Psychiatric Disorders (Depression, Anxiety, Sleep) Discussion essay

Module IV: Psychiatric Disorders (Depression, Anxiety, Sleep) Discussion

 

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Benzodiazepines are commonly prescribed medications for several indications, including anxiety and sleep disorders. Let’s discuss their use in our health care systems and the impact on our patients.
Things to consider might include (just getting you thinking):

Safety: How could the side effect profile affect your patients?
Efficacy: Are benzodiazepines efficacious for anxiety and sleep?
Use: Are they under or over prescribed? How can we ensure safe use of these medications?

Consider the following cases:

KT is a 24 year old female completing her studies. While home for spring break, she presents to her primary care physician because she has been worried about her academic, professional, and personal future since class restarted in late August. She is constantly worried about passing all of her exams and that she is going to be the only one of her friends that graduates school without a ring on her finger.

  • How would you help her assuming she meets the criteria for GAD?

WD is a 49-year-old male who suffered a myocardial infarction one week ago. Upon discharge, it was noted that WD appeared depressed. At a follow-up visit with his physician a week later, WD met criteria for a diagnosis of major depressive disorder. His past medical history includes: treatment refractory hypertension, diabetes mellitus (type II), and severe uncontrolled narrow angle glaucoma

  • How would you help him assuming he meets the criteria for MDD?

JM is a 42 year old female who was referred for management of insomnia. She reports that she is unable to sleep at all during the week (difficulty going to sleep and staying asleep) and sleeps all day on Sunday. She currently takes temazepam (Restoril) 30 mg HS (recently increased from 15mg). She also experiences depression due to an abusive relationship with her boyfriend as well as her current lack of employment. She reports poor sleep hygiene (reads and watches TV in bed), drinks 6-8 cups of coffee throughout the day and does not pay attention to how late she eats or exercises.

  • What non-pharmacological and pharmacological therapies would you recommend for JM?

Post your initial response by Wednesday at midnight. Respond to one student by Sunday at midnight.  Both responses should be a minimum of 150 words, scholarly written, APA formatted, and referenced.  A minimum of 2 references are required (other than your text). Refer to the Grading Rubric for Online Discussion in the Course Resource section.

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    Pawn Johnson-Hunter posted Sep 24, 2020 12:01 AM

    Generalized anxiety disorder is characterized by an excessive, persistent level of worry or consistent overwhelming feelings. University and college students may be at higher risk of developing Common mental health problems (CMHP) because they are often under significant stress, are in a transitional period, and fall within the age range when CMHPs are at their developmental peak (Huang et al., 2018). KT is experiencing an intolerant uncertainty, which may be increasing her anxiety. Her association with the failure of passing her classes and getting married after graduating are distorted thought processes. Brown and Tung (2018), the key diagnostic feature of generalized anxiety disorder (GAD) is excessive anxiety and difficult to control worry about a number of events or activities, occurring more days than not for at least six months. Her worrying initially during spring break and has continued into late August, nearing six months without any foreseen resolve from the patient. In attempting to help her, one must consider her current lifestyle when deciding; the treatment may consist of medication, therapy, or both. Benzodiazepines are typical drug treatments for GAD and have high abuse with the patient due to their addictive nature. Furthermore, KT is a student, and the effect of a benzodiazepine would cause sedative effects that may negative outcomes as she is a student. Before prescribing medication, it may be useful to suggest other options such as exercise and therapy than have KT revisit to see how she has progressed.

    In the case of WD his depression should be treated with medication therapy due to his comorbidities. Depression is associated with an increased risk of mortality in patients with coronary heart disease (Carney et al., 2016). Not treating WD depression could further exacerbate his heart condition. According to Schuster et al., (2016), …

    American Heart Association (AHA) Science Advisory advocated that patients with coronary heart disease be systematically screened for depression to identify those who may require further assessment and treatment. Indeed, depression is present in 20–25% of patients with established heart disease, and effective treatment can improve health-related quality of life and adherence with recommended care, and lower mood symptoms and health care costs.

    JM has a combination of factors that contribute to her depression and insomnia. One of the non-pharmacological recommendations that could be suggested is individual and possibly group therapy. Her unhealthy relationship is likely the cause of her depression and insomnia. Engagement with others in similar situations could help her identify that her lifestyle plays a significant role in her mental health. She should also be offered social services for additional counseling immediately to see if she feels that she is in an unsafe environment.

    References

    Brown, T. A., & Tung, E. S. (2018). The contribution of worry behaviors to the diagnosis of generalized anxiety disorder. Journal of Psychopathology and Behavioral Assessment, 40(4), 636-644. http://dx.doi.org.wilkes.idm.oclc.org/10.1007/s10862-018-9683-5

    Carney, R. M., Freedland, K. E., Steinmeyer, B., Rubin, E. H., Mann, D. L., & Rich, M. W. (2016). Cardiac risk markers and response to depression treatment in patients with coronary heart disease. Psychosomatic Medicine, 78(1), 49.

