Major Depressive Disorder Insomnia Essay

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Major Depressive Disorder Insomnia Essay

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. Major Depressive Disorder Insomnia Essay. 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 the client’s ethnicity. Discuss why the contraindication/alteration you identify exists. That is, what would be problematic with the use of this drug in individuals of other ethnicities? 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. Major Depressive Disorder Insomnia Essay. 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 ( THESE CAN BE TWO PARAGRAPHS EACH) PLEASE INCLUDE INTRODUCTION AND CONCLUSION AND RECENT RESOURCES

Major Depressive Disorder (MDD), Generalized Anxiety Disorder (GAD), and Insomnia: Pharmacotherapy, Neurobiologic Causes, and Risk Factors or Predictors

Psychiatric conditions are currently diagnosed definitively after conformity with the diagnostic criteria presented in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders or the DSM-5 (APA, 2013). The DSM-5 provides the complete symptom profile that each of these psychiatric disorders is supposed to resent with for the diagnosis to be made. The duration of these symptoms is also clearly indicated. Major Depressive Disorder Insomnia Essay. A condition may produce the stated symptoms but for a shorter duration than indicted in the diagnostic criteria. In that case, it does not qualify for that diagnosis. Major depressive disorder or MDD is one of the mental disorders found in the diagnostic category known as the ‘Depressive Disorders’ together with dysthymia, substance/ medication-induced depressive disorder, and disruptive mood dysregulation disorder amongst others (APA, 2013). The other important mental disorder is generalized anxiety disorder or GAD. It belongs to the diagnostic category referred to as the ‘Anxiety Disorders’ in the DSM-5 together with agoraphobia, panic disorder, selective mutism, and social anxiety disorder amongst others. The common characteristics for all the disorders in this diagnostic category are irrational fear and anxiety that has its roots in behavioral disturbances (APA, 2013). This paper discusses MDD, GAD, and insomnia in terms of pharmacotherapy, predictors or risk factors, neurobiological causes, and symptoms. The discussion is directed by specific questions the answers to which are provided in this paper.

Question 1

Major depressive disorder (MDD) is a depressive disorder that is characterized by mood depression for a large part of the day almost daily, lack of interest in pleasurable activities previously enjoyed for the most part of the day every day, marked weight loss, either hypersomnolence (excessive sleepiness during the day) or lack of sleep (insomnia), loss of energy (fatigue) almost always, either psychomotor agitation or psychomotor retardation every day, and repeated thoughts about death or dying as well as suicidality without a specific plan of actualization. These are just some of what appears in its diagnostic criteria in the DSM-5 (Sadock et al., 2015; APA, 2013). Usually, MDD occurs together with substance abuse such as alcohol abuse (alcohol use disorder or AUD). In that case, the two are regarded as being co-morbid. Since the two co-occur, the treatment of one may affect that of the other. Major Depressive Disorder Insomnia Essay

The appropriate drug therapy for those clients who present with MDD and a history of alcohol abuse or AUD includes the selective serotonin reuptake inhibitors (SSRIs) citalopram (Celexa), escitalopram (Lexapro), and sertraline or Zoloft (Stahl, 2017). These are atypical antidepressants that cause fewer side effects than the earlier antidepressants such as tricyclic antidepressants. They are all FDA-approved to treat depression and have comparable safety and efficacy profiles. These three do not compromise the treatment of the co-occurring AUD but produce effects that are helpful (Stahl, 2017). However, there are other drugs that are contraindicated in MDD that is comorbid with AUD. This is because of the effects of these medications on the body systems. The contraindicated medications in this case include the serotonin norepinephrine reuptake inhibitor (SN-RI) duloxetine (Cymbalta) and the norepinephrine dopamine reuptake inhibitor (NDRI) bupropion (Wellbutrin). Both of these two are FDA-approved for the treatment of major depressive disorder alone (Stahl, 2017). When MDD is comorbid with AUD, however, the two are contraindicated (DeVido & Weiss, 2012). The reason is that bupropion will cause the lowering of the seizure threshold such that the patient may suffer life-threatening seizures because of the alcohol they are taking. As for the duloxetine (Cymbalta), it is contraindicated because it produces liver toxicity. This may not be desirable in a patient who already has established liver dysfunction from chronic alcohol use.Major Depressive Disorder Insomnia Essay

The timeframe that the patient should see a resolution of symptoms will depend on the time that the appropriate medications stated above will start producing their therapeutic effects. According to Stahl (2017), this will be between the second and the fourth week for most of the medications (atypical antidepressants).

Question 2

Generalized anxiety disorder or GAD is a chronic mental health condition usually affecting older persons. It causes this population demographic significant morbidity and disability with ultimate mortality if not managed promptly and appropriately. This anxiety disorder with a diagnostic code of 300.02 (F41.1) in the DSM-5 is diagnosed if (Sadock et al., 2015; APA, 2013):

There is sustained anxiety and worry for at least six months
The client is unable to control the worry (cannot get it out of his or her mind)
The worry and anxiety above are related or associated with at least three of the following: a disturbance in sleep patterns, easy fatigability, restlessness, inability to concentrate, tension in the muscles, and irritability.
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The above symptoms cause clinically significant distress and impairment
The above symptoms cannot be attributed to drug or substance use, and
The symptoms above cannot be attributed to another mental disorder. Major Depressive Disorder Insomnia Essay
Late-onset generalized anxiety disorder has been studied and it has been shown to have particular predictors which may also be regarded as its risk factors. Zhang et al. (2015) in a study that went on for 12 years found that four of the predictors of late-onset generalized anxiety disorder or GAD are:

Having chronic medical/ physical conditions
The stress of having chronic physical conditions can lead to an elderly person developing symptoms of GAD. A logical explanation is that the elderly do not usually have a robust social support network and therefore are prone to suffering mental breakdown very easily with such physical conditions. This would however appear as an unavoidable eventuality because the older population is known to almost invariably suffer from pre-existing conditions such as heart disease, cognitive impairment, respiratory disorders, type II diabetes, and dyslipidemia amongst others.

