Everyone occasionally feels sad or blue. These feelings are, however, usually short-lived and pass within a couple of hours to days. Affective disorders, also called mood disorders, are health states or conditions that affect a person's emotional state (Townsend, 2014). Stahl (2013) ascertains that mood disorders interfere with someone's ability to perform normally. Examples of mood disorders include major depressive disorder, bipolar disease, cyclothymic disorder, depression induced by abuse of substances, or other medical conditions.
Globally, the population is aging at a rapid pace. Emotional well-being and mental health are so important in older age as at any other time of life. Depression is a common but serious illness. People across all ages, ethnicities, education levels, cultures, and socioeconomic groups are susceptible to depressive disorders. Depression is the most common mood disorder of old age (Hinkle & Cheever, 2018). Depression is most often less recognized and, therefore, undertreated. However, it is highly responsive to treatment. Some of the treatment modalities include pharmacotherapy, depression-focused psychotherapy, and somatic therapies.
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In this assignment, I will be reviewing the case of a Hispanic American man who presents with a Major Depressive Disorder (MDD). The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) provides the diagnostic criteria for MDD. MDD presents with psychotic, catatonic, seasonal, atypical, and melancholic features. I will be making three clinical decisions and critical analysis at each of the three decision points to the client in question.
Decision 1
The selected decision: start Zoloft 25mg orally
Zoloft (sertraline) is a selective serotonin reuptake inhibitor (SSRI) (Stahl, 2014). SSRIs selectively inhibit serotonin's reuptake by blocking serotonin transporters (serotonin pumps), thus boosting the effects of serotonin (5-HT). Serotonin is a neurotransmitter that transmits nerve impulses, perceptions of pain, and regulation of mood. Serotonin causes both inhibition and excitation of the central nervous system, depending on the receptors it activates. After transmitting information, 5-HT is quickly reabsorbed, ending its effects. What selective serotonin reuptake inhibitors do is block this reabsorption, thus prolonging the effects of the neurotransmitter in the synaptic cleft. This allows serotonin to send more information to the receiving neurons. The prolongation of the impact improves mood. For most patients, SSRIs provide optimal results in the management of MDD.
While settling for the decision to place the patient on Zoloft, I was hoping that the patients would experience an improvement in the symptoms. The patient had started to experience insomnia and difficulties in concentrating at work. The patient has also gained weight, which most probably is because of eating disorders; he may have developed as a defense mechanism, and at the same time, lost interest in most of the activities. These clinical presentations reduce the quality of life of a person. In addressing the patient’s problems, I was also hoping that the chosen drug would not create new issues in the form of side effects and adverse reactions.
When the client comes back to the clinic a month later, he reports a decline in his clinical symptoms, indicating that the drug has effectively attained the desired results. However, the patient is concerned over the onset of erectile dysfunction. This new finding was not anticipated, and it is attributable to the fact that sertraline has the potential side effect of causing erectile dysfunctions. A recent intervention should be put in place to address the arising problem.
Decision 2
At this point, the patient is showing considerable improvements in the depressive symptoms but presenting with erectile dysfunction. At this encounter, an augmenting agent such as Wellbutrin IR 150mg should be added.
There is a need to continue lowering the depressive symptoms and reduce the occurrence of erectile dysfunction. Since Zoloft has brought about the erectile dysfunction and has been partially effective in managing the depression symptoms, another drug should be added to augment the desirable effects of Zoloft. Wellbutrin is commonly used to augment the impacts of Zoloft. Wellbutrin (bupropion) is an antidepressant that decreases the uptake of the neurotransmitter dopamine (Adams, 2014). Dopamine is a monoamine neurotransmitter synthesized in the brain that transmits chemical messages between neurons. The effects of dopamine activity include feelings of happiness, liveliness, motivation, and alertness. Low levels of dopamine are related to sad moods and depression. Wellbutrin blocks the dopamine transporters (dopamine pumps) at neuronal synapses, prolonging dopamine's effects, causing an improvement in the mood of a person. Increasing the synaptic activity of dopamine provides a synergistic action in the mood elevation activity of the neurotransmitter's prolonged effects.
