May 30, | nursing, med, NURS, Paper
Discussion: Does Psychotherapy Have a Biological Basis?
Discussion: Does Psychotherapy Have a Biological Basis?
Many studies have found that psychotherapy is as effective as psychopharmacology in terms of influencing changes in behaviors, symptoms of anxiety, and changes in mental state. Changes influenced by psychopharmacology can be explained by the biological basis of treatments. But how does psychotherapy achieve these changes? Does psychotherapy share common neuronal pathways with psychopharmacology? For this Discussion, consider whether psychotherapy also has a biological basis. Discussion: Does Psychotherapy Have a Biological Basis?.
Learning Objectives
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Students will:
Evaluate biological basis of psychotherapy treatments
Analyze influences of culture, religion, and socioeconomics on personal perspectives of psychotherapy treatments
To prepare:
Review this week’s Learning Resources.
Reflect on foundational concepts of psychotherapy. Discussion: Does Psychotherapy Have a Biological Basis?
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 Submit, you cannot delete or edit your own posts, and cannot post anonymously. Please check your post carefully before clicking Submit!
By Day 3
Post an explanation of whether psychotherapy has a biological basis. Explain how culture, religion, and socioeconomics might influence one’s perspective of the value of psychotherapy treatments. Support your rationale with evidence-based literature.
Read a selection of your colleagues’ responses.
By Day 6
Respond to at least two of your colleagues by providing an additional scholarly resource that supports or challenges their position along with a brief explanation of the resource.
Submission and Grading Information
Grading Criteria
To access your rubric:
Week 1 Discussion Rubric
Post by Day 3 and Respond by Day 6
Discussion: Does Psychotherapy Have a Biological Basis?
Biological Basis of Psychotherapy
Psychotherapy has a biological basis. This is because psychotherapy deals with the brain according to the brain’s development, maturation as well as how the brain operates. According to Tyron (2016), psychotherapy follows ideologies of evolutionary adaptation and therefore targets the brain’s problematical adaptations and repairs them in the same way the problems developed. This means that psychotherapy disengages and repairs the maladaptive brain adaptations and substitutes them with new and positive pathways (Lebowitz & Ahn, 2014).
Basically, the brain is biological and it maps experiences and memories using neurons within the brain. As people adapt to the environment, the brain records the emotional experiences using the cortical memory. These experiences can be positive or negative ones. The negative experiences have defective mappings that produce psychiatric symptoms and therefore psychotherapy disengages such defective mappings and replaces them with maladaptive new mappings within the brain (Lebowitz & Ahn, 2014) Discussion: Does Psychotherapy Have a Biological Basis?.
Evidence from brain imaging studies indicates that psychotherapies such as cognitive behavioral therapy (CBT) generate biological changes within the brain. For example, a study conducted using a brain-scanning technique known as positron emission tomography (PET) showed that treatment of patients with obsessive-compulsive disorder (OCD) using CBT reduced the rate of glucose metabolism levels and therefore improved the OCD symptoms. Such a study indicates that a psychotherapy treatment like the CBT is a biological treatment just like pharmacological treatments since CBT effects objective and measurable changes within the brain and does not have any side effects (Tyron, 2016) Discussion: Does Psychotherapy Have a Biological Basis?.
Similarly, Amano & Toichi (2016) conducted a study using a psychotherapy technique known as eye movement desensitization and reprocessing (EMDR) to treat post-traumatic stress disorder (PTSD). The oxygenated Hb concentration which is used to indicate activation of the brain was measured after the psychotherapy treatment was done for the patients with PTSD. The findings indicated that the EMDR psychotherapy technique resulted in changes within the superior temporal sulcus (STS) as well as the orbitofrontal cortex (OFC) indicating a vital neural mechanism of the EMDR psychotherapy treatment. Discussion: Does Psychotherapy Have a Biological Basis? These results further indicate psychotherapy treatments involve brain areas associated with memory and emotions, for instance, the amygdala (Amano & Toichi, 2016).
Culture, Religion, and Socioeconomics Impact on an Individual’s Perspective of the Value of Psychotherapy Treatments
Cultural beliefs may influence people’s perspective regarding the significance of psychotherapy treatments. Cultural beliefs influence the perception of psychotherapy as well as care seeking behavior (Wegner & Rhoda, 2015). For example, in some cultures, seeking psychotherapy treatment for mental health illnesses are associated with stigmatization and shame and hence this may hinder people from seeking psychotherapy treatments. Cultural misconceptions regarding psychotherapy also influence people’s perspective on psychotherapy where for example an individual may believe that mental illness is a curse and a punishment and hence can only be healed through divine interventions and not treatments such as psychotherapy (Wegner & Rhoda, 2015).
