Psychopharmacologic Approaches to Treatment of Psychopathology

 Short Answer  

Short Answer Assignment

Assignment 1: Short Answer Assessment

As a psychiatric nurse practitioner, you will likely encounter patients who suffer from various mental health disorders. Not surprisingly, ensuring that your patients have the appropriate psychopharmacologic treatments will be essential for their overall health and well-being. The psychopharmacologic treatments you might recommend for patients may have potential impacts on other mental health conditions and, therefore, require additional consideration for positive patient outcomes. For this Assignment, you will review and apply your understanding of psychopharmacologic treatments for patients with multiple mental health disorders.

1. In 3 or 4 sentences, explain the appropriate drug therapy for a patient who presents with MDD and a history of alcohol abuse. Which drugs are contraindicated, if any, and why? Be specific. What is the timeframe that the patient should see resolution of symptoms?

2. List 4 predictors of late onset generalized anxiety disorder.

3. List 4 potential neurobiology causes of psychotic major depression.

4. An episode of major depression is defined as a period of time lasting at least 2 weeks. List at least 5 symptoms required for the episode to occur. Be specific.

5. List 3 classes of drugs, with a corresponding example for each class, that precipitate insomnia. Be specific. 

Question

Answered step-by-step

1. explain the appropriate drug therapy for a patient who presents with MDD and a history of alcohol abuse. Which drugs are contraindicated, if any, and why? Be specific. What is the timeframe that the patient should see resolution of symptoms?

2. List 4 predictors of late onset generalized anxiety disorder.
3. List 4 potential neurobiology causes of psychotic major depression.
4. An episode of major depression is defined as a period of time lasting at least 2 weeks. List at least 5 symptoms required for the episode to occur. Be specific.
5. List 3 classes of drugs, with a corresponding example for each class, that precipitate insomnia. Be specific. 

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Answer & Explanation

1) Explain the appropriate drug therapy for a patient who presents with MDD and a history of alcohol abuse. Which drugs are contraindicated, if any, and why? Be specific. What is the timeframe that the patient should see resolution of symptoms?

According to Devido & Weiss (2012) Substance use disorders (SUDs) and other psychiatric disorders can be frequently diagnosed at the same time. They also noted that when these two disorders occur at the same time together, the symptoms are commonly associated with worse clinical and functional outcomes than when they occur individually.

In their study, they concluded that pharmacological interventions and pharmacotherapies such as
antidepressants and serotonin reuptake inhibitors (SSRIs) such as fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), citalopram (Celexa) and escitalopram (Lexapro)
, which are both being considered as the first-line pharmacologic treatment, must also be complemented by abstinence from drinking, supportive care, and non-pharmacological interventions such as psychosocial therapies such as motivational enhancement therapies, cognitive therapies, and twelve-step facilitation may further improve treatment outcomes for patients with co-occurring depressive and alcohol use disorders. The antidepressants
nefazodone, desipramine, and imipramine
were found to have the most robust effects on decreasing depressive symptoms.

According to Schimelpfening (2020), the 10 Drugs that are considered to be contraindicated drugs for MDD patients are
Beta-blockers, Corticosteroids, Benzodiazepines, Parkinson’s drugs, Hormonal drugs, Stimulants, Anticonvulsants, Proton Pump Inhibitors (PPIs) and H2 Blockers, Statins and Other Cholesterol-Lowering Drugs, and Anticholinergic drugs
. These drugs are considered contraindicated drugs because these drugs can either cause depression or can worsen the symptoms of a patient with depression and substance use disorders. These drugs have direct or indirect effect on the patient’s central nervous system which is why these drugs are not recommended.

According to Harvard Medical School (2018), it usually takes
at least two to six weeks of taking any antidepressant to see improvement
. Additionally, they noted that a patient must need to take various trials in order to find the right medication that works fine for him or her.
Once the right medication is found, it may take up to a few months to find a proper dose and for the full positive effect to be seen
.

2) List 4 predictors of late onset generalized anxiety disorder

According to Zhang (2015) Generalized anxiety disorder (GAD) is characterized as a chronic and highly prevalent disorder which is commonly associated with the increased disability and mortality in the elderly. Their study noted that the treatment in this kind of disorder is “difficult with low rate of full remission” which indicates that the success rate of total treatment is too low which is why researchers and scientists worldwide are discussing and studying the 4 possible risk factors or predictors which cause this kind of disease. At the end of their study, they concluded that this disease is a multifactorial stress-related disorder which some factors are potentially modifiable through health care intervention.

The principal predictors of late-onset incident GAD over 12 years derived from a multivariate Cox model were being female, recent adverse life events, having chronic physical (respiratory disorders, arrhythmia and heart failure, dyslipidemia, cognitive impairment) and mental (depression, phobia and past GAD) health disorders. Poverty, parental loss or separation and low affective support during childhood, as well as history of mental problems in parents were also significantly and independently associated with incident GAD.

