Assignment: Practicum: Decision Tree

Introduction

The case study is about a 32-year-old female patient who presented with sleep difficulties. The patient reported that she can sleep for only 3 hours, without experiencing fatigue the next day. The problem started during college. She also reported episodes of increased levels of goal-directed activities that manifest every 2-3 weeks. She reports that during these episodes she feels fantastic and whimsical. However, when the energetic periods end, she ends up feeling depressed, sad and empty. She also experiences fatigue and reduced concentration. The findings from the physical assessment are within the normal limits. The MSE indicates that she is well-oriented and alert. Her speech is goal-directed, coherent, clear, and spontaneous. She reports her mood as sad. The affect matches dysphoria. She denies hallucinations. No delusional thought process or paranoia. She denies any suicidal ideation (Laureate Education, 2017d). The purpose of this paper is to come up with the patient’s diagnosis and then develop her treatment plan by selecting the appropriate treatment decisions. Each treatment decision will be guided by the appropriate ethical considerations.

Decision Point One

The diagnosis for the patient is cyclothymic disorder. This is because she manifests both depression and hypomania symptoms. Cyclothymic disorder is characterized by short episodes of hypomania and depression (Van Meter et al., 2017). The mood episodes are not severe enough to meet the diagnosis of full mania episodes or major depressive disorder (American Psychiatric Association, 2013). The patient in this case study reported mild cyclic mood changes (hypomania and depressive symptoms) as manifested by episodes of elevated moods and episodes of sadness/fatigue/poor concentration. Therefore, her symptoms meet the diagnostic criteria of cyclothymic disorder. The reason why options bipolar 1, current phase, depressed and bipolar II, current phase, hypomanic was not selected is because her symptoms do not meet diagnostic criteria of bipolar disorder. According to Ward (2017), bipolar disorder is normally characterized by extreme mood swings that manifest as emotional highs (hypomania or mania) and severe depressive symptoms.

By selecting the diagnosis of cyclothymic disorder for the patient, it is expected that this is the correct diagnosis that facilitates the formulation of the correct treatment plan for the patient.

When selecting the diagnosis for the patient, beneficence and non-maleficence ethical principles were used to ensure the appropriate diagnosis was made for the client to facilitate the development of the appropriate treatment plan. Additionally, the privacy and confidentiality of the patient were respected by ensuring that her diagnosis was not revealed to anyone else without her consent (Kadivar et al., 2017).

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Decision Point Two

The decision that was selected is for the patient to start Abilify 10 mg. Abilify is an antipsychotic that is approved to treat manic/hypomanic and depressive symptoms (Schouws et al., 2016). The medication works through pharmacodynamic properties of serotonin-dopamine activity modulation and partial agonism and hence improves the symptoms of psychiatric disorders such as cyclothymic disorder (Muneer, 2016). The appropriate psychotherapy treatment option for the patient is psychoeducation. This is because psychoeducation will help her to accept the diagnosis of a cyclothymic disorder, have confidence in the mental health practitioner, adhere to the medication, and address interpersonal and behavioral impacts of the diagnosis (Perugi et al., 2017). The decision to have the patient start Depakote 250 mg was not selected because the medication is associated with serious side effects such as edema, breathing problems, involuntary eye movements, easy bruising, unusual bleeding, and bleeding gums (Kakunje et al., 2018). The decision to arrange for the patient a routine follow-up was not chosen because she needs treatment to prevent worsening of the symptoms.
By choosing Abilify, it is expected that the patient would tolerate the medication and manifest symptom improvement as manifested by improved concentration, improved mood, and reduction of energy fluctuations. This is due to the efficacy of Abilify in treating cyclothymic disorder (Muneer, 2016). It is also expected that psychoeducation will help her adhere to medication and accept her diagnosis too. She also reported that during the first 2 weeks she experienced lightheadedness but this was no longer happening. Lightheadedness is attributable to the side effects of Abilify (Perugi et al., 2017).

This decision was guided by ethical principles of beneficence and non-maleficence. As a result, the treatment option (Abilify) likely to produce the best outcomes and with minimal side effects was chosen for the patient (Kadivar et al., 2017).

Decision Point Three

The third decision is to maintain the dose of Abilify. This decision was chosen because the client is currently manifesting adequate response (through symptom reduction) and she is no longer experiencing lightheadedness as a side effect. This is due to the efficacy of Abilify in treating symptoms of the cyclothymic disorder and the medication is also well-tolerated (Muneer, 2016). The decision to discontinue the dose was not selected because the withdrawal should be gradual and also the medication should be stopped after the patient has achieved full symptom remission. The decision to increase the Abilify dose was not chosen to avoid the patient experiencing unwanted side effects.

By maintaining the Abilify dose, the expectation is that she will continue tolerating the medication and eventually she will achieve complete symptom remission. This is due to Abilify’s effectiveness in treating and improving symptoms of cyclothymic disorder.

