Three Questions I might ask the client

  1. I would ask the client if he is currently depressed. This question will allow me to determine if there was a certain trigger for this depressive episode. The question will allow the client to share his thoughts about how he is viewing is current mental state.
  2. Are you often irritable with others, including coworkers due to the stress and demands of your career? How would you describe your mood at work? This question will help establish how he interacts with his coworkers.
  3. Have you in the past 3-4 weeks had any thoughts of suicide or causing harm to others around you? Clients that have major depressive disorder may have suicidal thoughts. The age of the client and having depressive episodes after each divorce also place the client at a higher risk (Taylor, 2015). The need for a suicide risk assessment is present.

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).

Differential Diagnosis

  1. Bipolar II Mixed – The client has depressive and manic symptoms currently. The depressive symptoms include depression episodes after each divorce, actively suicidal at one point, and overdosed on medications previously. According to Stahl (2013) manic episodes include irritable mood, decreased need for sleep, over talkativeness, euphoria, and hypomanic phases. I feel that the client mostly identifies with this diagnosis.
  2. Major Depressive Disorder – Depression is one of the most common mental health disorders. The client has different episodes of major depression reoccurring three times with each divorce. The client was diagnose at age 23 for the first time with depression and has had many episodes lasting a week or more.
  3. Borderline Personality Disorder – The client’s chief complaint was “unstable”. The client provided examples of emotional instability with the depressive episodes after each divorce. The client suffered “emotional trauma” as a child as a result of his mother and the emotional instability in his unsuccessful relationships. The client has difficulty returning to a stable baseline after emotionally triggered events (Stahl, 2013).

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.

Lesson Learned

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.

References

Blackburn, P., Wilkins-Ho, M., & Wiese, B. (2017). Depression in older adults: Diagnosis and management. BC Medical Journal, 59(3), 171-177. Retrieved from https://www.bcmj.org/articles/depression-older-adults-diagnosis-and-management

Pilhatsch, M., Marxen, M., Winter, C., Smolka, M., & Bauer, M. (2011). Hypothyroidism and mood disorders: Integrating novel insights from brain imaging techiniques. Thyroid Research, 4(S3). Retrieved from https://thyroidresearchjournal.biomedcentral.com/articles/10.1186/1756-6614-4-S1-S3

Stahl, S. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applicatons (4th ed.). New York, NY: Cambridge University Press.

Taylor, W. (2015). Should antidepressant medications be used in the elderly? Expert Review of Neurotherapeutics, 15(9), 91-93. doi: 10.1586/14737175.2015.107.0671

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