Three Questions I might ask the client
Identify people in the client’s life I need to speak to
The client has provided a family history that includes multiple relatives being diagnosed with depression. I would of course first ask permission of the client to interview the family members and coworkers without violating the client’s confidentiality. The family member with the history of depression would be good people to speak with about depression. The family members may be able to offer some insight to the symptoms the client is currently having. The nurse practitioner would then have the opportunity to ask the family how they deal with their depression. Do they take antidepressant medication? Have they tried psychotherapy? If so have they seen any positive effects from the chosen therapy? The coworkers would also be good people to ask about the client. The coworkers could be asked if they have noticed any changes in the client’s behavior or moods while at work.
Diagnostic Tests and Physical Exams
The client has not been taking any tricyclic antidepressants (TCAs) recently so blood level monitoring is not indicated (Blackburn, Ho, & Wiese, 2017). A physical assessment can be done on the client but the past medical history does not provide a reason for diagnostic testing. As a routine check, a urine drug test and urine analysis can be performed. However, the thyroid gland has been linked to some mood disorders. Thyroid hormones can have an influence on the brain impacting the mood and cognition (Pilhatsch, Marxen, Winter, Smolka, & Bauer, 2011). The thyroid stimulating hormone (TSH) levels can be checked to see if they are within normal range. If indicated, thyroid hormone treatment can enhance antidepressant therapy and provide maintenance therapy for some bipolar disorders (Pilhatsch, Marxen, Winter, Smolka, & Bauer, 2011).
Two Pharmacologic Agents
Olanzapine – is an atypical that can improve the mood while treating resistant depression (Stahl, 2013). This medication can work better when combined with fluoxetine. The client also expressed concern about weight gain and this medication causes a chance of weight gain. This medication is usually a second line of treatment option but the client has tried other medications unsuccessfully. The dosing is approved for 10-15mg/day, but the higher the dosage the greater the improvement in the symptoms.
Fluoxetine – The client has already tried this medication and it does provide relief from the depression symptoms, usually seen after the first dose. However the client has not taken this medication along with olanzapine. Fluoxetine in combination with olanzapine can treat bipolar depression more effectively. Both medications have the 5HT2C antagonist actions. The two mechanisms can boost the dopamine receptors and the norepinephrine release in the prefrontal cortex causing the improvement in the clinical symptoms (Stahl, 2013).
Follow up Check Points
Once the client returned for the first follow up and expressed the concerns about the sexual dysfunction and decreased libido, I would have wanted to prescribe him an alternate therapy. The client has already expressed having depressed episodes after each divorce. I would not want him to stay on a medication that can cause him to have a poor image of himself if he cannot perform sexually. This client would probably benefit from combination therapy which means psychotherapy would need to be added into his treatment plan. He did say he would be okay with it as long as he had a therapist he respected. The next follow up appointment at week 16, the client has stopped the lamotrigine due to the sexual side effects. I would have already prescribed the patient an antipsychotic medication and increased his follow up appointment frequency. The client’s history of the many depressive episodes indicate the need for close monitoring.
The main lesson here is that the physician should not be treating and prescribing himself medications. The client is having a hard time trusting that other physicians and providers can offer him the help and treatment he needs. As the advanced practice nurse, I would find ways to incorporate him into his treatment plan while educating him on the benefits of certain medication therapy. Hopefully the client will take medication long enough to see the benefits of the treatment. Mental health can be challenging and this client case study is no different than real life practice. As the provider, I would just have to continuously think of ways to treat the patient safely.
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