On the other hand, religious beliefs may influence an individual to seek divine healing and prayers to cure mental health problems rather than seeking psychotherapy treatments Discussion: Does Psychotherapy Have a Biological Basis?. For instance, Christians, Muslims, and Hindus believe that God through his miraculous ways can heal and therefore may tend to use religion as a coping mechanism to deal with trauma and sadness that comes with mental health issues (Goncalves et al, 2015).
Lastly, socio-economic status plays a significant role regarding people’s perspective on psychotherapy. Evidence indicates that a majority of people from low socio-economic status have a low tendency of seeking psychotherapy treatments when compared to individuals from higher socio-economic status. This can be associated with the cost of issues or a lack of knowledge regarding the importance and efficacy of the psychotherapy treatments (Sripada et al, 2015). Discussion: Does Psychotherapy Have a Biological Basis?.
References
Amano T & Toichi M. (2016). Possible neural mechanisms of psychotherapy for trauma-related symptoms: cerebral responses to the neuropsychological treatment of post-traumatic stress disorder model individuals. Scientific Reports. 6(34610.
Daniels C & Marilyn F. (2014). Integrating Spirituality into Counselling and Psychotherapy: Theoretical and Clinical Perspectives. Canadian Journal of Counseling and Psychotherapy. 47(3), 315–341.
Goncalves J, Luchetti G, Menezes P & Vallada H. (2015). Religious and spiritual interventions in mental health care: a systematic review and meta-analysis of randomized controlled clinical trials. Psychol Med. 45(14): 2937–2949. Discussion: Does Psychotherapy Have a Biological Basis?.
Lebowitz M & Ahn W. (2014). Effects of biological explanations for mental disorders on clinicians’ empathy. Proc Natl Acad Sci U S A. 111(50), 17786–17790.
Sripada R, Richards S, Sheila R, Walters H, Bohnert K, Gorman L, Kees M & Blow A. (2015). Socioeconomic Status and Mental Health Service Use Among National Guard Soldiers. Psychiatric Services. 1(66), 992-995;
Tyron W. (2016). Psychotherapy Integration via Theoretical Unification. International Journal of Integrative Psychotherapy. 7(1),1-26.
Wegner, L. & Rhoda, A. (2015). The influence of cultural beliefs on the utilization of rehabilitation services in a rural South African context: Therapists’ perspective. African Journal of Disability. 4(1), 128-136 Discussion: Does Psychotherapy Have a Biological Basis?.
May 30, | nursing, med, NURS, Paper
NURS 6630 – Psychopharmacologic Approaches to Treatment of Psychopathology Discussions and Assignments
NURS 6630 – Psychopharmacologic Approaches to Treatment of Psychopathology Discussions and Assignments
Case Study: An Elderly Iranian Man with Alzheimer’s Disease
Introduction
The client, Mr. Akkad is a 76 year old Iranian. Mr. Akkad’s diagnosis is major neurocognitive disorder due to Alzheimer’s disease (presumptive). For the MMSE, the client scores 18 out of 30 which indicate moderate dementia. The purpose of this paper is to present three decisions regarding the client’s medications. The paper will also discuss factors that might impact the client’s pharmacokinetic and pharmacodynamic processes. Finally, ethical considerations might impact treatment plan and communication with clients will be taken into account. NURS 6630 – Psychopharmacologic Approaches to Treatment of Psychopathology Discussions and Assignments.
Decision Point 1
The first decision is that the client start taking Exelon (rivastigmine) 1.5 mg orally BID with an increase to 3 mg orally BID in 2 weeks.
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Rationale of selecting the Decision
This decision was selected because evidence supports effectiveness of Exelon (rivastigmine) for treatment of Alzheimer’s disease and dementia as well (Su et al, 2015). Pathological changes present in Dementia of the Alzheimer type involve cholinergic neuronal pathways. Therefore, exelon (rivastigmine) exercises its therapeutic effect by improving cholinergic function (Kandiah et al, 2017). The medication stops breakdown of acetylcholine and hence improves synaptic transmissions in the brain, which are related to memory and other cognitive functions. The client has Alzheimer’s and hence has low levels of the acetylcholine chemical within the brain. In addition, the client has moderate dementia. FDA guidelines and evidence recommend first dosage to be 1.5 mg BID and if the patient tolerates the dose after treatment of at least 2 weeks, it is appropriate to increase the dosage to 3 mg BID (Birks et al, 2015).
