Case 5: The Sleepy Woman with Anxiety
A 44-year-old woman with a chief complaint of anxiety is diagnosed with resistant anxious depression alongside narcolepsy. Case 3: Volume 1, Case #5: The sleepy woman with anxiety NURS 6630The existence of these sleep disorders has made it extremely difficult to manage the resistant anxious depression. Thus, the present analysis will look to examine the various aspects of such a complex condition from clinical diagnosis and the necessary antidepressants for the client based on their mechanisms of action and pharmacokinetics and pharmacodynamics. Case 3: Volume 1, Case #5: The sleepy woman with anxiety NURS 6630Moreover, the manner in which the health practitioner has managed the patient is interesting and as such, there are important lessons to be learned by the current nurse practitioner. Case 3: Volume 1, Case #5: The sleepy woman with anxiety NURS 6630
Patient Interview Questions
Given that the current patient is suspected to have narcolepsy alongside resistant anxious depression, there are certain topics that a nurse will discuss with her during the clinical interview process. Case 3: Volume 1, Case #5: The sleepy woman with anxiety NURS 6630 Based on the scope of her symptomatology, it becomes important to focus on important aspects of the patient’s symptoms in order to understand certain factors. Thus, the following questions will be presented to the patient: Case 3: Volume 1, Case #5: The sleepy woman with anxiety NURS 6630
- How does the sleepiness that you have interfere with your daily functions, regarding the magnitude of the effects as well as the quality of the results? Case 3: Volume 1, Case #5: The sleepy woman with anxiety NURS 6630
- Do you experience mood disturbances? Do you have a history of panic attacks, depression, anxiety, suicidal ideations, or phobia?
- Do you have any family member(s) with a history of depression, anxiety, and sleep disorders?
The first questions is important as it will be used to gauge if the effect of sleepiness on the quality of the patient’s functional life is negative. Case 3: Volume 1, Case #5: The sleepy woman with anxiety NURS 6630By making this assessment, the nurse practitioner will thus be able to diagnose the presence of a sleep disorder (Thorpy & Dauvilliers, 2015). Similarly, the second question is important as it will be able to make the nurse practitioner to differentially diagnose anxious depression from other mood disorders that may have similar symptoms. Case 3: Volume 1, Case #5: The sleepy woman with anxiety NURS 6630 Lastly, the question about the patient’s family history intends to provide insight regarding the possibility of a genetic influence of the patient’s current condition according to Thorpy and Dauvilliers (2015). Case 3: Volume 1, Case #5: The sleepy woman with anxiety NURS 6630
Interview Questions for People in the Patient’s Life
During clinical interviewing, it becomes important to interview those individuals that interact with a patient. Case 3: Volume 1, Case #5: The sleepy woman with anxiety NURS 6630These people may offer significant insight into a patient’s behavioral patterns way better than the patient. In the present case, the nurse practitioner will question the husband and the family doctor. For the husband, the following question will be asked: “Do you think that the patient has left out any important part of her social life?” Case 3: Volume 1, Case #5: The sleepy woman with anxiety NURS 6630 This question is important as it will be used to corroborate the accounts of the patient regarding her social life and whether it is indeed true that their marriage lacks any strain. On the other hand, the family doctor will answer to the following question: “Can you remember any medication that you gave the patient that has not been included in the list that she provided?” Case 3: Volume 1, Case #5: The sleepy woman with anxiety NURS 6630 This question will reveal to the practice nurse the existence of any neurological or endocrinological condition that could be responsible for the client’s symptomatology.
Physical Exams and Diagnostic Tests
In the present condition, the patient should be checked for cerebral fluid to confirm the presence of hypocretin, which lacks in narcoleptic patients. Case 3: Volume 1, Case #5: The sleepy woman with anxiety NURS 6630Moreover, the usual thyroid hormone test (Avidan, 2012) is necessary to determine the existence of a medical condition that could be influencing the development of depression in the patient. In addition to the above physicals, the patient should be subjected to a multiple latency test (MLT) and a nocturnal polysomnography (Avidan, 2012). Case 3: Volume 1, Case #5: The sleepy woman with anxiety NURS 6630These diagnostic workouts are important as they help reduce the possibility of misdiagnosis or missed diagnosis in the present patient. Further, the results will be used to formulate the psychopharmacotherapy for the patient as they will reveal the exact diagnosis.
