schizophrenia/#:~:text=Quick%20Facts%20About%20Schizophrenia.%20Schizophrenia%20can%20be%20found,is%20one%20of%20the%20leading%20causes%20of%20disability
Learning Objectives
Students will:
• Assess client factors and history to develop personalized therapy plans for patients with insomnia
• Analyze factors that influence pharmacokinetic and pharmacodynamic processes in patients requiring therapy for insomnia
• Assess patient factors and history to develop personalized plans of antipsychotic therapy for patients
• Analyze factors that influence pharmacokinetic and pharmacodynamic processes in patients requiring antipsychotic therapy
• Synthesize knowledge of providing care to patients presenting for antipsychotic therapy
• Analyze ethical and legal implications related to prescribing antipsychotic therapy to patients across the lifespan

Learning Resources

Required Readings (click to expand/reduce)

Freudenreich, O., Goff, D. C., & Henderson, D. C. (2016). Antipsychotic drugs. In T. A. Stern, M. Favo, T. E. Wilens, & J. F. Rosenbaum. (Eds.), Massachusetts General Hospital psychopharmacology and neurotherapeutics (pp. 72–85). Elsevier.

American Psychiatric Association. (2019). Practice guideline for the treatment of patients with schizophrenia. https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/Clinical%20Practice%20Guidelines/APA-Draft-Schizophrenia-Treatment-Guideline.pdf

Clozapine REMS. (2015). Clozapine REMS: The single shared system for clozapine. https://www.clozapinerems.com/CpmgClozapineUI/rems/pdf/resources/Clozapine_REMS_A_Guide_for_Healthcare_Providers.pdf

Funk, M. C., Beach, S. R., Bostwick, J. R., Celano, C. M., Hasnain, M., Pandurangi, A., Khandai, A., Taylor, A., Levenson, J. L., Riba, M., & Kovacs, R. J. (2018). Resource document on QTc prolongation and psychotropic medications. American Psychiatric Association. https://www.psychiatry.org/File%20Library/Psychiatrists/Directories/Library-and-Archive/resource_documents/Resource-Document-2018-QTc-Prolongation-and-Psychotropic-Med.pdf

Kay, S. R., Fiszbein, A., & Opler, L. A. (1987). The Positive and Negative Syndrome Scale (PANSS) for schizophrenia. Schizophrenia Bulletin, 13(2), 261–276. https://doi.org/10.1093/schbul/13.2.261

Levenson, J. C., Kay, D. B., & Buysse, D. J. (2015). The pathophysiology of insomnia. Chest, 147(4), 1179–1192. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4388122/

McClellan, J. & Stock. S. (2013). Practice parameter for the assessment and treatment of children and adolescents with schizophrenia. Journal of the American Academy of Child and Adolescent Psychiatry, 52(9), 976–990. https://www.jaacap.org/article/S0890-8567(09)62600-9/pdf

Naber, D., & Lambert, M. (2009). The CATIE and CUtLASS studies in schizophrenia: Results and implications for clinicians. CNS Drugs, 23(8), 649–659. https://doi.org/10.2165/00023210-200923080-00002

Medication Resources (click to expand/reduce)

U.S. Food & Drug Administration. (n.d.). Drugs@FDA: FDA-approved drugs. https://www.accessdata.fda.gov/scripts/cder/daf/index.cfm

Note: To access the following medications, use the Drugs@FDA resource. Type the name of each medication in the keyword search bar. Select the hyperlink related to the medication name you searched. Review the supplements provided and select the package label resource file associated with the medication you searched. If a label is not available, you may need to conduct a general search outside of this resource provided. Be sure to review the label information for each medication as this information will be helpful for your review in preparation for your Assignments.
• amisulpride
• aripiprazole
• asenapine
• brexpiprazole
• cariprazine
• chlorpromazine
• clozapine
• flupenthixol
• fluphenazine
• haloperidol
• iloperidone
• loxapine
• lumateperone • lurasidone
• olanzapine
• paliperidone
• perphenazine
• pimavanserin
• quetiapine
• risperidone
• sulpiride
• thioridazine
• thiothixene
• trifluoperazine
• ziprasidone

Required Media (click to expand/reduce)

Case study: Pakistani woman with delusional thought processes
Note: This case study will serve as the foundation for this week’s Assignment.

