The PMHNP is seeing a patient who has been referred by primary care.
The PMHNP is seeing a patient who has been referred by primary care. The patient is a 41 year old Caucasian female with a primary diagnosis of major depressive disorder, as well as features of bipolar disease. Medication non-responsiveness has resulted in significant functional impairment and has prevented the attainment of remission. The patient is currently on both an SSRI (fluoxetine 25 mg) and SNRI (duloxetine 60 mg) for her depressive symptoms, but her depression is still not in remission. It is most likely that this patient will benefit from an addition of lithium to her current medications. Lithium’s effects are cumulative; therefore, we recommend documenting and charting the first few doses to assess for efficacy or adverse effects. Depending on the response and tolerability, we recommend considering increasing the dosage up to 600 mgs daily depending on need. The PMHNP is seeing a patient who has been referred by primary care.
PMHNP Action Point: The patient indicates a history of bipolar disease in both patient’s father and paternal aunt (this should be further explored) and that the patient had an MI within the past year. The patient has also done an adequate amount of research regarding his illness and is looking for other pharmaceutical options. By learning more about these two factors, one can begin to formulate a better plan of care for this patient in hopes of reaching remission; therefore, the nurse proceeds to ask relevant questions concerning the following factors: 1) Are there any other psychotropic medications that have been tried?; 2) Has he been on an antidepressant with lithium carbonate?; 3) Does he have any medications currently prescribed? And if so, what is it?; 4) Is there any evidence of medical problems affecting the primary or secondary diagnosis?; 5) Are there any current symptoms or clinical findings that are contributing factors to the clinical depression?; 6) Is there a family history of drug abuse/dependence, suicide, major psychiatric illness or psychotic symptoms? The PMHNP is seeing a patient who has been referred by primary care.
The Primary Care Nurse Practitioner (PMHNP) evaluates a patient who has been referred from the primary care physician for further management of depression. The physician had started the patient on an SSRI and an SNRI without improvement of symptoms, despite the fact that the patient met diagnostic criteria for both major depressive disorder and bipolar type I, with a family history of similar disorders. The PMHNP concludes that this patient most likely has bipolar type II and would benefit from quetiapine.
The nurse completes an assessment and develops a plan of care based on the above criteria. This patient would most likely benefit from a mood stabilizer, Aripiprazole, and psychotherapy. The patient’s family history is consistent with bipolar disease, as they share similar personality traits.
Caring and compassionate, the PMHNP provides psychiatric evaluation, diagnosis and treatment of mental disorders. The PMHNP provides education and counseling to address psycho-social issues associated with mental illness and recovery. This includes assessment, planning and individualized tailoring of care which includes clinical interviewing, psychopharmacology, case management and psychosocial rehabilitation. The PMHNP usually works as part of a health care team in a variety of settings, including but not limited to: hospitals/clinics, private practices or other community agencies or programs.
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If the patient has not responded to an SSRI or SNRI antidepressant, you may consider using lithium or lamotrigine. Lamotrigine has proven to be effective for unipolar and bipolar depression and may help stabilize mood as opposed to SSRIs and SNRIs, which can lead to a hypomanic or manic episode. Lithium is indicated for the treatment of bipolar disorder and can be used in conjunction with an antidepressant. Both medications are typically well tolerated. The PMHNP is seeing a patient who has been referred by primary care.
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A final note on the therapeutic consultation is that it differs from the typical psychiatric consultation in several ways. A therapeutic consultation is not just a facts-and-figures meeting, but rather an exploratory session in which both doctor and patient are focused on finding a treatment plan that fits the individual’s needs. Computers with guided protocols do not make therapeutic consultations obsolete, but the trend to prescribe medication without truly examining a patient’s psychological well-being does.
The PMHNP is seeing a patient who has been referred by primary care. The patient was diagnosed with major depressive disorder and trialed on both an SSRI and SNRI by the primary care provider. The patient appears refractory to therapy and has not had any appreciable clinical response. A more detailed psychiatric history is significant for indicators of bipolar disease, as well as a family history of bipolar disease in both the patient’s father and paternal aunt. This patient will most likely benefit from: