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

Assignment 3: Practicum: Decision Tree

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.

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.

Note: Support your rationale with a minimum of three academic resources. While you may use the course text to support your rationale, it will not count toward the resource requirement.

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)

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.

• Chapter 13, “Acute and Maintenance Treatment of Bipolar and Related Disorders”

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

• “Bipolar and Related Disorders”

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://sta…
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.

Required Media

Redfield Jamison, K. (Producer). (n.d.). Assessment & psychological treatment of bipolar disorder [Video file]. Mill Valley, CA: Psychotherapy.net.

Case #2
A young woman with Depression

SUBJECTIVE

Stefanie is a 32-year-old female from Puerto Rico who presents to your office today with complaints of difficulty sleeping. You learn that Stefanie can go for a few days with minimal sleep (about 3 hours/night), but does not seem to be fatigued the next day. Stefanie explains that after 3 days with minimal sleep, she “crashes” and has a good night’s sleep. She states that sleep will be “alright” for a few days, even a few weeks, and then she will have a similar issue with sleep.

You learn throughout the assessment process that Stefanie has had this problem for years. She noticed that it began in college and thought it was just because of the workload and academic demands. However, she found that it persisted after college. She also notices that she has periods where she will engage in increased amounts of goal-directed activity. She states that things will just “pile up” at work and she gets this burst of energy to “make everything right.” She states that these bursts will last most of the day. She states that these periods show up probably every 2 to 3 weeks.

Stefanie also confesses to problems with being “down in the dumps.” She states that when she has her episodes in which she endeavors to “make everything right,” she feels fantastic and on top of the world. However, when these periods of energy end, she reports that she feels “depressed”—but then states: “well, maybe not depressed, but I definitely feel sad and empty.” She also endorses feelings of fatigue and a decreased ability to concentrate when she is feeling sad. She finally tells you: “I have lived with this for so long, I have to admit that it is finally a relief to tell someone how I feel!”

OBJECTIVE

Stefanie is dressed appropriately to the weather. She has no gait abnormalities. Physical assessment is unremarkable. Gross neurological assessment is within normal limits.

MENTAL STATUS EXAM

Stefanie is alert and oriented × 4 spheres. Her speech is clear, coherent, goal directed, and spontaneous. Self-reported mood is “sad.” Affect does appear consistent with dysphoria. Eye contact is normal. Speech is clear, coherent, and goal directed. She denies visual or auditory hallucinations. No overt evidence of paranoid or delusional thought processes noted. She denies suicidal or homicidal ideation and is future oriented.

At this point, please discuss any additional diagnostic tests you would perform on Stefanie.

Decision Point One

BASED ON THE INFORMATION PROVIDED IN THE SCENARIO ABOVE, WHICH OF THE FOLLOWING DIAGNOSES WOULD THE PSYCHIATRIC/MENTAL HEALTH NURSE PRACTITIONER (PMHNP) GIVE TO STEFANIE?

In your write-up of this case, be certain to link specific symptoms presented in the case to DSM–5 criteria to support your diagnosis.

Bipolar I, current phase, depressed

Bipolar II, current phase, hypomanic

Cyclothymic disorder

Decision Point One

Cyclothymic disorder

Decision Point Two

BASED ON THIS DIAGNOSIS, SELECT YOUR CHOICE OF ACTIONS:

Begin Depakote 250 mg orally three times daily

Begin Abilify 10 mg orally daily

Arrange to see Stefanie every 3 months for routine follow-up

Decision Point Two

Begin Abilify 10 mg orally daily

RESULTS OF DECISION POINT TWO

• Client returns to clinic in four weeks
• Stefanie reports that her mood seems a bit more “stable.” She states that she notices that she has not been as “sad” since she started taking the medication. She does report that for the first 2 weeks, she noticed that whenever she went from a lying or sitting to a standing position, she felt “lightheaded.”
• She does report that the side effect was quite concerning at times. However, she reports that this is no longer happening.

Decision Point Three

BASED ON THE ABOVE INFORMATION, SELECT YOUR NEXT ACTION. BE CERTAIN TO DISCUSS THE RATIONALE FOR YOUR DECISION.

Maintain current dose of Abilify

Increase Abilify to 15 mg orally daily

Discontinue Abilify

Decision Point Three

Maintain current dose of Abilify

Guidance to Student

In order to meet the criteria for a major depressive episode, the client needs to have five or more symptoms (refer to DSM–5 major depressive episode criteria). She only demonstrates criteria # 1: depressed mood most of the day, nearly every day, as indicated by either subjective reports (e.g., feels sad, empty, or hopeless) or observation made by others (e.g., appears tearful); criteria # 6: “fatigue or loss of energy nearly every day”; and criteria # 8: “diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others).” Thus, Stefanie does not meet the criteria for a major depressive episode as she only has three out of the needed five criteria for the diagnosis of a major depressive episode.

In order to meet criteria for a hypomanic episode, the client needs to have a period of abnormally and persistently elevated, expansive, or irritable mood, and abnormally and persistently increased activity or energy, lasting at least 4 consecutive days and present most of the day, nearly every day. Stefanie’s symptoms last 3 days. Additionally, during the period of mood disturbance, the person must have three or more of the qualifying symptoms. Stefanie only has an increase in goal-directed activity and distractibility. Thus, Stefanie does not meet criteria for a hypomanic episode as she only has a decreased need for sleep and an increase in goal-directed activity.

Since Stefanie has symptoms of both hypomania and depression (but does not meet the criteria for a major depressive or hypomanic episode), and since these behaviors do not occur in the context of a drug/substance or medical condition, Stefanie meets the diagnostic criteria for cyclothymic disorder.

Some providers will treat cyclothymic disorder with pharmacologic agents used to treat bipolar disorder because individuals with cyclothymic disorder have a higher risk of progression to bipolar disorder. However, there is no consensus in the literature as to the optimal treatment, or if prophylactic psychopharmacologic treatment is beneficial in consideration of the side effects associated with antipsychotics and mood stabilizers.

Stefanie’s symptoms are most consistent with orthostatic hypotension, which is not uncommon when initiating Abilify. At this point, it sounds as if the side effects have subsided. There is nothing to tell us that we should increase the dose. Similarly, there is nothing in the case to tell us that we should discontinue the Abilify. Instead, routine monitoring should occur