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Optional Resources (click to expand/reduce)

Chakos, M., Patel, J. K., Rosenheck, R., Glick, I. D., Hammer, M. B., Tapp, A., Miller, A. L., & Miller, D. D. (2011). Concomitant psychotropic medication use during treatment of schizophrenia patients: Longitudinal results from the CATIE study. Clinical Schizophrenia & Related Psychoses, 5(3), 124–134. https://doi.org/10.3371/CSRP.5.3.2

Fangfang, S., Stock, E. M., Copeland, L. A., Zeber, J. E., Ahmedani, B. K., & Morissette, S. B. (2014). Polypharmacy with antipsychotic drugs in patients with schizophrenia: Trends in multiple health care systems. American Journal of Health-System Pharmacy, 71(9), 728–738. https://doi.org/10.2146/ajhp130471

Lin, L. A., Rosenheck, R., Sugar, C., & Zbrozek, A. (2015). Comparing antipsychotic treatments for schizophrenia: A health state approach. The Psychiatric Quarterly, 86(1), 107–121. https://doi.org/10.1007/s11126-014-9326-2

Discussion: Treatment for a Patient With a Common Condition

Insomnia is one of the most common medical conditions you will encounter as a PNP. Insomnia is a common symptom of many mental illnesses, including anxiety, depression, schizophrenia, and ADHD (Abbott, 2016). Various studies have demonstrated the bidirectional relationship between insomnia and mental illness. In fact, about 50% of adults with insomnia have a mental health problem, while up to 90% of adults with depression experience sleep problems (Abbott, 2016).

Due to the interconnected psychopathology, it is important that you, as the PNP, understand the importance of the effects some psychopharmacologic treatments may have on a patient’s mental health illness and their sleep patterns. Therefore, it is important that you understand and reflect on the evidence-based research in developing treatment plans to recommend proper sleep practices to your patients as well as recommend appropriate psychopharmacologic treatments for optimal health and well-being.

Reference:

Abbott, J. (2016). What’s the link between insomnia and mental illness? Health.

https://www.sciencealert.com/what-exactly-is-the-link-between-insomnia-and-mental-illness#:~:text=Sleep%20problems%20such%20as%20insomnia%20are%20a%20common,bipolar%20disorder%2C%20and%20attention%20deficit%20hyperactivity%20disorder%20%28ADHD%29
For this Discussion, review the case Learning Resources and the case study excerpt presented. Reflect on the case study excerpt and consider the therapy approaches you might take to assess, diagnose, and treat the patient’s health needs.

Case: An elderly widow who just lost her spouse.

Subjective: A patient presents to your primary care office today with chief complaint of insomnia. Patient is 75 YO with PMH of DM, HTN, and MDD. Her husband of 41 years passed away 10 months ago. Since then, she states her depression has gotten worse as well as her sleep habits. The patient has no previous history of depression prior to her husband’s death. She is awake, alert, and oriented x3. Patient normally sees PCP once or twice a year. Patient denies any suicidal ideations. Patient arrived at the office today by private vehicle. Patient currently takes the following medications:
• Metformin 500mg BID
• Januvia 100mg daily
• Losartan 100mg daily
• HCTZ 25mg daily
• Sertraline 100mg daily
Current weight: 88 kg
Current height: 64 inches
Temp: 98.6 degrees F
BP: 132/86
By Day 3 of Week 7
Post a response to each of the following:
• List three questions you might ask the patient if she were in your office. Provide a rationale for why you might ask these questions.
• Identify people in the patient’s life you would need to speak to or get feedback from to further assess the patient’s situation. Include specific questions you might ask these people and why.
• Explain what, if any, physical exams, and diagnostic tests would be appropriate for the patient and how the results would be used.
• List a differential diagnosis for the patient. Identify the one that you think is most likely and explain why.
• List two pharmacologic agents and their dosing that would be appropriate for the patient’s antidepressant therapy based on pharmacokinetics and pharmacodynamics. From a mechanism of action perspective, provide a rationale for why you might choose one agent over the other.
• For the drug therapy you select, identify any contraindications to use or alterations in dosing that may need to be considered based on ethical prescribing or decision-making. Discuss why the contraindication/alteration you identify exists. That is, what would be problematic with the use of this drug in individuals based on ethical prescribing guidelines or decision-making?
• Include any “check points” (i.e., follow-up data at Week 4, 8, 12, etc.), and indicate any therapeutic changes that you might make based on possible outcomes that may happen given your treatment options chosen.
Read a selection of your colleagues’ responses.
By Day 6 of Week 7
Respond to at least two of your colleagues on two different days in one of the following ways:
• If your colleagues’ posts influenced your understanding of these concepts, be sure to share how and why. Include additional insights you gained.
• If you think your colleagues might have misunderstood these concepts, offer your alternative perspective and be sure to provide an explanation for them. Include resources to support your perspective.Read a selection of your colleagues’ responses and respond to at least two of your colleagues on two different days and
Note: For this Discussion, you are required to complete your initial post before you will be able to view and respond to your colleagues’ postings. Begin by clicking on the “Post to Discussion Question” link and then select “Create Thread” to complete your initial post. Remember, once you click on Submit, you cannot delete or edit your own posts, and you cannot post anonymously. Please check your post carefully before clicking on Submit!
Submission and Grading Information
Grading Criteria

