NR 566 Week 7 Assignment; Management of Psychiatric Conditions in Primary Care - Depression

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Mike Trout

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Nursing

Course

NR 566 Advanced Pharmacology for Care of the Family

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Chamberlain

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16

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Management of Psychiatric Conditions in primary care - Depression Management of Psychiatric Conditions in primary care - Depression Student Name NR 566 Dr. Vanessa Bass Depression Most common psychiatric disorder Affects approximately 15 million adults in the United States Principal symptoms include depressed mood and loss of pleasure or interest in all or nearly all of one’s usual activities and pastimes. Associated symptoms: insomnia; anorexia; and weight loss (sometimes hyperphagia and weight gain); mental slowness and loss of concentration; feelings of guilt, worthlessness, and helplessness; thoughts of suicide and death; and overt suicidal behavior. Symptoms must be present most of the day, nearly every day, for at least 2 weeks (Rosenthal & Burchum, 2021) Depression Pathogenesis Some situations may happen unexpectedly without apparent cause For many episodes are brought on by a stressful life event (i.e., bereavement, loss of a job, or childbirth) Contributing factors to vulnerability: genetic heritage, difficult childhood, and chronic low self-esteem Monoamine-deficiency hypothesis of depression- caused by a functional deficiency of monoamine neurotransmitters (Rosenthal & Burchum, 2021) Treatment Depression can be treated with three major modalities Pharmacotherapy Depression-specific psychotherapy Somatic therapy (electroconvulsive therapy or transcranial magnetic stimulation) Mild to moderate depression- drug therapy and psychotherapy equally effective Severe depression- Combination therapy (drug and psychotherapy) better than single intervention Electroconvulsive therapy is reserved for rapid response OR Medication Benefits are mainly seen in patients with severe depression Five major classes of drugs: SSRI, SNRI, TCA, MAOI and atypical antidepressants All medications are equally effective, differences are due to side effects and drug interactions Symptoms resolve slowly- initial response develop in 1 to 3 weeks. Maximum benefits may take up to 12 weeks Drug failure should not be considered until patient has been on medication for 1 month Selection based on tolerability and safety Treatment starts low and slow Patient scenario R.M. is a 64-year-old male who presents to the primary health the clinic for a sick visit due to the following complaints: Lack of energy Unintended weight loss Decreased appetite Lack of concentration Inability to enjoy his usual activities of respite which include golf and regular exercise classes, which he used to attend 4-5 times per week Scenario continued RM is a 64-year-old male who presents to the office after approximately 2-3 months of lack of interest in usual pleasurable activities, lack of energy, unintended weight loss and decreased appetite. He reports in the previous months he suffered the unexpected loss of his son who died suddenly in a car accident. Given the symptoms and the recent social history a diagnosis of Depression is given. Social: RM is divorced, lives alone in a single-family home that he has owned for many years. He works part-time at the golf course he plays at but has been taking time off since the accident. He previously worked in the medical field as a medical device sales representative for over 20 years. In addition to his son, he has 2 daughters that live out of state who he sees 3-4 times per year. Family: Mother- depression, HTN, DM, HLD Father- Smoker, HTN Brother- depression, anxiety, HTN Sister- Breast CA, Anxiety, depression, smoker, DM R.M. continued Back surgery 5 years old for Past Medical History: HTN, HLD, DM. herniated disc. Medications: Lisinopril 10mg once daily Simvastatin 20mg once daily Metformin 500mg twice daily Treatment plan: Given the patient’s recent social issues, family history, and symptoms R.M. is diagnosed with severe depression. He is given a prescription for 20mg of Fluoxetine ( 1 capsule by mouth daily) as well as a referral to a psychotherapist. R.M. is to scheduled to follow-up via a telehealth check-in call once a week for 1 month to assess for increased risk of suicidality. Patient educated that reduction of symptoms may take up to 12 weeks and adjustments will be made if there is no evidence of remittance of symptoms. Education for medication side effects provided. Rhode Island Rhode Island NPs have full practice authority Can prescribe psychotropic and certain legend medications Can initiate and plan a therapeutic regimen for a patient that includes ordering and prescribing pharmacologic and non- pharmacologic treatment Can apply for further licensure for the prescriptive authority of controlled substance medications in pursuance with RI State Laws (https://www.ncsbn.org/14746.htm ) Affordable Care Act Afforded those who were not insured or underinsured the ability to get Medicaid if income below 138% of poverty line State marketplaces were allowed to sell federally subsidized insurance Under insured rate declined by 5.4% among individuals with mental illness Uninsured rate declined 4.3% among those individuals with mental illness Treatment increased 2.1% in those suffering from mental health issues (Saloner, Bandara, Bachhuber, & Barry, 2017) Enrollment process for those suffering may hinder them from obtaining coverage due to burdensome process (Fry& Sommers, 2018) More support??? How do I know if my patient needs more support?? Patient is in a crisis situation Unable to provide the support that patient needs Expertise level of the physician Patient preference Suspicion of concurrent psychiatric illness Community Resources Legal and Ethical issues Large number of users access to healthcare record Professional standard differences among specialties Complete knowledge of disease process/ stigma Ability to prescribe and manage medication appropriately Follow-up Continuity of care Patient provider relationship What’s next? R.M. should follow up with provider If symptoms persist, consider- psychotherapy and medication adjustment Document thoroughly- treatment plan in the EMR References Abuhammad, S., & Dalky, H. (2019). Ethical implications of mental HEALTH STIGMA: Primary health care Providers’ perspectives. Global Journal of Health Science, 11(12), 165. https://doi.org/10.5539/gjhs.v11n12p165 Fry, C. E., & Sommers, B. D. (2018). Effect of Medicaid expansion on health insurance coverage and access to care among adults with depression. Psychiatric Services, 69(11), 1146–1152. https://doi.org/10.1176/appi.ps.201800181 Jego, M., Debaty, E., Ouirini, L., Carrier, H., & Beetlestone, E. (2018). Caring for patients with mental disorders in primary care: A qualitative study on French GPS’ views, atittudes and needs. Family Practice, 36(1), 72–76. https://doi.org/10.1093/fampra/cmy107 ncsbn.org. (n.d.). https://www.ncsbn.org/14746.htm. References continued https://provider.carefirst.com/carefirst-resources/provi der/pdf/depression-guidelines-bok0023.pdf Rosenthal, L. & Burchum, J. (2021). Lehne's pharmacotherapeutics for advanced practice nurses and physician assistants (2nd ed.). Elsevier. pp214-219. Saloner, B., Bandara, S., Bachhuber, M., & Barry, C. L. (2017). Insurance coverage and treatment use under the affordable care act among adults with mental and substance use disorders. Psychiatric Services, 68(6), 542–548. https://doi.org/10.1176/appi.ps.201600182

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