30 Jul THERAPY FOR PATIENTS WITH SCHIZOPHRENIA
Order Instructions
Insomnia case – Discussion
For this Discussion, review the case below. Reflect on the case study excerpt and consider the therapy approaches you might take to assess, diagnose, and treat the patient’s health needs.
Case: An elderly widow who just lost her spouse.
Subjective: A patient presents to your primary care office today with chief complaint of insomnia. Patient is 75 YO with PMH of DM, HTN, and MDD. Her husband of 41 years passed away 10 months ago. Since then, she states her depression has gotten worse as well as her sleep habits. The patient has no previous history of depression prior to her husband’s death. She is awake, alert, and oriented x3. Patient normally sees PCP once or twice a year. Patient denies any suicidal ideations. Patient arrived at the office today by private vehicle. Patient currently takes the following medications:
Metformin 500mg BID
Januvia 100mg daily
Losartan 100mg daily
HCTZ 25mg daily
Sertraline 100mg daily
Current weight: 88 kg
Current height: 64 inches
Temp: 98.6 degrees F
BP: 132/86
By Day 3 (Wednesday) of Week 7:
Post a response to each of the following:
List three questions you might ask the patient if she were in your office. Provide a rationale for why you might ask these questions.
Identify people in the patient’s life you would need to speak to or get feedback from to further assess the patient’s situation. Include specific questions you might ask these people and why.
Explain what, if any, physical exams, and diagnostic tests would be appropriate for the patient and how the results would be used.
List a differential diagnosis for the patient. Identify the one that you think is most likely and explain why.
List two pharmacologic agents and their dosing that would be appropriate for the patient’s antidepressant therapy based on pharmacokinetics and pharmacodynamics. From a mechanism of action perspective, provide a rationale for why you might choose one agent over the other.
For the drug therapy you select, identify any contraindications to use or alterations in dosing that may need to be considered based on the client’s ethnicity. Discuss why the contraindication/alteration you identify exists. That is, what would be problematic with the use of this drug in individuals of other ethnicities?
Include any “check points” (i.e., follow-up data at Week 4, 8, 12, etc.), and indicate any therapeutic changes that you might make based on the data provided.
Explain “lessons learned” from this case study, including how you might apply this case to your own practice when providing care to patients with similar clinical presentations.
Read a selection of your colleagues’ responses.
By Day 6 (Saturday) of Week 7:
Respond to at least two of your colleagues on two different days in one of the following ways:
If your colleagues’ posts influenced your understanding of these concepts, be sure to share how and why. Include additional insights you gained.
If you think your colleagues might have misunderstood these concepts, offer your alternative perspective and be sure to provide an explanation for them. Include resources to support your perspective.Read a selection of your colleagues’ responses and respond to at least two of your colleagues on two different days and
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 on Submit, you cannot delete or edit your own posts, and you cannot post anonymously. Please check your post carefully before clicking on Submit!
TREATMENT FOR A PATIENT WITH A COMMON CONDITION
RESOURCES
Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources.
WEEKLY RESOURCES
Insomnia is one of the most common medical conditions you will encounter as a PMHNP. Insomnia is a common symptom of many mental illnesses, including anxiety, depression, schizophrenia, and ADHD (Abbott, 2016). Various studies have demonstrated the bidirectional relationship between insomnia and mental illness. In fact, about 50% of adults with insomnia have a mental health problem, while up to 90% of adults with depression experience sleep problems (Abbott, 2016). Due to the interconnected psychopathology, it is important that you, as the PMHNP, understand the importance of the effects some psychopharmacologic treatments may have on a patient’s mental health illness and their sleep patterns. Therefore, it is important that you understand and reflect on the evidence-based research in developing treatment plans to recommend proper sleep practices to your patients as well as recommend appropriate psychopharmacologic treatments for optimal health and well-being.
Reference: Abbott, J. (2016). What’s the link between insomnia and mental illness? Health. https://www.sciencealert.com/what-exactly-is-the-link-between-insomnia-and-mental-illness#:~:text=Sleep%20problems%20such%20as%20insomnia%20are%20a%20common,bipolar%20disorder%2C%20and%20attention%20deficit%20hyperactivity%20disorder%20%28ADHD%29
For this Discussion, review the case Learning Resources and the case study excerpt presented. Reflect on the case study excerpt and consider the therapy approaches you might take to assess, diagnose, and treat the patient’s health needs.
Case: An elderly widow who just lost her spouse.
Subjective: A patient presents to your primary care office today with chief complaint of insomnia. Patient is 75 YO with PMH of DM, HTN, and MDD. Her husband of 41 years passed away 10 months ago. Since then, she states her depression has gotten worse as well as her sleep habits. The patient has no previous history of depression prior to her husband’s death. She is awake, alert, and oriented x3. Patient normally sees PCP once or twice a year. Patient denies any suicidal ideations. Patient arrived at the office today by private vehicle. Patient currently takes the following medications:
Metformin 500mg BID
Januvia 100mg daily
Losartan 100mg daily
HCTZ 25mg daily
Sertraline 100mg daily
Current weight: 88 kg
Current height: 64 inches
Temp: 98.6 degrees F
BP: 132/86
BY DAY 3 OF WEEK 7
Post a response to each of the following:
List three questions you might ask the patient if she were in your office. Provide a rationale for why you might ask these questions.
Identify people in the patient’s life you would need to speak to or get feedback from to further assess the patient’s situation. Include specific questions you might ask these people and why.
Explain what, if any, physical exams, and diagnostic tests would be appropriate for the patient and how the results would be used.
List a differential diagnosis for the patient. Identify the one that you think is most likely and explain why.
List two pharmacologic agents and their dosing that would be appropriate for the patient’s antidepressant therapy based on pharmacokinetics and pharmacodynamics. From a mechanism of action perspective, provide a rationale for why you might choose one agent over the other.