To access your rubric:
Week 7 Discussion Rubric

Post by Day 3 of Week 7 and Respond by Day 6 of Week 7

To Participate in this Discussion:
Week 7 Discussion

Insomnia is a compliant of difficulty falling and staying asleep that has result in the patient’s inability to function during the day and some major risk factors include some disorders such as major depressive disorder, anxiety disorder, hypertension, diabetes (Krystal, Prather & Ashbrook, 2019). Other risk facts include loss of a loved one, older adults, women, medications (Krystal, Prather & Ashbrook, 2021).

To qualify as insomnia the patient must have adequate opportunity to sleep in a safe and dark environment and yet is unable to sleep (Krystal, Prather & Ashbrook, 2019) The international Classification of Sleep Disorder 3^rd edition and DSM-5 states that insomnia must last for at least three days per week and about three months for chronic cases. The case study presents:

The Patient  is    Age: 75years    Gender: Female

Subjective Data:

Chief Compliant (CC): “Insomnia”.

History of Present Illness (HPI): Patient presents at the clinic today and reports that her husband of 41 years passed away 10 months ago and since then she has been suffering from depression which has worsened as well as her sleep habit which she describes as insomnia.

 

Medications:

• Metformin 500mg BID
• Januvia 100mg daily
• Losartan 100mg daily
• HCTZ 25mg daily
• Sertraline 100mg daily

Past Medical History (PMH)

• DM, HTN & MDD

Objective Data: Vital Signs; BP 132/86; Temp 98.6F; Current -Weight:88kg Height:64 inches

Lists three Questions for the Patient

• What has life been like since your husband passed away 10 months ago?

Asking the above open-ended question will give the patient the opportunity to discuss in detail how her husband’s passing led to the insomnia and depression and how it has worsened in the last 10 months. Under this question, if the patient does not talk about weight, the patient could be asked a sub-question like have you gained or lost weight in the last 10 months.

• Tell me about your sleep habits?

This question is also an open-ended question that gives the patient the opportunity to talk about her sleep habits which will include her sleep /wake patterns. What time does she sleep and what time does she wake up? How many hours does she sleep for. Does she take a nap during the day? Or sleeps only at night? Answers to these questions will help the PNP to reach a diagnosis and decide on an intervention (Krystal, Prather & Ashbrook, 2019)

• Give
  me a detail description of your bedtime routine in a typical night?

A response to this question which is also open-ended talk about what she typically does before going to sleep and the condition such as does she take a bedtime snack, tea, ice cream, does she put off the lights or TV before getting into bed to create a quiet and dark environment to foster sleep? (Krystal, Prather & Ashbrook, 2019).

The Patient’s daughter who is single and moved back home to be with her mother since the passing of her father and drove the Patient to the clinic today will be asked the following questions:

• Tell me about how the passing of your father has affected your mother’s health?
• Describe your mother’s sleep pattern?

The daughter’s answers will tell the PNP how many hours the patient sleeps, if she snores, sleeps during the day and have a bedtime routine that promotes sleeping. Though the patient is alert and oriented x3 getting these answers from the daughter will provide more details objective data that will help the PNP to provide appropriate intervention.