Expected Outcome
With this decision, it was hoped that the client will the client’s cognitive performance would improve. It was also hoped that the client’s behavior, functioning, and he would be able to carry out some activities of daily living. This is because Exelon (rivastigmine) has been shown to be effective in improving symptoms associated with Alzheimer’s disease (Birks et al, 2015). NURS 6630 – Psychopharmacologic Approaches to Treatment of Psychopathology Discussions and Assignments
Differences with the Decision Outcome
However, the client’s condition did not improve as indicated by the son’s report and his MMSE, score of 18 out of 30 with major deficits in orientation, attention and memory. The difference with what was hoped to be achieved and the results of the selected decision can be attributed to the low dosage administered to the patient because higher doses of Exelon have been shown to be more effective (Farlow et al, 2013). For the MMSE, absence of change is not a source of concern because MMSE should be evaluated after months, and not weeks.
Decision Point 2
The second decision is to increase rivastigmine dosage to 4.5 mg orally BID.
Rationale of selecting the Decision
The rationale behind this decision is that evidence shows that higher-dose of Exelon is more effective for individuals with Alzheimer’s disease (Farlow et al, 2013 & Stahl, 2008). Rivastigmine indicates dose-dependent efficacy on cognitive functions, activities of daily living, as well as global functioning and hence it was hoped higher dose would be more effective (Su et al, 2015).
Expected Outcome
With this decision, it was hoped that that the client’s cognitive performance would improve and that the increased dosage would have minimal side effects on the client. As aforementioned, higher dosage of Rivastigmine has been associated improved cognitive function as well as better ability to carry out activities of daily living (Birks et al, 2016). Some of side effects of Rivastigmine encompass nausea, diarrhea, vomiting, constipation, abdominal pain, lack of appetite, as well as reduced weight (Mahoney et al, 2014).
Differences with the Decision Outcome
The result of the selected decision is that there was slight improvement as indicated by the client attending religious service with the family. This indicates that the increased medication dosage is improving patient’s symptoms. The client is also tolerating the medication well. There is no statistical difference with the projected results and the actual results of the decision.
Decision Point 3
The third decision is to increase Rivastigmine dosage to 6 mg orally BID.
Rationale of selecting the Decision
The rationale for this decision is that an increased dose of Rivastigmine would increase the concentration of acetylcholine (ACh) for synaptic transmission and hence increase the efficacy of the medication (Sadowsky et al, 2015).
Expected Outcome
The expected result for this decision was that the client’s cognitive performance would improve and that he would be able to better carry out activities of daily living. It was also hoped that the increased dosage would have minimal side effects on the client. A study conducted by Su et al (2015) indicated improved cognitive function and well as improved capability to carry out activities of daily living when the dose of Rivastigmine among individuals having Alzheimer’s Disease.
Differences with the Decision Outcome
There were no notable differences with the expected results and the decision outcome. The client did not report any side effects and also took part in religious services indicating improvement of some of symptoms. Therefore, it is important for the PMHNP to counsel the son of the client regarding the mechanism action of cholinesterase inhibitors such as Rivastigmine. Rivastigmine cannot reverse the patient’s degenerative proves but can stabilize and improve symptoms, and this process is not sudden but gradual (Stahl, 2008).
Ethical Considerations
Ethical issues that might impact the treatment plan and communication with the client include informed consent and capacity determination. This is because clients with Alzheimer’s disease such as Mr. Akkad have cognitive impairments that can hinder their capacity to understand treatment options (Fields & Calvert, 2015).
Conclusion
The first decision was administration of Exelon (rivastigmine) 1.5 mg orally BID with an increase to 3 mg orally BID in 2 weeks. This decision was selected because rivastigmine has been demonstrated to be efficient in improving cognitive functioning for individuals with Alzheimer’s disease by improving cholinergic function. There was no improvement and hence the second decision and third decision were to increase the dose to 4.5 mg orally BID and 6 mg orally BID. Evidence shows that higher-dose of rivastigmine is more effective for individuals with Alzheimer’s Disease. With the increased dosage, there was improvement on the symptoms because the client was able to participate in important family activities such as religious activities. Finally, since the cognitive function is impaired, it is important to take ethical aspects such as informed consent and decision making capacity when developing client’s treatment plan.
References
Birks J, Chong L & Grimley J. (2015). Rivastigmine for Alzheimer’s disease. Cochrane Database of Systematic Reviews. 9(2).
Birks J, Chong L & Grimley J. (2016). Rivastigmine for Alzheimer’s disease. Cochrane Database of Systematic Reviews. Cochrane Dementia and Cognitive Improvement Group.
