NSG6005 Week 9 Discussion Post
Angela is a 54-year-old married woman with three adult children. She has been the office
manager of a small law firm for 20 years and has enjoyed her work until this past year. She has
r
...
NSG6005 Week 9 Discussion Post
Angela is a 54-year-old married woman with three adult children. She has been the office
manager of a small law firm for 20 years and has enjoyed her work until this past year. She has
rheumatoid arthritis with minimal impairment that has been managed well with NSAIDs. She has
been taking conjugated estrogens for 8 years and decided to stop taking them because of her
concern of their risks without sufficient medical benefit. She has tolerated the discontinuation
without difficulty.
Assessment:
At her annual medical checkup appointment, she told her primary care provider that she seemed
to be tired all the time, and she was gaining weight because she had no interest in her usual
exercise activities and had been overeating, not from appetite but out of boredom. She denied
that she and her husband have had marital difficulties beyond the ordinary and she was pleased
with the achievements of her children. She noticed that she has difficulty falling asleep at night
and awakens around 4 a.m. most mornings without her alarm and cannot go back to sleep even
though she still feels tired. She finds little joy in her life but cannot pinpoint any particular
concern. Although she denies suicidal feelings, she does not feel that there is meaning to her life:
“My husband and kids would go on fine if I died and probably wouldn’t miss me that much.”
The primary care provider asks Angela to fill out a Beck’s Depression Scale, which
indicated she has moderate depression.
As we know ”Depression is one of the most common conditions treated in primary care and
nearly 10% of all primary care office visits are depression related” and one thing we also know
based on reports and research is that, “Depression in primary care is under detected,
underdiagnosed, and undertreated” (Jong, Berg, Tobi, & Berg, 2003, p. 594).
Effective management of depression in primary care requires a number of steps: detection and
diagnosis, patient education and engagement in treatment, initiation of evidence-based
pharmacotherapy or psychotherapy, close follow-up focusing on treatment adherence, treatment
effectiveness, and treatment side effects (Patel et al., 2016, p. 106).Treatment should be
considered in 3 phases: an acute treatment phase to achieve remission of symptoms; a
continuation phase to prevent recurrence of the same episode of illness (relapse); and a
maintenance (prophylaxis) phase to prevent future episodes (recurrence) (Patel et al., 2016, p.
106).
Wellbutrin has a unique pharmacology, inhibiting the reuptake of noradrenaline and dopamine,
potentially providing pharmacological augmentation to more common antidepressants such as
selective serotonergic reuptake inhibitors (SSRIs) (Woo & Robinson, 2016).1. What medication would you first prescribe to this patient? An SSRI would be my
initial treatment however SSRI’s can interact with NSAIDs by causing potential GI ulcers
and GI bleeds, I would avoid an SSRI because Angela is taking for her rheumatoid
arthritis (Woo & Robinson, 2016). These GI symptoms may not occur at all however In
Dutch pharmacies the prescription medication of all patients is carefully monitored, and
warnings about possible adverse effects, contraindications, and interactions are consequently
generated (Jong, Berg, Tobi, & Berg, 2003, p. 593) So for this reason I would steer clear of
SSRI’s. Angela would start on duloxetine (Cymbalta). I would start her on 20mg/day and
increase it to 60mg/day in 20mg increments every 4 days.
2. She comes back in 2 weeks and states she has not noticed and change in her mood since
starting on the medication. What would be your response? I would educate her that Wellbutrin
therapy as a first line treatment starts out as with any other medication as the first
medicatrion in the “trial” trying to find what will work best, I would educate her that we
would need to give the Wellbutrin 6 weeks to see it’s optimal effect(Patel et al., 2016, p. 107).
This is what is recommended before considering a medication change. I would also inquire about
her depressive symptoms she was having previously and ensure they are not worse or
progressing into a deeper level. I would assess if there are any additional risks of increased
depression and assess any suicidal thoughts with the initiation of the Wellbutrin therapy. If
things are not better but not worse, then I would recommend continuing to take the
medication and monitor the results closely. I would also recommend she utilize CBT in
addition to medications to aid in ways to cope in more healthy ways while waiting for the
medication to kick in. I would also suggest small groups/counseling for the husband and
children as well, so they are educated on how to best support Angela in her diagnosis. Iwould make sure her husband knew the symptoms of worsening depression and to monitor
for any suicidal tendencies.
3. What are the possible problems with the medication you prescribed? It would be imperative to
monitor liver therapy while using Duloxetine because it can negatively affect the liver. Liver
studies should be done regularly and make sure education about the importance of having
lab values drawn and the compliance of regular checkups as well and ensure her husband
is aware as well for increased compliance. Other side effects include anxiety so therefore we
need to make sure she knows to expect it and educate her to keep track of symptoms of
depression and anxiety in a log so she can look back and track trends and they can be
reviewed on her follow up appointments. Additionally, somnolence, fatigue, decreased
appetite, hallucinations, agitation, headache, and aggression are other side effects or issues
we need to monitor Angela for as well (Skidmore-Roth, 2013).
4. How long should you continue the treatment regimen? If Wellbutrin is effective and
controls, her depressive symptoms and increases her quality of life then I would keep
Angela on this medication indefinitely. According to the National Alliance on Mental
Illness there has been no known instances of harm from long-term use of duloxetine, so
therefore this would be a medication I would keep her on while maintaining her labs and
monitoring for any adverse effects (NAMI, 2018).References
NAMI. (2018). Duloxetine (Cymbalta). Retrieved August 3, 2019, from
https://www.nami.org/Learn-More/Treatment/Mental-Health-Medications/Duloxetine-
(Cymbalta)
Skidmore-Roth, L. (2013). Mosbys 2013 nursing drug reference (26th ed.). St. Louis, MO:
Mosby.
Woo, T. M., & Robinson, M. V. (2016). Pharmacotherapeutics for advance practice nurse
prescribers. Retrieved from
https://digitalbookshelf.southuniversity.edu/#/books/undefined/
less
Jong, J. C., Berg, P. B., Tobi, H., & Berg, L. T. (2003). Combined use of SSRIs and NSAIDs
increases the risk of gastrointestinal adverse effects. British Journal of Clinical
Pharmacology, 55, 591-595. https://doi.org/doi: 10.1046/j.0306-5251.2002.01770.x
TEST PAPER FOR SCHOOL 1
Patel, K., Allen, S., Haque, M. N., Angelescu, I., Baumeiste, D., & Tracy, D. K. (2016).
Bupropion: a systematic review and meta-analysis of effectiveness as an antidepressant.
Therapeutic Advances in Psychopharmacology, 6, 99-144. https://doi.org/doi:
10.1177/2045125316629071
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