    Huang, J., Nigatu, Y. T., Smail-Crevier, R., Zhang, X., & Wang, J. (2018). Interventions for common mental health problems among university and college students: A systematic review and meta-analysis of randomized controlled trials. Journal of Psychiatric Research, 107, 1-10. doi:10.1016/j.jpsychires.2018.09.018

    Schuster, James M., MD, MBA, Belnap, B. H., Roth, L. H., MD, & Rollman, Bruce L., M.D., M.P.H. (2016). The checklist manifesto in action: Integrating depression treatment into routine cardiac care. General Hospital Psychiatry, 40, 1-3. doi:10.1016/j.genhosppsych.2016.01.005

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    Tomiko Edmonds posted Sep 23, 2020 9:57 PM

    When referring to Benzodiazepines, they are often prescribed however, they are recommended to be used for short term use for anxiety. They have a potential for dependence and abuse. They will have a sedative effect on the patient and can cause amnesia. While in an acute situation, a Benzodiazepine may be warranted but care must be taken to provide interventions that can be given long term if needed. In the elderly population, it should not be used long term as they may not be able to metabolize the medication hence it will stay in their system longer and can be detrimental. It can also cause safety risks by way of falls with the potential for fractures as well as skin breakdown due to the sedative effects that may not allow them to change positions on their own. Prolonged use is associated with the development of dependence, tolerance and adverse reactions, including cognitive impairment, dementia, falls and consequent fractures, (Fulone et al., 2018).

    Benzodiazepines act fast and can be effective for acute situations. Alprazolam, clonazepam, and lorazepam are among the 10 most commonly prescribed psychotropic medications in the United States, (Lembke et al., 2018). A common problem with this is that those who use illicit drugs combined with this are at greater risk for addiction and untoward events. Benzodiazepines have proven utility when they are used intermittently and for less than 1 month at a time. When they are used for extended periods, the benefits of benzodiazepines diminish and the risks associated with their use increase, (Lembke et al., 2018).

    When speaking with KT regarding her general anxiety disorder, it is important to assess her physically to determine if there are any physiological reasons or perhaps other medications that she is taking that could be the reason for her anxiety. After this is ruled out, it would be important to determine what, if any coping mechanisms she has to deal with the many concerns she has being a new student and coping with her various obligations. Therapy would be the initial course of action. If therapy is being utilized and it is not effective, then medications can be prescribed at its lowest dose. A selective serotonin reuptake inhibitor (SSRI) would be started in combination with therapy to treat her symptoms and coping mechanisms will be taught. She would be advised that the medication may take some time to have its greatest effect before she may see some improvement.

    WD may meet the criterion for Major Depressive Disorder as he had a major health event that one can consider life changing. Major depressive disorder is the most prevalent and disabling form of depression, affecting more than 32 million Americans. In any given year, nearly 7% of the American adult population has an episode of major depressive disorder, (Amick et al., 2015).  With his past medical history, the first course of treatment would be intensive counseling. A meta‑analysis showed that patients who received psychosocial treatment had significant reductions in psychological distress and systolic BP (SBP), (Seyedhosseini et al., 2016). Refractory hypertension, being hard to treat may have caused his depression. The inherent complexity of psychological distress may in fact raise the blood pressure. The most common cardiovascular-related side effects of SSRIs include mild bradycardia and hypotension, mild QRS prolongation, and first-degree cardiac block, (Nezafati et al., 2016). Behavioral modification would be the first line of defense however, if this is not sufficient, medications would be introduced. The provider must assess the willingness of the patient to be compliant with the prescribed medications as all medications have some sort of side effects. Regardless of which treatment patients prefer, some evidence suggests that patients who receive their treatment of choice fare better than those whose treatment is incongruous with their preferences, (Amick et al., 2015). When starting medications, again the use of SSRIs is considered. To initiate antidepressant treatment, modern guidelines recommend new generation antidepressants and in particular (SSRIs), (Kato et al., 2018).

    When prescribing medication for WD, it is important to note that SSRIs are thought to contribute to glaucoma so care must be taken in his circumstance. It has been hypothesized that SSRIs may increase intraocular pressure via serotonergic effects on ciliary body muscle activation and pupil dilation, (Chen et al., 2017). Serotonin has been shown to play a critical role in lens transparency, and, thus, it is postulated that increased levels of serotonin may be associated with lens opacity in human eyes, (Karaküçük et al., 2019). The effect on the body may make their eyes dry and gritty so this should be considered when prescribing medications.

    In addition to the above, SSRIs can potentially induce Diabetes. SSRIs are potential inducers of insulin resistance, and its role may be to act as a direct inhibitor of the insulin signaling cascade in β-cells, (Yao et al., 2018). The effect of comorbid diabetes and depression on decrements in health has been shown to be interactive, suggesting a negative effect on health beyond that expected by adding the effect of the two disorders, (Berge & Riise, 2015).