Farlow M, Grossberg G, Sadowsky C, Meng X & Somogyi M. (2013). A 24-Week, Randomized, Controlled Trial of Rivastigmine Patch 13.3 mg/24 h Versus 4.6 mg/24 h in Severe Alzheimer’s Dementia. CNS Neurosci Ther. 19(10): 745–752.
Fields L & Calvert J. (2015). Informed consent procedures with cognitively impaired patients: A review of ethics and best practices. Psychiatry and Clinical Neurosciences. 1(69): 462–471
Kandiah N, Pai M, Looi I, Ampil E, Park K, Karanam A & Christopher S. (2017). Rivastigmine: the advantages of dual inhibition of acetylcholinesterase and butyrylcholinesterase and its role in subcortical vascular dementia and Parkinson’s disease dementia. Clin Interv Aging. 1(12), pp: 697–707.
Mahoney J, Ari K, Verrico C, Arnoudse N, Shapiro B & Garza R. (2014). Preliminary findings of the effects of rivastigmine, an acetylcholinesterase inhibitor, on working memory in cocaine-dependent volunteers. Prog Neuropsychopharmacol Biol Psychiatry. 3(50): 137–142.
Sadowsky C, Micca J, Grossberg G & Velting D. (2014). Rivastigmine From Capsules to Patch: Therapeutic Advances in the Management of Alzheimer’s Disease and Parkinson’s Disease Dementia. Prim Care Companion CNS Disord. 16(5).
Stahl, S. M. (2008). Essential Psychopharmacology Online. Retrieved July 13, 2018 from
https://stahlonline.cambridge.org/prescribers_drug.jsf?page=9781316618134c111.html.therapeutics&name=Rivastigmine&title=Therapeutics
Su J, Liu Y, Liu Y & Ren L. (2015). Long-term effectiveness of rivastigmine patch or capsule for mild-to-severe Alzheimer’s disease: a meta-analysis. Expert Rev Neurother. 15(9):1093–1103.
Week 1 Discussion
Discussion: Foundational Neuroscience
Explain the agonist-to-antagonist spectrum of action of psychopharmacologic agents.
The spectrum of agonists to antagonists describes how substances, either occurring naturally (ligand) or synthetically such as psychopharmacologic agent, effect receptor sites (Stahl, 2008). The agonists are agents can increase an action on the receptor by mimicking a naturally occurring agent (Strange, 2008). An antagonist acts by blocking the receptor site to decrease the action of agents (Strange, 2008). Substances can also be partial agonists, which is an action that ranges between full agonist and full antagonist. Instead of increasing an action to the maximum level or blocking the action completely, it is an action that is somewhere in between the two levels (Strange, 2008). Many psychopharmacologic agents work by acting on G-protein-linked systems and ion-channel systems because these are triggered by neurotransmitters (Stahl, 2008).
Compare and contrast the actions of g couple proteins and ion gated channels.
G protein-coupled and ion-gated channels are both triggered by neurotransmitters (Stahl, 2008). G protein-coupled receptors (GPCRs) have seven transmembrane alpha helices (Strange, 2008). G proteins have three subunits (alpha, beta, and gamma). Ion-gated channels can be activated by electrical signals and neurotransmitters (Stahl, 2008). Ion-gated channels change the flow of ions, causing an almost-immediate effect and GPCRs take longer to work because they may make changes to cellular function over time (Stahl, 2008).
Explain the role of epigenetics in pharmacologic action.
Epigenetics is the study of gene expression, or which genes are turn off or on (Stahl, 2008). Pharmacologic actions can turn genes on or off to gain a desired effect. Epigenetic regulation of brain functions is important in the etiology of psychiatric disorders (Boks, et al., 2012). Epigenetic mechanisms, such as DNA methylation and histone acetylation, are affected by many pharmaceuticals, including psychiatric drugs (Boks, et al., 2012).
Explain how this information may impact the way you prescribe medications to clients. Include a specific example of a situation or case with a client in which the psychiatric mental health nurse practitioner must be aware of the medication’s action.
Thorough knowledge of how medications work will allow the nurse practitioner to prescribe the best medication for the client. For example, knowing that many anxiolytics work on inotropic receptors and will work very quickly to calm a client in an acute situation rather than prescribing an antidepressant that works on GPCRs and will take much longer to help with an acute episode.
As a psychiatric mental health nurse practitioner, it is essential for you to have a strong background in foundational neuroscience. In order to diagnose and treat clients, you must not only understand the pathophysiology of psychiatric disorders, but also how medications for these disorders impact the central nervous system. These concepts of foundational neuroscience can be challenging to understand. Therefore, this Discussion is designed to encourage you to think through these concepts, develop a rationale for your thinking, and deepen your understanding by interacting with your colleagues.