Having recently suffered adverse life events
Adverse life events include the loss of significant people in the life of a person. This could be a partner of many decades, a child, a caregiver or any other significant other. The loss of this kind of person to an elderly person without enough psychosocial support may trigger the symptoms of GAD. For this reason, it is important that a n elderly person who loses a significant person in their lives is not left alone but counselled and given company (Corey, 2017). This will help them cope and keep GAD symptoms from developing. Major Depressive Disorder Insomnia Essay

Being female
It has been determined that being female is also a major predictor for the development of GAD. This is definitely linked to constitutional make-up that differentiates the genders. Generally, females may have a lower threshold for anxiety and worry and this may play a part in the pathophysiology of GAD in females.

Suffering from chronic mental disorders
Lastly but not least, older people who are already suffering from other mental disorders have been found to be at a higher risk of developing GAD. These include a history of past GAD and depression amongst others.

Question 3

Major depressive disorder (MDD) may sometimes manifest with psychosis and be referred to as psychotic major depression. It has a number of etiological factors. Of these, neurobiological causes feature prominently and four of these are (Sadock et al., 2015; Stahl, 2013): Major Depressive Disorder Insomnia Essay

Chemical derangement of neural circuits, neurobehavioral systems, and neuroregulatory mechanisms: In these systems, the principal agents of communication are chemicals known as neurotransmitters. In this case, the monoamine neurotransmitters serotonin, dopamine, and norepinephrine (Sadock et al., 2015) are known to play a role.
Heredity: These are inherited characteristics that predispose the carrier to GAD. The condition develops when the environmental triggers are present, such as bereavement.
Specific biomarker carriage: Biomarkers are signs that can be assessed and be determined to predispose to GAD.
Epigenetics: Alterations of the structure of genes by external biologic influences without mutation may also be predictor of GAD.Major Depressive Disorder Insomnia Essay
Question 4

The DSM-5 specifies that symptoms of MDD must have lasted for at least two weeks for the diagnosis to be made (APA, 2013). Five of the symptoms required for this to be true are:

Loss of weight: This has to be significant and noticeable. Objectively, people should see that the client has lost weight.
Insomnia: The client must be having a disturbance of sleep almost always.
Depressed mood: There must be depressed mood expressed as sadness most of the day for almost every day.
Inappropriate guilt and feelings of worthlessness: There will also be inappropriate guild that cannot be explained and they will feel worthless.
Loss of energy: They feel fatigued and devoid of energy to do anything.
Question 5

Insomnia is a disturbance in sleep patterns causing loss of sleep (Levenson et al., 2015). According to Morgenthaler et al. (2007), three classes of drugs that may cause insomnia are:

Amphetamines (e.g. methamphetamine)
Atypical antidepressants (e.g. escitalopram, sertraline, or fluoxetine)
Psychostimulants (e.g. modafinil).Major Depressive Disorder Insomnia Essay
References

American Psychological Association APA. Diagnostic and Statistical Manual of Mental Disorders (DSM-5), 5th ed. Author.

Corey, G. (2017). Theory and practice of counselling and psychotherapy, 10th ed. Cengage Learning.

DeVido, J.J., & Weiss, R.D. (2012). Treatment of the depressed alcoholic patient. Current Psychiatry Reports, 14(6), 610-618. http://dx.doi.org/10.1007/s11920-012-0314-7

Levenson, J.C., Kay, D.B., Buysse, D.J. (2015). The pathophysiology of insomnia. Chest, 147(4), 1179-1192. https://doi.org/10.1378/chest.14-1617

Morgenthaler, T.I., Kapur, V.K., Brown, T.M., Swick, T.J., Alessi, C., Aurora, R.N., Boehlecke, B., Chesson Jr., A., Friedman, L., Maganti, R., Owens, J., Pancer, J., Zak, R., and AASM (2007). Practice parameters for the treatment of narcolepsy and other hypersomnias of central origin: An American Academy of Sleep Medicine report. SLEEP, 30(12), 1705-1711. https://j2vjt3dnbra3ps7ll1clb4q2-wpengine.netdna-ssl.com/wp-content/uploads/2017/07/PP_Narcolepsy.pdf

Sadock, B.J., Sadock, V.A., & Ruiz, P. (2015). Synopsis of psychiatry: Behavioral sciences clinical psychiatry, 11th ed. Wolters Kluwer.Major Depressive Disorder Insomnia Essay

Stahl, S.M. (2017). Stahl’s essential psychopharmacology: Prescriber’s guide, 6th ed. Cambridge University Press.

Stahl, S.M. (2013). Stahl’s essential Psychopharmacology: Neuroscientific basis and practical application, 4th ed. Cambridge University Press.

Zhang, X., Norton, J., Carrière, I., Ritchie, K., Chaudieu, I., & Ancelin, M-L. (2015). Risk factors for late-onset generalized anxiety disorder: Results from a 12-year prospective cohort (The ESPRIT study). Translational Psychiatry, 5(e536), 1-8. http://dx.doi.org/10.1038/tp.2015.31 Major Depressive Disorder Insomnia Essay