    When assessing JW, it is important to note that she has significant concerns that are causing her to have anxiety and depression based on her situation. Her immediate safety needs to be addressed wherever possible and resources for job preparedness and training should be referred. Again, counseling should be incorporated first in her treatment plan and coping mechanisms should be taught prior to medication administration. In patients with conditions such as pain, cancer or depression, treatment focused on relieving the primary disorder, (Geiger-Brown et al., 2015). Her primary disorder are the burdens that she deals with on a daily basis. Most likely she is thinking too much of her current situation which is leading to her insomnia. At some point, the body is forcing her to sleep and she finds herself sleeping for extended periods of time on Sunday. Sleep is an important aspect of health and is restorative in nature. The lack of sleep can cause numerous problems both psychologically and physiologically. Sleep problems can be addressed through simple precautions, such as sleep hygiene, relaxation techniques, and behavioral therapy, before recommending medication, (Duman & Timur Taşhan, 2018).

    Alternative, nonpharmacological approaches should be explored such as warm milk, providing a warm quiet environment absent of television or other stimulants prior to the hour of sleep. Late night exercising may prevent her from sleeping as her energy levels may increase however, for some, it can help them sleep better so it advisable to discuss with JW how she feels after exercise. Listening to white noise and calming sounds may prove to be effective. Additionally, avoiding the use of anything that contains caffeine would be advisable.

    JW is noted to be taking a benzodiazepine for sleep. While effective for sleep, it does not have an effect on the reason why she is not getting enough sleep. Temazepam has a longer half life than other benzodiazepines and with continued use will not be effective at the same dose. I would opt to try a more natural approach in addition to nonpharmacological treatments for her insomnia.

     

    References

    Amick, H. R., Gartlehner, G., Gaynes, B. N., Forneris, C., Asher, G. N., Morgan, L. C., Coker-Schwimmer, E., Boland, E., Lux, L. J., Gaylord, S., Bann, C., Pierl, C., & Lohr, K. N. (2015). Comparative benefits and harms of second generation antidepressants and cognitive behavioral therapies in initial treatment of major depressive disorder: Systematic review and meta-analysis. BMJ, h6019. https://doi.org/10.1136/bmj.h6019

    Berge, L., & Riise, T. (2015). Comorbidity between type 2 diabetes and depression in the adult population: Directions of the association and its possible pathophysiological mechanisms. International Journal of Endocrinology2015, 1–7. https://doi.org/10.1155/2015/164760

    Chen, V.-H., Ng, M.-H., Chiu, W.-C., McIntyre, R. S., Lee, Y., Lin, T.-Y., Weng, J.-C., Chen, P.-C., & Hsu, C.-Y. (2017). Effects of selective serotonin reuptake inhibitors on glaucoma: A nationwide population-based study. PLOS ONE12(3), e0173005. https://doi.org/10.1371/journal.pone.0173005

    Duman, M., & Timur Taşhan, S. (2018). The effect of sleep hygiene education and relaxation exercises on insomnia among postmenopausal women: A randomized clinical trial. International Journal of Nursing Practice24(4), e12650. https://doi.org/10.1111/ijn.12650

    Fulone, I., Silva, M., & Lopes, L. (2018). Long-term benzodiazepine use in patients taking antidepressants in a public health setting in brazil: A cross-sectional study. BMJ Open8(4), e018956. https://doi.org/10.1136/bmjopen-2017-018956

    Geiger-Brown, J. M., Rogers, V. E., Liu, W., Ludeman, E. M., Downton, K. D., & Diaz-Abad, M. (2015). Cognitive behavioral therapy in persons with comorbid insomnia: A meta-analysis. Sleep Medicine Reviews23, 54–67. https://doi.org/10.1016/j.smrv.2014.11.007

    Karaküçük, Y., Beyoglu, A., Çömez, A., Orhan, F., & Demir, M. (2019). Early effects of selective serotonin reuptake inhibitors (ssris) on cornea and lens density in patients with depression. Psychiatry and Clinical Psychopharmacology29(4), 387–393. https://doi.org/10.1080/24750573.2019.1673944

    Kato, T., Furukawa, T. A., Mantani, A., Kurata, K., Kubouchi, H., Hirota, S., Sato, H., Sugishita, K., Chino, B., Itoh, K., Ikeda, Y., Shinagawa, Y., Kondo, M., Okamoto, Y., Fujita, H., Suga, M., Yasumoto, S., Tsujino, N., Inoue, T.,…Guyatt, G. H. (2018). Optimising first- and second-line treatment strategies for untreated major depressive disorder — the sun☺d study: A pragmatic, multi-centre, assessor-blinded randomised controlled trial. BMC Medicine16(1). https://doi.org/10.1186/s12916-018-1096-5

    Lembke, A., Papac, J., & Humphreys, K. (2018). Our other prescription drug problem. New England Journal of Medicine378(8), 693–695. https://doi.org/10.1056/nejmp1715050

    Nezafati, P., Nezafati, M., Eshraghi, A., Vojdanparast, M., & Abtahi, S. (2016). Selective serotonin reuptake inhibitors and cardiovascular events: A systematic review. Journal of Research in Medical Sciences21(1), 66. https://doi.org/10.4103/1735-1995.189647

    Seyedhosseini, S., Razavi Ratki, S., Valizadeh, A., Rastgoo, T., Tavakkoli, R., Golabchi, A., Ghashghaei, F., Nemayandeh, S., Boroomand, A., & Shirinzade, A. (2016). Can antidepressant drug impact on blood pressure level in patients with psychiatric disorder and hypertension? a randomized trial. International Journal of Preventive Medicine7(1), 26. https://doi.org/10.4103/2008-7802.174891

    Yao, S., Li, J., Fan, X., Liu, Q., & Lian, J. (2018). The effect of selective serotonin re-uptake inhibitors on risk of type ii diabetes mellitus and acute pancreatitis: A meta-analysis. Bioscience Reports38(5). https://doi.org/10.1042/bsr20180967

     

     

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    Shante Hunt posted Sep 23, 2020 6:45 PM

    KT is a 24 year old female who is exhibiting symptoms of generalized anxiety disorder resulting from worries related to her personal, professional, and academic life.  Treatment of generalized anxiety disorder can begin with cognitive behavioral therapy, pharmacotherapy, or a combination of both methods.  Assessment of her symptoms would include questions related to severity and duration of anxiety, impact on her daily life, assessment of her sleep habits, and whether or not she has other diagnoses such as major depressive disorder.  I would begin KT’s treatment with an SSRI such as Escitalopram 5 mg daily (Stein and Sereen, 2015) and refer her to a psychologist for cognitive behavioral therapy.  In addition to pharmacotherapy, I would suggest lifestyle modifications to avoid stimulants like caffeine.

     

    WD is a 49 year old male with a recent history of MI one week ago.  He presents with symptoms of major depressive disorder on follow up and has a history of uncontrolled hypertension, diabetes type II, and uncontrolled narrow angle glaucoma.  My first recommendation for WD would be psychotherapy to help him explore his feelings of depression.  If psychotherapy is either ineffective or not reaching an optimal effect, I would start him on an SSRI like Paroxetine since this class of drug is considered first line treatment and Paroxetine does not have the anticholinergic effects of other SSRIs that would be contraindicated for him due to his history of HTN and glaucoma (Citrome, 2018).

     

    JM is a 42 year old female reporting symptoms of insomnia and additive depression due to personal difficulties in her relationship and lack of employment.  She reports that she has trouble achieving and maintaining sleep despite taking Restoril 30 mg at bedtime.  She also reports poor sleep hygiene and high caffeine intake so treatment would begin with instructing her to limit her caffeine intake and not consume coffee close to bedtime; we would select a time that is agreeable to her.  Additional non-pharmacological recommendations would include eliminating the use of her cell phone for at least 30 minutes before bedtime to allow her brain to prepare for sleep (Lie et al, 2015).  Pharmacological intervention would include a medication such as Suvorexant 10 mg at bedtime(Belsomra) which is approved for insomnia characterized by difficulty falling asleep and maintaining sleep and has  (Lie et al, 2015).  If Suvoxerant is too expensive for her due to her lack of employment and because she reports depressive symptoms I may recommend Doxepin which is a TCA but does not demonstrate the common side effects of other TCAs due to the lower dose appropriate for insomnia (Lie et al, 2015).

     

    References:

     

    Citrome, L. (2018). Improving diagnosis and treatment strategies for major depressive disorder. Journal of Managed Care Medicine, 21(1), 24-28. http://web.a.ebscohost.com.wilkes.idm.oclc.org/ehost/pdfviewer/pdfviewer?vid=5&sid=140a33b2-ea8d-4391-9cc4-df4e0b1f96a8%40sdc-v-sessmgr02

     

    Lie, J., Tu, K., Shen, D., & Wong, B. (2015). Pharmacological treatment of insomnia. P&T: A Peer-Reviewed Journal for Managed Care and Formulary Management, 40(11), 759-771. http://web.a.ebscohost.com.wilkes.idm.oclc.org/ehost/pdfviewer/pdfviewer?vid=8&sid=140a33b2-ea8d-4391-9cc4-df4e0b1f96a8%40sdc-v-sessmgr02

     

    Stein, M., & Sareen, J. (2015). Clinical practice. Generalized anxiety disorder. New England Journal of Medicine, 373(21), 2059-2068. Doi: http://dx.doi.org.wilkes.idm.oclc.org/10.1056/NEJMcp1502514

     

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    Candace Whitman-Workman posted Sep 23, 2020 9:51 PM

    KT

    I would begin by having an open and frank conversation with KT.  I would inquire as to how her studies are going and about life goals.  I would complete the GAD-7 assessment to establish if she met the conditions for a diagnosis of GAD.  I also would want to glean a better understanding of her treatment goals.  Is she requesting an anxiolytic medication?  Has she tried medications whether her prescriptions or those obtained from friends or acquaintances?  I would want to know what type of social supports she has both at home and at school and if local family and friends continue their support while she’s away at school.  I would continue to explore and do a PHQ-9 to further evaluate depression and the potential for self-harm.