The following are the 4 most common predictors late onset generalized anxiety disorder that the study of Zhang et.al. have gathered:

·
Females
 are more prone than males

·
Having recent adverse life
 events such as accidents, suicide, or crime-related situations.

·
Having chronic physical diseases
 such as respiratory disorders, arrhythmia and heart failure, dyslipidemia, cognitive impairment

·
Having mental health disorders
 such as depression, phobia and past GAD.

3) List 4 potential neurobiology causes of psychotic major depression

Scientists correlate and conclude that the imbalances of certain brain chemicals or neurotransmitters specifically the dopamine, glutamate, and serotonin, are the most valuable cause for a person to develop psychotic major depression . Those three neurotransmitters have the responsibility to connect and allow the nerve cells to reach and communicate to one another and produce what is called a stimuli. So, if those neurotransmitters are altered, then the body’s normal processes to respond to a stimuli will also be damaged which is why one of the most common characteristic of a schizophrenic or psychotic patient is that he or she cannot normally respond to a stimuli and may be overwhelmed by different sensory information such as bright lights or loud music which normal people can easily handle. Their thought process to receive and to respond to an environmental stimuli is different from a normal person that is why they can misinterpret different sensory information like a sound, smell, sight, and taste and produce delusions and hallucinations.

The following are 4 potential neurobiology causes of psychotic major depression:

·
Alteration and imbalances of neurotransmitters in the brain
 specifically the dopamine, glutamate, and serotonin

· Depressed patients in the primary sample had 
decreased between-network functional connectivity in the default mode network (DMN) and bilateral insular, somatosensory/motor, and auditory cortices with the greatest peak of decreased connectivity within the right planum polare
 compared to healthy control subjects – This study means that there is a correlation between the decreased DMN which is associated functional connectivity and attenuated between-network connectivity to remission of psychotic depression

·
Monoamine neurotransmitters serotonin and norepinephrine hypothesis
 – this means that the depressed individuals are likely to have low levels of these neurotransmitters because various antidepressant drugs acutely increase their level (this is different from number 1 since this approach focuses more on the possibility of correlation of the drugs and medications used in psychotic major depression)

· Researchers and neurologists hypothesized that 
in the gene that codes for brain-derived neurotrophic factor, one polymorphism may moderate the interactive effect of the serotonin transporter polymorphism and psychosocial stress
 which results to psychotic major depression.

4) An episode of major depression is defined as a period of time lasting at least 2 weeks. List at least 5 symptoms required for the episode to occur. Be specific.

According to Mayo Clinic (2018), MDD or Major Depressive Disorder, commonly referred to as clinical depression, is a type of mood disorder which is characterized by persistent feeling of sadness and loss of interest. A person can be diagnosed with this disorder if the feelings and emotions of the patient are interfering into the patient’s physical functions like sleep and appetite. According to Kerr (2020), Major Depressive Disorder is considered as one of the most common mental health disorder in United States of America which supported by the data indicating that in 2017, almost 7% of U.S adults have already experienced a major depressive episode in their lives.

The following are the 5 common symptoms to diagnose a patient with major depressive disorder.

· Violence – the patient show angry outbursts, frequent irritability even on small and non-irritable matters, anxiety, agitation and restlessness.

· Extreme emotions – the patient isolate himself/herself because he/she feels extreme sadness, tearfulness, hopelessness and emptiness.

· Appetite problems – the patient may either have a reduced appetite and excessively lose weight OR the patient may have increased appetite and excessively gain weight.

· Sleep disturbances – insomnia and nightmares

· Apathy & Anhedonia – Apathy is when the patient lacks feeling, emotion, interest, or concern about the things in his/her environment. On the other hand, anhedonia is the feeling of loss of interest in activities that the patient used to enjoy such as sports, hobbies, and sex. These 2 are symptoms are being considered as 1 most of the time since they occur at the same time.

5) List 3 classes of drugs, with a corresponding example for each class, that precipitate insomnia. Be specific.

· Melatonin Receptor Agonists

Example:
Ramelteon (Rozerem)
– It is a melatonin receptor agonist which is beneficial for people experiencing sleep-onset insomnia and people with high risk of falls.

·  Dual Orexin Receptor Antagonists

Example: Suvorexant (Belsomra)
– It is a dual orexin receptor antagonist which antagonize or inhibit the orexin receptor. The job of an orexin receptor is to promote wakefulness in the body, so people with insomnia must regulate and control their orexin recpetors.

·  Benzodiazepines

Example: Lorazepam – It is a shorter-acting agent kind of benzodiazepines which regulates and treats insomnia, or sleep difficulty due to anxiety or stress.

