Case 3: Volume 1, Case #5: The sleepy woman with anxiety

Case 3: Volume 1, Case #5: The sleepy woman with anxiety

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. The 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. Moreover, 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.

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. 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:

• 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?
• 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. By 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. 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).

Interview Questions for People in the Patient’s Life

            During clinical interviewing, it becomes important to interview those individuals that interact with a patient. These 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?” 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?” 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. Moreover, 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). These 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. Thus, 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. Lastly, 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.

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). The 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. The 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.

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. This 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. According 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. Indeed, 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. The 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. In 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. 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. Also, 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.

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.

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.

Thorpy,M.J., & Dauvilliers, Y. (2015). Clinical and practical considerations in the pharmacologic management of narcolepsy. Sleep Medicine, 16 (1). 9-18.

Important information for writing discussion questions and participation

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I understand this is a lot of information to cover in 5 weeks, however, the Bible says in Philippians 4:13 that we can do all things through Christ that strengthens us. Even in times like this, we are encouraged by God’s word that we have that ability in us to succeed with His strength. I pray that each and every one of you receives strength for this course and life generally as we navigate through this pandemic that is shaking our world today. Relax and enjoy the course!

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Please read through the following information on writing a Discussion question response and participation posts.

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Important information on Writing a Discussion Question

• Your response needs to be a minimum of 150 words (not including your list of references)
• There needs to be at least TWO references with ONE being a peer reviewed professional journal article.
• Include in-text citations in your response
• Do not include quotes—instead summarize and paraphrase the information
• Follow APA-7th edition
• Points will be deducted if the above is not followed

Participation –replies to your classmates or instructor

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• Responses need to be substantive by bringing information to the discussion or further enhance the discussion. Responses of “I agree” or “great post” does not count for the word count.
• Follow APA 7th edition
• Points will be deducted if the above is not followed

• Remember to use and follow APA-7th edition for all weekly assignments, discussion questions, and participation points.
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