    I would highly encourage her to see a therapist and attempt to link her with campus mental health assistance.  I would speak with her in an accepting, destigmatizing way in order to get her buy in for therapy.  My personal opinion is that medications, without changing thinking or thought patterns, are only partially treating the anxiety issue.

    Working in addictions, I see all too much that people want a pill to fix everything and do not necessarily want to do the personal work behind the situation or symptoms.  I would not, unless there was some significant information uncovered in the interview that is not obvious in the case scenario, start a benzodiazepine.  I would, however, opt for starting an SSRI in conjunction with therapy.  Given that the SSRI would not have effect for two (2) to four (4) weeks, I would also use Vistaril and or a beta-blocker on an as needed basis until the SSRI is more fully effective; longer if breakthrough symptoms continue to occur.

    I would provide education that in young people, such as herself, antidepressants can potentiate the thoughts of suicide and encourage her to reach out to her local provider should she experience any type of suicidal thinking.  I would encourage her to continue follow up on campus in her school’s city with a collaborative provider to help to manage her symptoms.  I would want her to continue to follow up with me.

    WD

    WD’s depression must have been occurring long before his cardiac symptoms or event to meet the guidelines for MDD.  As Chisholm-Burns et al. (2019) explains, untreated anxiety disorders can lead to MDD.  Also, anxiety producing hormones lead to tissue and organ damage, very likely contributing to WD’s cardiac event.   I would evaluate WD and treating much like KT further evaluate symptoms and encouraging him to see a therapist.  While it is not clear in this case scenario whether WD has any psychotic symptoms, I would fully evaluate for them.  I would start an antidepressant only if his symptoms were moderate to severe.  With his recent cardiac event, he will be on many medications and I would rather not add another unless absolutely necessary.  However, if WD does have symptoms of psychosis, I would start an antipsychotic.  I would also begin folic acid as this drug has little drug to drug interactions and aids in depression.  I would also add Omega 3s since it would have dual benefit on mood and cardiac issues.  Appleton et al. (2016) reviews the benefits of Omega 3 fatty acids for the treatment of depression.  I would re-evaluate in 4-8 weeks and per Chisholm-Burns et al. (2019) and if no symptom improvement, reassess the diagnosis and treatment.

    JM

    For JM, non-pharmalogical approaches would include patient education regarding sleep hygiene, stimulus reduction, and caffeine reduction.  I would also educate JM on the importance of getting regular exercise and engaging herself in something on Sunday to avoid day time sleep.  It’s important to re-establish the circadian rhythm.  I would complete a NPSG to fully evaluate the potential sleep disturbance.  Prior to making pharmacologic changes, I would want to further evaluate how her sleep changed since instituting the Restoril.  It is possible that a paradoxical effect could be occurring and if this is suspected, I would immediately discontinue the Restoril.  Given JM’s abusive environment, it is possible she is experiencing PTSD and or depression.  Rather than using Restoril, I would tend to prescribe something such as Trazadone or Seroquel at HS.  I would also encourage JM to get involved with a therapist to work through some of her other issues that are most likely contributing factors.  I would also start Melatonin and as recommended by Madsen, et al. (2017), would initiate a sleep diary.  Through the use of a sleep diary, JM can drill down on sleep cycle, diet and environmental factors precipitating sleep.

    References

    Appleton, K. M., Sallis, H. M., Perry, R., Ness, A. R., & Churchill, R. (2015). Omega-3 fatty acids for depression in adults. Cochrane Library, 2016(12), CD004692. doi:10.1002/14651858.cd004692.pub4

    Chisolm-Burns, M. A., S, Schwinghammer, T. L., Malone, P. M., Kolesar, J. M., Lee, J. M., & Bookstaver, P. B. (2019). Pharmacotherapy Principles & Practice (Fifth ed.). McGrraw-Hill Education.