Differential Diagnosis
The diagnostic process concerning the patient’s condition is difficult as many mood or mental conditions have comorbidity with narcolepsy. Case 3: Volume 1, Case #5: The sleepy woman with anxiety NURS 6630Thus, the patient’s condition can be diagnosed as idiopathic hyeperinsomnia associated with psychiatric conditions (depression and anxiety) (Domino, 2015). Additionally, anxiety depression comorbid with medications can be diagnosed as the patient’s condition. Case 3: Volume 1, Case #5: The sleepy woman with anxiety NURS 6630Lastly, the condition can be diagnosed as anxious depression with sleep disorder. Nevertheless, the last option is the correct diagnosis as the patient has demonstrated sleep-onset rapid eye movement (Domino, 2015). Moreover, the naps taken by the patient appear refreshing to her, which directly eliminates the possibility of the former two diagnoses. Case 3: Volume 1, Case #5: The sleepy woman with anxiety NURS 6630
Pharmacological Agents
In order to treat the depressive symptoms of the condition, the present nurse practitioner should consider using either mirtazapine (Rameron) or Quetiapine XR (Seroquel XR). Mirtazapine’s approved dosage ranges from 15-45 mg/day and this is what the patient will be given (Stahl, 2013). Case 3: Volume 1, Case #5: The sleepy woman with anxiety NURS 6630The drug was chosen because of its half-life of between 20-40 hours and the fact that it does not inhibit any of the CYP 450 isoenzyme and the fact that it lacks any drug-to-drug interactions. In addition, its oral administration implies that peak plasma concentration will be reached within two hours, making it instantly effective. The molecule also is quickly absorbed into the system. Seroquel, on the other hand, will be administered in dosages of between 50-300 mg PO at bedtime. Case 3: Volume 1, Case #5: The sleepy woman with anxiety NURS 6630The drug has superior pharmacokinetic properties such as rapid absorption and a median time of 2 hours to reach its peak plasma concentration (Stahl, 2013). Additionally, it accounts for 1% of the product of its hepatic elimination process, implying that a greater concentration of the drug’s active metabolites participate in its antidepressant activity. Case 3: Volume 1, Case #5: The sleepy woman with anxiety NURS 6630
Mirtazapine works by acting on two neurochemical receptors. The drug is both a noradrenergic and specific serotonergic antidepressant (NaSSA). Researchers reveal that it works by antagonizing the alpha2-heteroreceptors and adrenergic alpha2-autoreceptors in addition to blocking 5-HT3 and 5-HT2 receptors (Kryger, Roth, & Dement, 2017). These actions influence 5-HT1A-mediated serotonergic transmission and the release of norepinephrine. Case 3: Volume 1, Case #5: The sleepy woman with anxiety NURS 6630This mechanism of action is different from Quetiapine’s. Studies reveal that while the drug’s mechanism of action lacks clarity, it has demonstrated affinity for D2, alpha 1, 5-HT2A, H1, and 5-HT1A receptors (Stahl, 2013). Thus, the antidepressant effect of the drug may be related to its ability to inhibit the mesombilic pathway from neurotransmitting dopamine. Case 3: Volume 1, Case #5: The sleepy woman with anxiety NURS 6630According to literature, any antidepressant that inhibits the release of norepinephrine is more effective; as such, the present nurse will consider prescribing mirtazapine to the patient.
Contraindications to Use
According to the FDA, no clinical study has been conducted to examine the influence of ethnicity on the pharmacokinetics of mirtazapine. However, in a study known as The Effects of Race and Ethnicity on Depression Treatment Outcomes: The CO-MED Trial, Lesser and her colleagues (2011) determined that the outcomes of treatment do not differ by ethnicity. Case 3: Volume 1, Case #5: The sleepy woman with anxiety NURS 6630Indeed, only the population of the study varied yet the remission rates among all the ethnicities were similar. Consequently, ethnicity does not affect the dosage nor does it influence contraindications when mirzapatine is prescribed to a patient.
Checkpoint Changes
Mizarpatine is naturally a potent inhibitor of the progression of depressive and anxiety symptoms. However, given that the client’s condition may be complicated, the present nurse may consider to augment the drug with venlafaxine. Case 3: Volume 1, Case #5: The sleepy woman with anxiety NURS 6630The essence of such a decision will be to increase the antidepressant effect of the drug. Even then, the augmentation will only happen after the dosage of mirzapatine has been titrated to the maximum tolerable level.
Lessons Learned
The way that the case was handled revealed important lessons to the present nurse practitioner. One of the most significant one is that the treatment of a sleep disorder with anxiety does not have to be psychopharmacological. Case 3: Volume 1, Case #5: The sleepy woman with anxiety NURS 6630In addition, the nurse has also learnt that the narcolepsy symptom of the condition may actually be exacerbated by medications. As such, it is important to carefully formulate the pharmacotherapy by eliminating drugs that are clinically ineffectual. Case 3: Volume 1, Case #5: The sleepy woman with anxiety NURS 6630 Lastly, the nurse learnt that in some cases, agents such as mirtazapine and other MAOIs as well as ECT and VNS should be introduced early enough to prevent complications.
In lieu of the above lessons, the present nurse practitioner has resolved to ensure that augmentation of antidepressants with typical antipsychotics is part of the treatment regimen options. Case 3: Volume 1, Case #5: The sleepy woman with anxiety NURS 6630Also, it will be important in future to leverage the husband regarding treatment options as the patient may be in danger of developing long-term depression. Lastly, in cases such as this one, the nurse will consider psychotherapy in earnest so as to determine the aptness of either individual or group therapy for the patient. Case 3: Volume 1, Case #5: The sleepy woman with anxiety NURS 6630
References
Avidan, A. Y. (2012). Hypersomnia, An Issue of Sleep Medicine Clinics – E-Book.
Domino, F. J., STAT!Ref (Online service), & Teton Data Systems (Firm). (2015). The 5-minute clinical consult, 2015. Philadelphia, PA: Lippincott Williams & Wilkins. Case 3: Volume 1, Case #5: The sleepy woman with anxiety NURS 6630
Kryger, M. H., Roth, T., & Dement, W. C. (2017). Principles and practice of sleep medicine. Philadelphia: Elsevier.
Lesser, I., Zisook, S., Gaynes, B., Wisniewski, S., Luther, J., & Fava, M. (2011). Effects of race and ethnicity on depression treatment outcomes: The CO-MED trial. Psychiatry Serv, 62(10), 1167-69.
Stahl, S M. (2013). Stahl’s Essential Psychopharmacology: Neuroscientific Basis and Practical Applications. 4thd ed. New York: Cambridge University Press. Case 3: Volume 1, Case #5: The sleepy woman with anxiety NURS 6630
Thorpy,M.J., & Dauvilliers, Y. (2015). Clinical and practical considerations in the pharmacologic management of narcolepsy. Sleep Medicine, 16 (1). 9-18.