Physical exams and diagnostics

• Physical exam to assess body mass index, neck circumference and airway for obstructive sleep apnea.
• The Patient Completing the Insomnia Assessment tools such as the Pittsburg Sleep Quality Index used to collect objective information on the patient’s self -perceived sleep quality.
• Polysomnography used in the diagnosis of insomnia which helps to rule out other possible explanation for poor sleep pattern such as sleep apnea or restless leg syndrome (Krystal, Prather & Ashbrook, 2019).
• Using the 3P Model can be used to assess the patient from the history of present illness, that is the sleep history to assess factors predisposing the patient to insomnia, factors precipitating the patient to acute episodes and factors perpetuating the insomnia from acute to chronic (over the last 10 months) (Krystal, Prather & Ashbrook, 2019)

Two Differential Diagnosis

Chronic Insomnia and Major depressive disorder

Two Pharmacological agents

Triazolam 0.125mg PO tablet at bedtime daily (which maybe be increased to 0.25mg depending on how effective the patient reports in two weeks).

Which is FDA approved for major depressive disorder also has an off-label use for indication for insomnia because it is a Benzodiazepine that has a sleep enhancing effect because of its positive allosteric modulation of GABA type A receptor (Krystal, Prather & Ashbrook, 2019). Triazolam has therapeutic effect on both sleep onset and maintenance and does not have the side effect of dependence as demonstrated from double-blinded studies (Krystal, Prather & Ashbrook, 2019)

Sample Answer for NURS 6630 Week 7 Therapy for Patients With Schizophrenia

Case: An Elderly Widow Who Just Lost Her Spouse 

The case study portrays a 75-year-old female patient presenting with a chief complaint of insomnia. She has a history of DM, HTN, and MDD. The patient’s husband passed away ten months ago. Since the husband’s demise, she states her depression has worsened and her sleep habits. She had no history of depression before her husband’s death. 

Three Questions I Might Ask the Patient  

1. How has insomnia and depression affected your daily activities or interactions with people? The question will determine if the depressive symptoms have caused social and occupational dysfunction. 

1. When did you begin experiencing insomnia? To determine if insomnia started after starting Sertraline since it is an adverse effect of the drug.  

1. What is your current living status? The question will identify the persons currently living with the patient and her social support system. Living alone may be a cause of the depressive symptoms. 

People in the Patient’s Life I Would Need to Speak To 

Patient’s Primary Caregiver 

1. Which activities of daily living have the patient had difficulties in carrying out in the past days?  The question will determine the impact of depression on the patient’s daily functioning. 

1. Does the patient engage in activities that put her life at risk? To identify the presence of self-mutilating behaviors. 

1. How have been your interactions with the patient in the past weeks? To determine whether the patient’s depression and insomnia have resulted in impaired interpersonal or social functioning.   

Physical Exams and Diagnostic Tests Appropriate For the Patient 

1. Depression screening using the Patient Health Questionnaire (PHQ)-9. The PHQ-9 self-questionnaire will help rate the severity of the patient’s depression (Avasthi & Grover, (2018).  

1. Hemoglobin A1c- To identify the mean glycemic level and establish whether the patient has achieved adequate glycemic control. 

1. Cardiovascular Exam: To assess any abnormalities in the cardiovascular system, this can be caused by hypertension and diabetes mellitus.  

1. Thyroid-stimulating Hormone Test to rule out Hypothyroidism, which presents with depression (Avasthi & Grover, (2018).  

1. Mental Status Examination (MSE). An MSE will assess the patient’s affect, speech, memory, judgment, and cognition, which can be grossly affected by depression. 

Differential Diagnoses 

Major Depressive Disorder 

Major depressive disorder (MDD) is a mood condition marked by a depressed mood or diminished pleasure or interest in most pleasurable activities.  The DSM V diagnostic criteria require that a person presents with four other symptoms in addition to a depressed mood or diminished interest (APA, 2013). The symptoms are changes in appetite, weight changes, fatigue or low energy levels, sleeping difficulties, psychomotor agitation or retardation, reduced ability to concentrate and think or indecisiveness, feelings of worthlessness, and recurrent thoughts of death, suicidal ideations, or attempt (APA, 2013). MDD is a presumptive diagnosis based on the patient’s symptoms of worsening depression and insomnia. Besides, she has a history of MDD, which suggest a relapse of the disorder. 