    Madsen, M. T., Isbrand, A., Andersen, U. O., Andersen, L. J., Taskiran, M., Simonsen, E., & Gögenur, I. (2017). The effect of MElatonin on depressive symptoms, anxiety, CIrcadian and sleep disturbances in patients after acute coronary syndrome (MEDACIS): Study protocol for a randomized controlled trial. Trials, 18(1), 81. doi:10.1186/s13063-017-1806-x

     

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    Anna McMullen posted Sep 21, 2020 4:47 PM

    Benzodiazepines (BZDs) are useful medications for the acute treatment of seizures, severe muscle spasms, tremors, alcohol withdrawal syndrome, anxiety, and insomnia (Harvard Health Publishing, 2019). Though short-term administration can be efficacious and pose minimal risk, long-term administration causes physical dependence, resulting in withdrawal syndrome when abruptly discontinued. BZDs are generally recommended as a short-term option for acute anxiety or while pending a response towards antidepressants, since they have a rapid anxiolytic and sedative/hypnotic effect (Tanguay Bernard et al., 2018). Assuming that KT meets the criteria for GAD, first-line therapy to recommend would be cognitive behavioral therapy (CBT)/ cognitive therapy (CT) to help her evaluate and cope with her anxious thoughts through cognitive restructuring, problem solving, worry exposure, and applied relaxation (Powers et al., 2015). KT might also want to consider pharmacologic therapy along with CBT/CT, such either an SNRI or an SSRI, approved therapies including Venlafaxine XR, Paroxetine, or Escitalopram (Powers et al., 2015). These medications are as effective and safer for long-term administration than benzodiazepines for GAD, while also reducing the risk of dependence (Harvard Health Publishing, 2019).

    Assuming WD meets the criteria for MDD, recommendations to help him cope with his recent life-alternating event (suffering from an MI) and resolve his depressive symptoms to return to a euthymic state is the goal. Interpersonal and CBT would be recommended for first-line therapy, along with pharmacotherapy, as combination therapy is helpful for patients with psychosocial stressors such as WD (Chisholm-Burns et al., 2019). SSRI’s would be most appropriate for first-line pharmacotherapy, however, precautions on which medication to prescribe must be taken considering WD’s past medical history. A dose related elevation in BP can occur with the SNRI’s venlafaxine and desvenlafaxine, and due to WD’s HTN, these would not be recommended (Chisholm-Burns et al., 2019). Additionally, the SSRI paroxetine has mild anticholinergic effects, and with WD’s severe uncontrolled narrow angle glaucoma, this medication would also not be recommended. According to the Cleveland Clinic (2019) there is a link between and heart disease and depression; these patients should adopt a healthy lifestyle including regular exercise, proper sleep, a healthy diet, and may also benefit from the SSRIs sertraline (Zoloft) and citalopram (Celexa) which have been deemed effective and safe in patients with heart disease.

    Given JM’s current circumstances, I would first recommend that she improve her sleep hygiene. Ways that she can improve her sleep hygiene include: keeping a consistent routine before bedtime, allowing 30 minutes for winding down before sleep, dimming the lights in the room, unplugging from electronics 30-60 minutes before bed, cut down on caffeine, don’t eat late in the evening, get daylight exposure to help with circadian rhythm, exercise but not within a few hours of going to sleep, and restrict in bed activity (such as reading and watching TV) (Vyas & Suni, 2020). JM is also suffering from psychosocial issues, her abusive relationship with her boyfriend and unemployment. CBT/CT would be helpful and aid in coping with these recent life stressors. Moving on from an abusive relationship and gaining employment may help reduce the stress she is currently experiencing. JM is currently taking a benzodiazepine, Restoril 30mg HS, and this dose was recently increased. The increased dose may be helpful while JM is working on improving her sleep hygiene and her psychosocial stressors, but it is not recommended for long-term use. Though JM would benefit from antidepressant therapy, SSRI’s and SNRI’s may cause insomnia and worsen sleep quality, and since JM is already experiencing poor sleep, other options may want to be considered (Aiken, 2019). Although quetiapine (Seroquel) should not be used for primary insomnia, it is appropriate to be used for antidepressant augmentation, as it is not just sedating, it also improves the deep, restorative phase of sleep (Aiken, 2019). Another drug that may be considered for JM is buproprion; though it can increase daytime energy, it causes no more insomnia than SSRIs and has neutral to positive effects on overall sleep (Aiken, 2019). Overall, JM has many psychosocial factors that are likely influencing her ability to sleep and once she improves upon her relationship, employment status, and sleep hygiene, her sleep will likely improve.

     

    References

    Aiken, C. (2019, May 22). Sleep problems can guide antidepressant selection. Psychiatric Times. https://www.psychiatrictimes.com/view/sleep-problems-can-guide-antidepressant-selection

    Chisholm-Burns, M., Schwinghammer, T., Malone, P., Kolesar, J., Lee, K. C., & Bookstaver, P. B. (2019). Pharmacotherapy principles and practice (5th ed.). Mcgraw-hill Education / Medical.