This decision was guided by ethical principles of beneficence and non-maleficence (Kadivar et al., 2017). As a result, the treatment option of maintaining the Abilify dose is the option likely to produce the best outcomes and with minimal side effects was chosen for the patient.

Conclusion

The diagnosis for the patient is cyclothymic disorder as she is experiencing episodes of depression and hypomania that are not severe enough to meet the diagnosis of full mania episodes or major depressive disorder. Therefore, Abilify was selected as the appropriate medication as it has shown efficacy in treating symptoms of cyclothymic disorder. The appropriate psychotherapy is to have the patient undergo psychoeducation in order to accept the diagnosis and adhere to the medication. With Abilify, the patient-reported symptom improvement as she was no longer having a sad mood. She also reported that the side effect (lightheadedness) she was initially experiencing had diminished. Therefore, the third decision was for the patient to continue taking the same dose of Abilify as she was showing an adequate response, without any side effects. With this decision, it is expected that she will achieve complete symptom remission. The patient’s confidentiality and privacy were respected as her diagnosis and health information were not revealed to unauthorized parties. Additionally, the ethical principles of beneficence and non-maleficence were applied to facilitate the best treatment outcomes with minimal side effects.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

Kadivar, M., Manookian, A., Asghari, F., Niknafs, N., Okazi, A., & Zarvani, A. (2017). Ethical and legal aspects of patient’s safety: a clinical case report. Journal of medical ethics and history of medicine, 10, 15.

Kakunje, A., Prabhu, A., Sindhu Priya, E. S., Karkal, R., Kumar, P., Gupta, N., & Rahyanath, P. K. (2018). Valproate: Its Effects on Hair. International journal of trichology, 10(4), 150–153. https://doi.org/10.4103/ijt.ijt_10_18

Laureate Education (Producer). (2017d). A young woman with depression [Multimedia file]. Baltimore, MD: Author.

Muneer A. (2016). The Treatment of Adult Bipolar Disorder with Aripiprazole: A Systematic Review. Cureus, 8(4), e562. https://doi.org/10.7759/cureus.562

Perugi, G., Hantouche, E., & Vannucchi, G. (2017). Diagnosis and Treatment of Cyclothymia: The “Primacy” of Temperament. Current Neuropharmacology, 15(3), 372–379. https://doi.org/10.2174/1570159X14666160616120157

Schouws, S. M., Comijs, H. C., Dols, A., Beekman, A. F., & Stek, M. L. (2016). Five-year follow-up of cognitive impairment in older adults with bipolar disorder. Bipolar Disorders, 18(2), 148–154.  doi:10.1111/bdi.1237

Van Meter, A. R., Youngstrom, E. A., Birmaher, B., Fristad, M. A., Horwitz, S. M., Frazier, T. W., Arnold, L. E., & Findling, R. L. (2017). Longitudinal course and characteristics of cyclothymic disorder in youth. Journal of affective disorders, 215, 314–322. https://doi.org/10.1016/j.jad.2017.03.019

Ward, I. (2017). Pharmacologic options for bipolar disorder. Clinical Advisor, 20(3), 17–25.

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PRAC 6670: Psychiatric Mental Health Nurse Practitioner Role II: Adults and Older Adults
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Practicum Week 5
This week, you will use the decision tree format to justify your rationale for diagnosis, pharmacological treatment, and psychotherapy of a patient with a mental illness.
Learning Resources
Required Readings
American Nurses Association. (2014). Psychiatric-mental health nursing: Scope and standards of practice (2nd ed.). Washington, DC: Author.

Standard 13 “Collaboration” (pages 78-79)
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
“Bipolar and Related Disorders”
Gabbard, G. O. (2014). Gabbard’s treatment of psychiatric disorders (5th ed.). Washington, DC: American Psychiatric Publications.
Chapter 13, “Acute and Maintenance Treatment of Bipolar and Related Disorders”
Marsee, K., & Gross, A. F. (2013). Bipolar disorder or something else? Current Psychiatry, 12(2), 43–49. Retrieved from http://www.mdedge.com/currentpsychiatry/article/66320/bipolar-disorder/bipolar-disorder-or-something-else
Miller, L. J., Ghadiali, N. Y., Larusso, E. M., Wahlen, K. J., Avni-Barron, O., Mittal, L., & Greene, J. A. (2015). Bipolar disorder in women. Health Care for Women International, 36(4), 475–498. doi:10.1080/07399332.2014.962138
Schouws, S. M., Comijs, H. C., Dols, A., Beekman, A. F., & Stek, M. L. (2016). Five-year follow-up of cognitive impairment in older adults with bipolar disorder. Bipolar Disorders, 18(2), 148–154. doi:10.1111/bdi.12374
Sadock, B. J., Sadock, V. A., & Ruiz, P. (2014). Kaplan & Sadock’s synopsis of psychiatry: Behavioral sciences/clinical psychiatry (11th ed.). Philadelphia, PA: Wolters Kluwer.
Chapter 8, “Mood Disorders” (pp. 347–386)
Note: This is review from the Learning Resource in Week 2.
Stahl, S. M. (2014). Prescriber’s Guide: Stahl’s Essential Psychopharmacology (5th ed.). New York, NY: Cambridge University Press.