NURS 6630 – Psychopharmacologic Approaches to Treatment of Psychopathology Essay Assignment Week 1 Discussion: Foundational Neuroscience.
Required Readings
Note: All Stahl resources can be accessed through the Walden Library using this link. This link will take you to a log-in page for the Walden Library. Once you log into the library, the Stahl website will appear.
Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (4th ed.). New York, NY: Cambridge University Press *Preface, pp. ix–x
Note: To access the following chapters, click on the Essential Psychopharmacology, 4th ed tab on the Stahl Online website and select the appropriate chapter. Be sure to read all sections on the left navigation bar for each chapter.
Chapter 1, “Chemical Neurotransmission”
Chapter 2, “Transporters, Receptors, and Enzymes as Targets of Psychopharmacologic Drug Action”
Chapter 3, “Ion Channels as Targets of Psychopharmacologic Drug Action”
Document: Midterm Exam Study Guide (PDF)
Document: Final Exam Study Guide (PDF)
Required Media
Laureate Education (Producer). (2016i). Introduction to psychopharmacology [Video file]. Baltimore, MD: Author.
NURS 6630 – Psychopharmacologic Approaches to Treatment of Psychopathology Essay Week 1 Discussion: Foundational Neuroscience
Note: The approximate length of this media piece is 3 minutes.
Accessible player
Discussion: Foundational Neuroscience Optional Resources
Laureate Education (Producer). (2009). Pathopharmacology: Disorders of the nervous system: Exploring the human brain [Video file].
Essay Assignment NURS 6630 – Psychopharmacologic Approaches to Treatment of Psychopathology
Baltimore, MD: Author.NURS 6630 – Psychopharmacologic Approaches to Treatment of Psychopathology Essay Assignment
Note: The approximate length of this media piece is 15 minutes.
Dr. Myslinski reviews the structure and function of the human brain. Using human brains, he examines and illustrates the development of the brain and areas impacted by disorders associated with the brain.
Discussion: Foundational Neuroscience Accessible player
Laureate Education (Producer). (2012). Introduction to advanced pharmacology [Video file]. Baltimore, MD: Author.NURS 6630 – Psychopharmacologic Approaches to Treatment of Psychopathology Essay Assignment
Note: The approximate length of this media piece is 8 minutes.
In this media presentation, Dr. Terry Buttaro, associate professor of practice at Simmons School of Nursing and Health Sciences, discusses the importance of pharmacology for the advanced practice nurse.
Accessible player
To prepare for this Discussion:
Review this week’s Learning Resources.
Reflect on concepts of foundational neuroscience.
Assignment: Assessing and Treating Clients With Dementia
The Alzheimer’s Association defines dementia as “a general term for a decline in mental ability severe enough to interfere with daily life” (Alzheimer’s Association, 2016). This term encompasses dozens of cognitive disorders of impaired memory formation, recall, and communication. The care and treatment of clients with dementia is dependent on multiple factors, including the stage of dementia, comorbidities, family support, and even the care setting. In your role, as the psychiatric mental health nurse practitioner, you must be prepared to not only treat clients with these various cognitive disorders, but also the multiple behavioral issues that often accompany them. For this Assignment, as you examine the client case study in this week’s Learning Resources, consider how you might assess and treat clients presenting with dementia.
Reference: Alzheimer’s Association. (2016). What is dementia? Retrieved from http://www.alz.org/what-is-dementia.asp
To prepare for this Assignment:
· Review this week’s Learning Resources. Consider how to assess and treat clients requiring therapy for dementia.
The Assignment
Examine Case Study: An Elderly Iranian Man With Alzheimer’s Disease. You will be asked to make three decisions concerning the medication to prescribe to this client. Be sure to consider factors that might impact the client’s pharmacokinetic and pharmacodynamic processes. At each decision point stop to complete the following:
Introduction regarding disease state
High-level summary of patient case
Purpose of the essay statement
Decision #1
What options were listed?
Which decision did you select?
Why did you select this decision? Support your response with evidence and references to the Learning Resources.
Why didn’t you select the other two options?
What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
Explain any difference between what you expected to achieve with Decision #1 and the results of the decision. Why were they different?
Decision #2
What options were listed?
What option did you choose?
Why did you select this decision? Support your response with evidence and references to the Learning Resources.
Why didn’t you select the other two options?