    Depression & heart disease management and treatment. (2019, April 29). Cleveland Clinic. https://my.clevelandclinic.org/health/diseases/16917-depression–heart-disease/management-and-treatment

    Harvard Health Publishing. (2019, March 15). Benzodiazepines (and the alternatives). Harvard Health. https://www.health.harvard.edu/mind-and-mood/benzodiazepines_and_the_alternatives

    Powers, M., Becker, E., Gorman, J., Kissen, D., & Smits, J. (2015, July 2). Clinical practice review for GAD. Anxiety and Depression Association of American (ADAA). https://adaa.org/resources-professionals/practice-guidelines-gad

    Tanguay Bernard, M.-M., Luc, M., Carrier, J.-D., Fournier, L., Duhoux, A., Côté, E., Lessard, O., Gibeault, C., Bocti, C., & Roberge, P. (2018). Patterns of benzodiazepines use in primary care adults with anxiety disorders. Heliyon4(7). https://doi.org/10.1016/j.heliyon.2018.e00688

    Vyas, N., & Suni, E. (2020, August 14). What is sleep hygiene? Sleep Foundation. https://www.sleepfoundation.org/articles/sleep-hygiene

     

     

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    Gisselle Mustiga posted Sep 24, 2020 12:50 AM

    Benzodiazepines are sedative-hypnotics that provide quick relief for anxiety and insomnia symptoms. Regardless of their usage period, long-term or short-term, benzodiazepines are known to pose various adverse side effects (Hashmi, Han, French-Rosas, Jabbar, Khan & Shah,2018).

    Anxiety is one of the main symptoms of many psychiatric disorders; its prevalence in the U.S is at least 4%. According to Bachhuber, Hennessy, Cunningham and Starrels (2016), though benzodiazepines are efficacious in treating anxiety, insomnia, and panic disorder, the efficacy is lost in 4 to 6 weeks of usage, and the patient becomes dependent. This particular risk significantly increases with the duration and dose of the treatment. Benzodiazepines are a short-term treatment. The long and safer shot includes psychotherapy, non- pharmacological interventions, and drug management. Moreover, situational insomnia cannot be managed without addressing underlying issues such as stress, depression and practicing good sleep hygiene.

    Benzodiazepines are widely prescribed, especially in the western regions. The use of these drugs increases with age and is prolonged by its addictive nature. Therefore, a medical practitioner needs to apply a professional and evidence-based approach in prescribing (Kennedy & O’Riordan,2019). It can be done through a comprehensive assessment of the patient, offering an acute description of alternative treatments in a long-term case, amongst others.

    For the first scenario involving KT, I would conduct a thorough assessment in order to exclude a substance, medical, or psychological condition as the causative factor of KT’s anxiety. Next, I would assess the severity and span of her symptoms. Having passed the criteria for GAD, I would recommend KT an individualized multimodal therapy that consists of psychotherapy, and non-pharmacological management. In the event that psychotherapy alone doesn’t prove successful, I would follow the treatment algorithm for GAD and prescribe an SSRI such as Lexapro 10mg QD and up-titrate the dose accordingly. Additionally, I would add a two to three week course of a BZD such as Xanax as a short term adjunct during the initiation phase of the SSRI therapy.

    Delving into WD’s case, form the background information provided, it would seem as if he’s experiencing a bout of situational depression although it could also be attributed to his CAD. Following a thorough physical, psychiatric evaluation, medication regimen, and lifestyle assessment, I would evaluate him for the presence of any other psychiatric comorbidities as this would guide the selection of the right ATD agent. Moreover, I would assess his adherence to medications and any history of previous depression as this may indicate a trial with a different ATD drug. Given that he has a history of refractory HTN, I would look into his current medication list for any use of propanolol or clonidine as these drugs cause depressive symptoms. In order to help WD out, I would suggest psychotherapy and if needed, a course of a first line ATD such as an SSRI namely Celexa 20mg QD or Prozac 20mg QD and up-titrate accordingly. If necessary, a 2 to 3 week course of BZDs may be added until effects of ATD are reported.

    Lastly, in regards to JM, as expected I would conduct a thorough physical, psychiatric evaluation, medication regimen, and lifestyle assessment. After ruling out any underlying conditions such as OSA, RLS, CRDs, Parasomnias, or Narcolepsy, I would counsel her on non-pharmacological therapy such as start practicing better sleep hygiene (behavior changes such as stopping caffeine consumption by 5pm, exercising or eating no more than 5 hours before retiring to sleep, and using her bed only for sleep and intimacy) and refraining from any stressful situation, i.e. abusive boyfriend. She also needs to reduce and ultimately discontinue her use of temazepam as it may be causing the lack of sleep due to loss of efficacy. In the event that her insomnia persists despite behavioral, environmental, and lifestyle modifications, I would prescribe her a course of a Z-drug such as Ambien with a starting dose of 10mg QHS, as it has shown to induce and sustain sleep. Similarly, a course of Mirtrazapine 15mg QHS could be considered as it is commonly used for insomnia and concomitant depression.

    References

    Bachhuber, M. A., Hennessy, S., Cunningham, C. O., & Starrels, J. L. (2016). Increasing benzodiazepine prescriptions and overdose mortality in the United States, 1996–     2013. American journal of public health106(4), 686-688.