For the drug therapy you select, identify any contraindications to use or alterations in dosing that may need to be considered based on ethical prescribing or decision-making. Discuss why the contraindication/alteration you identify exists. That is, what would be problematic with the use of this drug in individuals based on ethical prescribing guidelines or decision-making?
Include any “check points” (i.e., follow-up data at Week 4, 8, 12, etc.), and indicate any therapeutic changes that you might make based on possible outcomes that may happen given your treatment options chosen.
Read a selection of your colleagues’ responses.
BY DAY 6 OF WEEK 7
Respond to at least two of your colleagues on two different days in one of the following ways:
If your colleagues’ posts influenced your understanding of these concepts, be sure to share how and why. Include additional insights you gained.
If you think your colleagues might have misunderstood these concepts, offer your alternative perspective and be sure to provide an explanation for them. Include resources to support your perspective. Read a selection of your colleagues’ responses and respond to at least two of your colleagues on two different days.
LEARNING RESOURCES
Required Readings
Stahl, S. M. (2021). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (5th Ed.) Cambridge University Press.
Chapter 4, “Psychosis, Schizophrenia, and the Neurotransmitter Networks Dopamine, Serotonin, and Glutamate” (pp. 77-158)
Chapter 5, “Targeting Dopamine and Serotonin Receptors for Psychosis, Mood, and Beyond: So-Called “Antipsychotics” (pp. 159-243)
American Psychiatric Association. (2019). Practice guideline for the treatment of patients with schizophreniaLinks to an external site.. https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/Clinical%20Practice%20Guidelines/APA-Draft-Schizophrenia-Treatment-Guideline.pdf
Clozapine REMS. (2015). Clozapine REMS: The single shared system for clozapineLinks to an external site.. https://www.clozapinerems.com/CpmgClozapineUI/rems/pdf/resources/Clozapine_REMS_A_Guide_for_Healthcare_Providers.pdf
Funk, M. C., Beach, S. R., Bostwick, J. R., Celano, C. M., Hasnain, M., Pandurangi, A., Khandai, A., Taylor, A., Levenson, J. L., Riba, M., & Kovacs, R. J. (2018). Resource document on QTc prolongation and psychotropic medicationsLinks to an external site.. American Psychiatric Association. https://www.psychiatry.org/File%20Library/Psychiatrists/Directories/Library-and-Archive/resource_documents/Resource-Document-2018-QTc-Prolongation-and-Psychotropic-Med.pdf
Kay, S. R., Fiszbein, A., & Opler, L. A. (1987). The Positive and Negative Syndrome Scale (PANSS) for schizophrenia. Schizophrenia BulletinLinks to an external site., 13(2), 261–276. https://doi.org/10.1093/schbul/13.2.261
Levenson, J. C., Kay, D. B., & Buysse, D. J. (2015). The pathophysiology of insomnia. ChestLinks to an external site., 147(4), 1179–1192. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4388122/
McClellan, J. & Stock. S. (2013). Practice parameter for the assessment and treatment of children and adolescents with schizophrenia. Journal of the American Academy of Child and Adolescent PsychiatryLinks to an external site., 52(9), 976–990. https://www.jaacap.org/article/S0890-8567(09)62600-9/pdf
Naber, D., & Lambert, M. (2009). The CATIE and CUtLASS studies in schizophrenia: Results and implications for clinicians. CNS DrugsLinks to an external site., 23(8), 649–659. https://doi.org/10.2165/00023210-200923080-00002
Utah State University. (n.d.). Creating study guidesLinks to an external site.. https://www.usu.edu/academic-support/test/creating_study_guides
Medication Resources
U.S. Food & Drug Administration. (n.d.). Drugs@FDA: FDA-approved drugsLinks to an external site.. https://www.accessdata.fda.gov/scripts/cder/daf/index.cfm
Links to an external site.
Note: To access the following medications, use the Drugs@FDA resource. Type the name of each medication in the keyword search bar. Select the hyperlink related to the medication name you searched. Review the supplements provided and select the package label resource file associated with the medication you searched. If a label is not available, you may need to conduct a general search outside of this resource provided. Be sure to review the label information for each medication as this information will be helpful for your review in preparation for your Assignments.
amisulpride
aripiprazole
asenapine
brexpiprazole
cariprazine
chlorpromazine
clozapine
flupenthixol
fluphenazine
haloperidol
iloperidone
loxapine
lumateperone
lurasidone
olanzapine
paliperidone
perphenazine
pimavanserin
quetiapine
risperidone
sulpiride
thioridazine
thiothixene
trifluoperazine
ziprasidone
Optional Resources
Chakos, M., Patel, J. K., Rosenheck, R., Glick, I. D., Hammer, M. B., Tapp, A., Miller, A. L., & Miller, D. D. (2011). Concomitant psychotropic medication use during treatment of schizophrenia patients: Longitudinal results from the CATIE study. Clinical Schizophrenia & Related PsychosesLinks to an external site., 5(3), 124–134. https://doi.org/10.3371/CSRP.5.3.2
Fangfang, S., Stock, E. M., Copeland, L. A., Zeber, J. E., Ahmedani, B. K., & Morissette, S. B. (2014). Polypharmacy with antipsychotic drugs in patients with schizophrenia: Trends in multiple health care systems. American Journal of Health-System PharmacyLinks to an external site., 71(9), 728–738. https://doi.org/10.2146/ajhp130471
Lin, L. A., Rosenheck, R., Sugar, C., & Zbrozek, A. (2015). Comparing antipsychotic treatments for schizophrenia: A health state approach. The Psychiatric QuarterlyLinks to an external site., 86(1), 107–121. https://doi.org/10.1007/s11126-014-9326-2