What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
Explain any difference between what you expected to achieve with Decision #2 and the results of the decision. Why were they different?
Decision #3
What options were listed?
What option did you choose?
Why did you select this decision? Support your response with evidence and references to the Learning Resources.
Why didn’t you select the other two options?
What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
Explain any difference between what you expected to achieve with Decision #3 and the results of the decision. Why were they different?
Also include how ethical considerations might impact your treatment plan and communication with clients.
Note : Support your rationale with a minimum of three academic resources. While you may use the course text to support your rationale, it will not count toward the resource requirement.
Note: To access this week’s required library resources, please click on the link to the Course Readings List, found in the Course Materials section of your Syllabus.
References
Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (4th ed.). New York, NY: Cambridge University Press.
To access the following chapter, click on the Essential Psychopharmacology, 4th ed tab on the Stahl Online website and select the appropriate chapter. Be sure to read all sections on the left navigation bar for each chapter.
· Chapter 13, “Dementia and Its Treatment”
Stahl, S. M. (2014b). The prescriber’s guide (5th ed.). New York, NY: Cambridge University Press.
To access information on the following medications, click on The Prescriber’s Guide, 5th ed tab on the Stahl Online website and select the appropriate medication.
Review the following medications:
For insomnia
· donepezil
· galantamine
· memantine
· rivastigmine
Bui, Q. (2012). Antidepressants for agitation and psychosis in patients with dementia. American Family Physician, 85(1), 20–22. Retrieved from http://www.aafp.org/journals/afp.html
Note: Retrieved from from the Walden Library databases.
Meltzer, H. Y., Mills, R., Revell, S., Williams, H., Johnson, A., Bahr, D., & Friedman, J. H. (2010). Pimavanserin, a serotonin receptor inverse agonist for the treatment of Parkinson’s disease psychosis. Neuropsychopharmacology, 35, 881–891. Retrieved from http://www.nature.com/npp/journal/v35/n4/pdf/npp2009176a.pdf
Required Media
Laureate Education. (2016h). Case study: An elderly Iranian man with Alzheimer’s disease [Interactive media file]. Baltimore, MD: Author.
BACKGROUND
Mr. Akkad is a 76 year old Iranian male who is brought to your office by his eldest son for “strange behavior.” Mr. Akkad was seen by his family physician who ruled out any organic basis for Mr. Akkad’s behavior. All laboratory and diagnostic imaging tests (including CT-scan of the head) were normal.
According to his son, he has been demonstrating some strange thoughts and behaviors for the past two years, but things seem to be getting worse. Per the client’s son, the family noticed that Mr. Akkad’s personality began to change a few years ago. He began to lose interest in religious activities with the family and became more “critical” of everyone. They also noticed that things he used to take seriously had become a source of “amusement” and “ridicule.”
Over the course of the past two years, the family has noticed that Mr. Akkad has been forgetting things. His son also reports that sometimes he has difficult “finding the right words” in a conversation and then will shift to an entirely different line of conversation.
SUBJECTIVE
During the clinical interview, Mr. Akkad is pleasant, cooperative and seems to enjoy speaking with you. You notice some confabulation during various aspects of memory testing, so the PMHNP performs a Mini-Mental State Exam. Mr. Akkad scores 18 out of 30 with primary deficits in orientation, registration, attention & calculation, and recall. The score suggests moderate dementia.
MENTAL STATUS EXAM
Mr. Akkad is 76 year old Iranian male who is cooperative with today’s clinical interview. His eye contact is poor. Speech is clear, coherent, but tangential at times. He makes no unusual motor movements and demonstrates no tic. Self-reported mood is euthymic. Affect however is restricted. He denies visual or auditory hallucinations. No delusional or paranoid thought processes noted. He is alert and oriented to person, partially oriented to place, but is disoriented to time and event [he reports that he thought he was coming to lunch but “wound up here”- referring to your office, at which point he begins to laugh]. Insight and judgment are impaired. Impulse control is also impaired as evidenced by Mr. Akkad’s standing up during the clinical interview and walking towards the door. When the PMHNP asked where he was going, he stated that he did not know. Mr. Akkad denies suicidal or homicidal ideation.
Diagnosis: Major neurocognitive disorder due to Alzheimer’s disease (presumptive)
RESOURCES
§ Folstein, M. F., Folstein, S. E., & McHugh, P. R. (2002). Mini-Mental State Examination (MMSE). Lutz, FL: Psychological Assessment Resources.