Insomnia  

Insomnia is characterized by a continuous difficulty in initiating sleep, maintaining sleep, consolidation, or quality of sleep. Persons with insomnia present with difficulty falling asleep, frequent awakenings, or early morning awakening (APA, 2013). Persons with insomnia report dissatisfaction with quantity or quality of sleep. Insomnia is associated with daytime effects, such as fatigue, tiredness, lack of energy, irritability, reduced work performance, and difficulty concentrating (APA, 2013). Insomnia is a differential diagnosis based on the patient’s symptoms of difficulties in sleeping. Insomnia could be due to MDD, in which patients present with sleeping difficulties of insomnia or hypersomnia. Insomnia can also be attributed to the side effects of Sertraline.  

Persistent Complex Bereavement Disorder (PCBD) 

PCBD is a condition marked by unshakeable grief that does not follow the typical pattern of improvement over time. Persons continue to exhibit persistent and intense emotions or moods and unusual (APA, 2013). They also experience adverse symptoms that impair significant areas of functioning or cause extreme distress. Symptoms of PCBD include Indefinitely yearning for the deceased; A preoccupation with the events of the deceased’s death; Intense sorrow and distress that does not improve over time; Depression; Difficulty trusting others; Detachment and isolation (APA, 2013). In addition, one may experience difficulties pursuing interests or activities, persistent feelings of loneliness or emptiness, and impairment in occupational, social, and other areas of life (APA, 2013). PBCD is a differential diagnosis based on the patient’s report of depression and insomnia that has worsened since his husband’s death.  

Pharmacologic Agents Appropriate For The Patient’s Antidepressant Therapy 

1. Fluoxetine (Prozac) 10 mg PO once daily. 

Prozac is an antidepressant belonging to the class of Selective serotonin reuptake inhibitors (SSRIs). SSRIs are indicated as first-line agents in uncomplicated depression owing to their few anticholinergic effects. Prozac is a preferred treatment choice in geriatric patients due to its fewer side effects (Avasthi & Grover, (2018). The dose will be gradually increased by 10-20 mg after four weeks based on the patient’s tolerance to the drug.  Contraindications for Prozac include hypersensitivity to the drug and concomitant administration of Pimozide or Thioridazine (Avasthi & Grover, (2018). According to Simon et al. (2015), African Americans have a worse response to SSRIs than Whites. If the patient were an African American, she would have a low response rate.  

1. Duloxetine (Cymbalta) 30 mg PO once daily. 

Duloxetine is an antidepressant under the class of serotonin-norepinephrine reuptake inhibitors (SNRIs). SNRIs are indicated as second-line agents in patients who have not responded to SSRIs (Muscatello et al., 2019). The patient will be started on a low dose of 30mg/day due to her advanced age. The dose will be increased after two weeks to a target dose of 60 mg/day. Contraindications for Duloxetine include concomitant administration of the drug with Monoamine oxidase inhibitors (MAOIs) prescribed to treat a psychiatric disorder (Muscatello et al., 2019). I would choose Prozac over Duloxetine since the former exerts no effect on cardiac conduction, heart rate, or blood pressure (Avasthi & Grover, (2018). It would thus be appropriate for this patient with HTN. 

Check Points 

After four weeks, I would evaluate the patient for improvement of depressive symptoms and insomnia. I would also assess for side effects. If there is a partial improvement of symptoms and no associated side effects with Prozac treatment, I will increase the dose to 20 mg per day. In week 8, I would assess for severity of depressive symptoms and compare them with the patient’s depression in the previous visit. If there is a partial improvement, I would increase the dose to 40 mg/day and monitor any side effects.  

 

References 

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub. 

Avasthi, A., & Grover, S. (2018). Clinical Practice Guidelines for Management of Depression in the Elderly. Indian journal of psychiatry, 60(Suppl 3), S341–S362. https://doi.org/10.4103/0019-5545.224474 

Muscatello, M., Zoccali, R. A., Pandolfo, G., Mangano, P., Lorusso, S., Cedro, C., Battaglia, F., Spina, E., & Bruno, A. (2019). Duloxetine in Psychiatric Disorders: Expansions Beyond Major Depression and Generalized Anxiety Disorder. Frontiers in psychiatry, 10, 772. https://doi.org/10.3389/fpsyt.2019.00772 

Simon, G. E., Coleman, K. J., Waitzfelder, B. E., Beck, A., Rossom, R. C., Stewart, C., & Penfold, R. B. (2015). Should measures of antidepressant treatment quality be adjusted for race and ethnicity?. JAMA psychiatry, 72(10), 1055.https://doi.org/10.1001/jamapsychiatry.2015.1437