Note: All Stahl resources can be accessed through the Walden Library using the link below. This link will take you to a login page for the Walden Library. Once you log in to the library, the Stahl website will appear. http://ezp.waldenulibrary.org/login?url=http://stahlonline.cambridge.org/

To access information on specific medications, click on The Prescriber’s Guide, 5th Ed. tab on the Stahl Online website and select the appropriate medication.

Bipolar depression Bipolar disorder Bipolar maintenance Mania
amoxapine
aripiprazole
armodafinil
asenapine
bupropion
carbamazepine
fluoxetine
iloperidone
lamotrigine
lithium
lurasidone
modafinil
olanzapine
olanzapine-fluoxetine combination
quetiapine
risperidone
sertindole
valproate (divalproex)
ziprasidone
alprazolam (adjunct)
amoxapine
aripiprazole
asenapine
bupropion
carbamazepine
chlorpromazine
clonazepam (adjunct)
cyamemazine
doxepin
fluoxetine
flupenthixol
fluphenazine
gabapentin (adjunct)
haloperidol
iloperidone
lamotrigine
levetiracetam
lithium
lorazepam (adjunct)
loxapine
lurasidone
molindone
olanzapine
olanzapine-fluoxetine combination
oxcarbazepine
paliperidone
perphenazine
pipothiazine
quetiapine
risperidone
sertindole
thiothixene
topiramate (adjunct)
trifluoperazine
valproate (divalproex)
ziprasidone
zonisamide
zotepine
zuclopenthixol
aripiprazole
asenapine
carbamazepine
iloperidone
lamotrigine
lithium
lurasidone
olanzapine
olanzapine-fluoxetine combination
quetiapine
risperidone (injectable)
sertindole
valproate (divalproex)
ziprasidone
alprazolam (adjunct)
aripiprazole
asenapine
carbamazepine
chlorpromazine
clonazepam (adjunct)
iloperidone
lamotrigine
levetiracetam
lithium
lorazepam (adjunct)
lurasidone
olanzapine
quetiapine
risperidone
sertindole
valproate (divalproex)
ziprasidone
zotepine
Ward, I. (2017). Pharmacologic options for bipolar disorder. Clinical Advisor, 20(3), 17–25.
Required Media
Laureate Education (Producer). (2017d). A young woman with depression [Multimedia file]. Baltimore, MD: Author.
Redfield Jamison, K. (Producer). (n.d.). Assessment & psychological treatment of bipolar disorder [Video file]. Mill Valley, CA: Psychotherapy.net.
Optional Resources
Malhi, G. S., McAulay, C., Gershon, S., Gessler, D., Fritz, K., Das, P., & Outhred, T. (2016). The lithium battery: Assessing the neurocognitive profile of lithium in bipolar disorder. Bipolar Disorders, 18(2), 102–115. doi:10.1111/bdi.12375
Samalin, L., de Chazeron, I., Vieta, E., Bellivier, F., & Llorca, P. (2016). Residual symptoms and specific functional impairments in euthymic patients with bipolar disorder. Bipolar Disorders, 18(2), 164–173. doi:10.1111/bdi.12376
Assignment: Practicum: Decision Tree (Due in Week 7)
For this Assignment, as you examine the client case study in this week’s Learning Resources, consider how you might assess and treat adult and older adult clients presenting symptoms of a mental health disorder.

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Learning Objectives
Students will:
Evaluate clients for treatment of mental health disorders
Analyze decisions made throughout diagnosis and treatment of clients with mental health disorders
Examine Case 2: You will be asked to make three decisions concerning the diagnosis and treatment for this client. Be sure to consider co-morbid physical, as well as mental factors that might impact the client’s diagnosis and treatment.
At each Decision Point stop to complete the following:
Decision #1: Differential Diagnosis
Which Decision did you select?
Why did you select this Decision? Support your response with evidence and references to the Learning Resources.
What were you hoping to achieve by making this Decision? Support your response with evidence and references to the Learning Resources.
Explain any difference between what you expected to achieve with Decision #1 and the results of the Decision. Why were they different?
Decision #2: Treatment Plan for Psychotherapy
Why did you select this Decision? Support your response with evidence and references to the Learning Resources.
What were you hoping to achieve by making this Decision? Support your response with evidence and references to the Learning Resources.
Explain any difference between what you expected to achieve with Decision #2 and the results of the Decision. Why were they different?
Decision #3: Treatment Plan for Psychopharmacology
Why did you select this Decision? Support your response with evidence and references to the Learning Resources.
What were you hoping to achieve by making this Decision? Support your response with evidence and references to the Learning Resources.
Explain any difference between what you expected to achieve with Decision #3 and the results of the decision. Why were they different?
Also include how ethical considerations might impact your treatment plan and communication with clients and their family.

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