Step-by-step explanation

Hello student!! 🙂 I made sure that I gathered information from these credible sources 🙂

1) Appropriate drug therapy for a patient who presents with MDD and a history of alcohol abuse

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

· Harvard Medical School. (2018). Major Depression. Retrieved from https://www.health.harvard.edu/a_to_z/major-depression-a-to-z

· Schimelpfening, N, (2020). 10 Drugs That Can Cause Depression. Retrieved from https://www.verywellmind.com/drugs-that-can-cause-depression-1067458

2) 4 predictors of late onset generalized anxiety disorder

· Zhang, X., Norton, J., Carriere, I., Chaudieu, I., & Ancelin, M. (2015). Risk factors for late-onset generalized anxiety disorder: results from a 12-year prospective cohort (The ESPRIT study). Retrieved from https://www.nature.com/articles/tp201531#:~:text=The%20principal%20predictors%20of%20late,phobia%20and%20past%20GAD)%20health

3) 4 potential neurobiology causes of psychotic major depression

· Croarkin P. E. (2018). Indexing the neurobiology of psychotic depression with resting state connectivity: Insights from the STOP-PD study. EBioMedicine, 37, 32-33. https://doi.org/10.1016/j.ebiom.2018.10.010

· aan het Rot, M., Mathew, S. J., & Charney, D. S. (2009). Neurobiological mechanisms in major depressive disorder. CMAJ : Canadian Medical Association journal = journal de l’Association medicale canadienne, 180(3), 305-313. https://doi.org/10.1503/cmaj.080697

4) Symptoms of MDD

· Mayo Clinic. (2018). Depression (major depressive disorder). Retrieved from https://www.mayoclinic.org/diseases-conditions/depression/symptoms-causes/syc-20356007

· Kerr, M. (2020). Major Depressive Disorder (Clinical Depression). Retrieved from https://www.healthline.com/health/clinical-depression

5) 3 class drugs and examples

· Anderson, U. (2016). 5 Drug Classes for Sleep Disorders. Retrieved from https://www.pharmacytimes.com/contributor/uri-anderson-pharmd-candidate-2016/2016/01/5-drug-classes-for-sleep-disorders

Learning Resources

Required Readings (click to expand/reduce)

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596

Fernandez-Mendoza, J., & Vgontzas, A. N. (2013). Insomnia and its impact on physical and mental health. Current Psychiatry Reports, 15(12), 418. https://doi.org/10.1007/s11920-012-0418-8

Levenson, J. C., Kay, D. B., & Buysse, D. J. (2015). The pathophysiology of insomnia. Chest, 147(4), 1179–1192. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4388122/

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

Morgenthaler, T. I., Owens, J., Alessi, C., Boehlecke, B, Brown, T. M., Coleman, J., Friedman, L., Kapur, V. K., Lee-Chiong, T., Pancer, J., & Swick, T. J. (2006). Practice parameters for behavioral treatment of bedtime problems and night wakings in infants and young children. SLEEP, 29(1), 1277–1281. https://j2vjt3dnbra3ps7ll1clb4q2-wpengine.netdna-ssl.com/wp-content/uploads/2017/07/PP_NightWakingsChildren

Sateia, M. J., Buysse, D. J., Krystal, A. D., Neubauer, D. N., & Heald, J. L. (2017). Clinical practice guideline for the pharmacologic treatment of chronic insomnia in adults: An American Academy of Sleep Medicine clinical practice guideline. Journal of Clinical Sleep Medicine, 13(2), 307–349. https://jcsm.aasm.org/doi/pdf/10.5664/jcsm.6470

Winkleman, J. W. (2015). Insomnia disorder. The New England Journal of Medicine, 373(15), 1437–1444. https://doi.org/10.1056/NEJMcp1412740

Medication Resources 

IBM Corporation. (2020). IBM Micromedex. https://www.micromedexsolutions.com/micromedex2/librarian/deeplinkaccess?source=deepLink&institution=SZMC%5ESZMC%5ET43537

Note: To access the following medications, use the IBM Micromedex resource. Type the name of each medication in the keyword search bar. Be sure to read all sections on the left navigation bar related to each medication’s result page, as this information will be helpful for your review in preparation for your Assignments.

· alprazolam · amitriptyline · amoxapine · amphetamine · desipramine · diazepam · doxepin · eszopiclone · flunitrazepam · flurazepam · hydroxyzine ·  imipramine · lemborexant · lorazepam · melatonin · methylphenedate · modafinil

· armodafinil · carnitine · clomipramine · clonazepam · nortriptyline · pitolisant · ramelteon · sodium oxybate · solriamfetol · SSRI’s · temazepam · trazodone · triazolam · trimipramine · wellbutrin · zaleplon · zolpidem