Decision Point One
Select what the PMHNP should do:
https://mym.cdn.laureate-media.com/2dett4d/Walden/NURS/6630/10/mm/alzheimers_disease/img/pill-red.pngBegin Exelon (rivastigmine) 1.5 mg orally BID with an increase to 3 mg orally BID in 2 weeks
https://mym.cdn.laureate-media.com/2dett4d/Walden/NURS/6630/10/mm/alzheimers_disease/img/pill-blue.png Begin Aricept (donepezil) 5 mg orally at BEDTIME
https://mym.cdn.laureate-media.com/2dett4d/Walden/NURS/6630/10/mm/alzheimers_disease/img/pill-yellow.pngBegin Razadyne (galantamine) 4 mg orally BID
Decision Point One
https://mym.cdn.laureate-media.com/2dett4d/Walden/NURS/6630/10/mm/alzheimers_disease/img/pill-blue.pngBegin Aricept (donepezil) 5 mg orally at BEDTIME
RESULTS OF DECISION POINT ONE
· Client returns to clinic in four weeks
· The client is accompanied by his son who reports that his father is “no better” from this medication
· He reports that his father is still disinterested in attending religious services/activities, and continues to exhibit disinhibited behaviors
· You continue to note confabulation and decide to administer the MMSE again. Mr. Akkad again scores 18 out of 30 with primary deficits in orientation, registration, attention & calculation, and recall
Decision Point Two
Select what the PMHNP should do next:
https://mym.cdn.laureate-media.com/2dett4d/Walden/NURS/6630/10/mm/alzheimers_disease/img/pill-red.pngIncrease Aricept to 10 mg orally at BEDTIME
https://mym.cdn.laureate-media.com/2dett4d/Walden/NURS/6630/10/mm/alzheimers_disease/img/pill-blue.pngDiscontinue Aricept and begin Razadyne (galantamine) extended release 24 mg orally daily
https://mym.cdn.laureate-media.com/2dett4d/Walden/NURS/6630/10/mm/alzheimers_disease/img/pill-yellow.pngDiscontinue Aricept and begin Namenda (memantine) extended release, 28 mg orally daily
Decision Point Two https://mym.cdn.laureate-media.com/2dett4d/Walden/NURS/6630/10/mm/alzheimers_disease/img/pill-red.pngIncrease Aricept to 10 mg orally at BEDTIME
RESULTS OF DECISION POINT TWO
· Client returns to clinic in four weeks
· Client’s son reports that the client is tolerating the medication well, but is still concerned that his father is no better
· He states that his father is attending religious services with the family, which the son and the rest of the family is happy about. He reports that his father is still easily amused by things he once found serious
Decision Point Three
Select what the PMHNP should do next:
https://mym.cdn.laureate-media.com/2dett4d/Walden/NURS/6630/10/mm/alzheimers_disease/img/pill-red.pngContinue Aricept 10 mg orally at BEDTIME
https://mym.cdn.laureate-media.com/2dett4d/Walden/NURS/6630/10/mm/alzheimers_disease/img/pill-blue.pngIncrease Aricept to 15 mg orally at BEDTIME x 6 weeks, then increase to 20 mg orally at BEDTIME
https://mym.cdn.laureate-media.com/2dett4d/Walden/NURS/6630/10/mm/alzheimers_disease/img/pill-yellow.pngDiscontinue Aricept and begin Namenda 5 mg orally daily
Decision Point Three
https://mym.cdn.laureate-media.com/2dett4d/Walden/NURS/6630/10/mm/alzheimers_disease/img/pill-red.pngContinue Aricept 10 mg orally at BEDTIME
Guidance to Student
At this point, it would be prudent for the PMHNP to continue Aricept at 10 mg orally at bedtime. Recall that this medication can take several months before stabilization of deterioration is noted. At this point, the client is attending religious services with the family, which has made the family happy. Disinhibition may improve in a few weeks, or it may not improve at all. This is a counseling point that the PMHNP should review with the son.
There is no evidence that Aricept given at doses greater than 10 mg per day has any therapeutic benefit. It can, however, cause side effects. Increasing to 15 and 20 mg per day would not be appropriate.
There is nothing in the clinical presentation to suggest that the Aricept should be discontinued. Whereas it may be appropriate to add Namenda to the current drug profile, there is no need to discontinue Aricept. In fact, NMDA receptor antagonist therapy is often used with cholinesterase inhibitors in combination therapy to treat Alzheimer’s disease. The key to using both medications is slow titration upward toward therapeutic doses to minimize negative side effects.