Dopamine activity provides not only improved effects on the mood but also the male process of erection. Wellbutrin will, therefore, help in the attainment of the desired goal of improving depressive symptoms and in treating erectile dysfunction that the client has a side effect of using Zoloft. Simonsen et al. (2016) reported that dopamine provides a crucial role in controlling sexual functions by acting on the hypothalamus and the spinal cord. The paraventricular nucleus, located in the hypothalamus, contains the oxytocinergic neurons, while the spinal cord holds the pre-erectile parasympathetic nucleus. Giuliano and Allard (2001) concluded that dopamine activity on the two nuclei enhances erectile impulses, thus treating erectile dysfunction. The desired outcomes in decision point two are to improve both the depressive and erectile dysfunction symptoms.
The client reports that the depressive symptoms have improved and that the erectile dysfunction has stopped. However, he reports occasional periods of nervousness and being filled with jitter. This presentation is because a combination of antidepressant medication may cause suicidal thoughts, mania, inner restlessness, and agitation. The unanticipated feelings are due to using the two antidepressants together.
Decision 3
The decision: Change Wellbutrin to XL 150mg daily.
The patient’s jittery feelings could be due to the fast release of Wellbutrin. Adjusting the dosage of Wellbutrin to an extended-release form may be useful and helpful in addressing the side effects. Since Zoloft and Wellbutrin's combination has shown to be effective in managing the patient, the combination should continue to be used. However, to address the feelings of anxiety the patient is experiencing, a dose modification should be tried out.
The expected outcome of this decision is that the patient’s depressive symptoms will continue to be managed with no side effects from using the preferred medication combination.
Ethical Considerations
Psychiatric nurses may be faced with several ethical issues in their management of patients with mental illnesses. Patients have the right to confidentiality and privacy. These two rights are considered absolute rights of patients and state that not unless patients consent for their information to be shared with other parties, such disclosure should not happen. Involving the patient’s family members in the care of the client may be useful and beneficial. However, the nurse cannot just do so without consulting with the client.
Another instance is where the nurse may want to discuss the patient’s progress and condition with other nurses or healthcare professionals to guide better care. The nurse is ethically restrained from engaging in such discussions regardless of whether a client would benefit from them.
A nurse should also treat patients as authentic human beings with dignity. They should provide full disclosure of information to their clients, respect their culture, display positive attitudes, maintain a non-judgmental environment, and ensure that all patients' rights are respected.
References
Adams, M. P. (2014). Pharmacology for Nurses: a Pathophysiologic Approach Fourth Edition . Pearson.
Giuliano, F., & Allard, J. (2001). Dopamine and male sexual function. European urology , 40 (6), 601–608. https://doi.org/10.1159/000049844
Halter, M. J. (2017). Varcarolis' Foundations of Psychiatric-Mental Health Nursing-E-Book: A Clinical Approach . Elsevier Health Sciences.
Hinkle, J. L., & Cheever, K. H. (2018). Brunner and Suddarth’s textbook of medical-surgical nursing . Wolters Kluwer India Pvt Ltd.
Simonsen, U., Comerma‐Steffensen, S., & Andersson, K. E. (2016). Modulation of dopaminergic pathways to treat erectile dysfunction. Basic & clinical pharmacology & toxicology , 119 , 63-74.
Stahl, S. M. (2013). Stahl ’s essential psychopharmacology: Neuroscientific basis and practical applications (4th ed.). New York, NY: Cambridge University Press.
Stahl, S. M. (2014b). The prescriber’s guide (5th ed.). New York, NY: Cambridge University Press.
Townsend, M. C. (2014). Psychiatric nursing: assessment, care plans, and medícations . FA Davis.