Finally, it is important to note that changes in the MMSE should be evaluated over the course of months, not weeks. The absence of change in the MMSE after 4 weeks of treatment should not be a source of concern.a
NURS 6630 Week 2 Assignment
Assessing and Treating Pediatric Clients With Mood Disorders
Therapy for Pediatric Clients With Mood Disorders
Case Study: An African American Child Suffering From Depression
Mood disorders can impact every facet of a child’s life, making the most basic activities difficult for clients and their families. This was the case for 13-year-old Kara, who was struggling at home and at school. For more than 8 years, Kara suffered from temper tantrums, impulsiveness, inappropriate behavior, difficulty in judgment, and sleep issues. As a psychiatric mental health nurse practitioner working with pediatric clients, you must be able to assess whether these symptoms are caused by psychological, social, or underlying growth and development issues. You must then be able recommend appropriate therapies.
This week, as you examine antidepressant therapies, you explore the assessment and treatment of pediatric clients with mood disorders. You also consider ethical and legal implications of these therapies.
Case Study: An African American Child Suffering From Depression
When pediatric clients present with mood disorders, the process of assessing, diagnosing, and treating them can be quite complex. Children not only present with different signs and symptoms than adult clients with the same disorders, but they also metabolize medications much differently. As a result, psychiatric mental health nurse practitioners must exercise caution when prescribing psychotropic medications to these clients. For this Assignment, as you examine the client case study in this week’s Learning Resources, consider how you might assess and treat pediatric clients presenting with mood disorders.NURS 6630 – Psychopharmacologic Approaches to Treatment of Psychopathology Essay Assignment
Note: This Case Study: An African American Child Suffering From Depression Assignment is the first of 10 assignments that are based on interactive client case studies. For these assignments, you will be required to make decisions about how to assess and treat clients. Each of your decisions will have a consequence. Some consequences will be insignificant, and others may be life altering. You are not expected to make the “right” decision every time; in fact, some scenarios may not have a “right” decision. You are, however, expected to learn from each decision you make and demonstrate the ability to weigh risks versus benefits to prescribe appropriate treatments for clients.
NURS 6630 – Psychopharmacologic Approaches to Treatment of Psychopathology Essay Assignment
Case Study: An African American Child Suffering From Depression Required Readings
Note: All Stahl resources can be accessed through the Walden Library using this link. This link will take you to a log-in page for the Walden Library. Once you log into the library, the Stahl website will appear.
Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (4th ed.). New York, NY: Cambridge University Press.
Note: To access the following chapters, click on the Essential Psychopharmacology, 4th ed tab on the Stahl Online website and select the appropriate chapter. Be sure to read all sections on the left navigation bar for each chapter.
Chapter 6, “Mood Disorders”
Chapter 7, “Antidepressants”
Stahl, S. M. (2014b). The prescriber’s guide (5th ed.). New York, NY: Cambridge University Press.
Note: To access the following medications, click on the The Prescriber’s Guide, 5th ed tab on the Stahl Online website and select the appropriate chapter. Be sure to read all sections on the left navigation bar for each chapter.
Review the following medications:
amitriptyline
bupropion
amitriptylinebupropioncitalopramclomipraminedesipraminedesvenlafaxinedoxepinduloxetineescitalopramfluoxetinefluvoxamineimipramineketamine
mirtazapine
nortriptyline
paroxetine
selegiline
sertraline
trazodone
venlafaxine
vilazodone
vortioxetine
citalopram
clomipramine
Case Study: An African American Child Suffering From Depression
Magellan Health, Inc. (2013). Appropriate use of psychotropic drugs in children and adolescents: A clinical monograph. Retrieved from http://www.magellanhealth.com/media/445492/magellan-psychotropicdrugs-0203141.pdf
Rao, U. (2013). Biomarkers in pediatric depression. Depression & Anxiety, 30(9), 787–791. doi:10.1002/da.22171
Note: Retrieved from Walden Library databases.
Vitiello, B. (2012). Principles in using psychotropic medication in children and adolescents. In J. M. Rey (Ed.), IACAPAP e-Textbook of Child and Adolescent Mental Health. Geneva: International Association for Child and Adolescent Psychiatry and Allied Professions. Retrieved from http://iacapap.org/wp-content/uploads/A.7-PSYCHOPHARMACOLOGY-072012.pdf
Poznanski, E., & Mokros, H. (1996). Child Depression Rating Scale–Revised. Los Angeles, CA: Western Psychological Services.
Note: Retrieved from Walden Library databases.
Case Study: An African American Child Suffering From Depression Required Media
Laureate Education (2016e). Case study: An African American child suffering from depression [Interactive media file]. Baltimore, MD: Author.
Note: This case study will serve as the foundation for this week’s Assignment.
Case Study: An Afr