    Hashmi, A. M., Han, J. Y., French-Rosas, L., Jabbar, Q., Khan, B. A., & Shah, A. A. (2018).

    Benzodiazepine use and abuse. Psychiatric Annals48(8), 360-365.

    Kennedy, K. M., & O’Riordan, J. (2019). Prescribing benzodiazepines in general practice. Br J

    Gen Pract69(680), 152-153.

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    Carlita Lockett posted Sep 19, 2020 8:52 PM

    Attached is the word document of Discussion 4.

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    Jessica Faltinowski posted Sep 22, 2020 5:15 PM

    Psych Disorders Discussion

    Benzodiazepines are a class of medications often prescribed to treat insomnia, anxiety, and seizures among other disorders.  These medications are highly effective, as they have a rapid onset, crossing the blood-brain barrier, where they increase activity at neurotransmitter gamma-aminobutyric acid (GABA) (Soyka, 2017).  As this transmitter decreases the activity of neurons, the resultant effect is rapid decrease in the fight or flight response feeling of anxiety.  While benzodiazepines do have a place, their use should be for short-term relief, less than 2-4 weeks, while waiting for medications that potentiate the reuptake of serotonin to reach therapeutic levels.   Benzodiazepines are considered safe medications as they have low toxicity, but are very addicting and have high potential for abuse.  As such, these medications should not be prescribed for patients with a history of polysubstance abuse, except in short-term detox settings.

    Generalized anxiety disorder (GAD) is a disorder which is characterized by chronic incessant worry, poor concentration, irritability, and decreased level of social functioning (Stein & Sareen, 2015).  This disorder is also often associated with somatic complaints such as back pain, stomachaches, and headaches.  Women are diagnosed with GAD twice as often as men (Kato et al., 2018).  As GAD is chronic, the persistent anxiety must last for 6 months or longer in order to meet the criteria.  A diagnosis of GAD must meet DSM-V criteria, and can be assessed utilizing different screening tools such as GAD-7 or the Penn State Worry Questionnaire (Spitzer et al., 2006).  The GAD-7 is an 8 question self-answered diagnostic tool that helps a clinician assess the level of anxiety and the overall effect on the patient’s life. Treatment of GAD requires a stepped approach and should also include cognitive behavior therapy as pharmacological interventions are not a “cure” for anxiety, but rather they suppress activity in the amygdala and pre-frontal cortex (Abejuela & Osser, 2016).

     

     

    KT is a young adult female who is experiencing anxiety related to a generalized adjustment disorder.  Utilizing DSM-V criteria, KT has been given a diagnosis of Generalized Anxiety Disorder.  The first line therapy for GAD is a selective serotonin reuptake inhibitor (SSRI) (Abejuela & Osser, 2016), although a serotonin and norepinephrine reuptake inhibitor (SNRI) such as duloxetine is also an option, especially if KT had more somatic symptoms such as pain.  In KT’s case, given her age, a few options to consider would be fluoxetine or escitalopram (Kato et al., 2018).  As both medications are generally well tolerated with few side effects, either would be beneficial.  SSRIs reach therapeutic levels in 6-8 weeks, with a patient seeing the first signs of improvement in sleep, appetite, and energy within the first 2 weeks, and significant improvement in anxiety in 2-4 weeks.  In the interim, KT could be prescribed an as needed medication that would help decrease the uncomfortable feelings of anxiety such as hydroxyzine, propranolol, gabapentin, or clonidine.  If her anxiety was not manageable in the short-term with these medications, then a small dose of a benzodiazepine, such as clonazepam, could be considered for the first 2 weeks (Stein & Sareen, 2015).  KT should follow up in 4-6 weeks.  If she has not achieved a 50% decrease in her symptoms at that time, it would be time to re-evaluate medications and either consider an increase in dose, a medication change, or an addition of another medication (Kato et al., 2018).

    Major Depressive Disorder (MDD) is characterized by pervasive feelings of sadness, loss of interest, hopelessness, and trouble completing activities of daily living (Depression, n.d.).  One tool clinicians use when evaluating depression in patients is the Hamilton Rating Scale for Depression (Sharp, 2015).  This is a series of either 17 or 21 questions to evaluate symptomatology of depression including sleep, social functioning, quality of life, and feelings of hopelessness.  SSRI’s are considered the gold standard for treating MDD, but other medications such as SNRIs or bupropion, a norepinephrine dopamine reuptake inhibitors (NDRI) may be used (Kato et al., 2018).  As with medications for GAD, these medications take 6-8 weeks to reach maximum therapeutic levels, with patients generally endorsing decreased levels of depression within the first 2-4 weeks.

    WD, a 49-year-old male, with underlying health conditions, recently suffered a myocardial infarction, and is noted to be depressed. As criteria for major depressive disorder (MDD) has already been established, it is in WD’s best interest to start an anti-depressant.  Given WD’s medical health, an SSRI such as fluoxetine or sertraline would be a first-line treatment.  These medications are generally considered safe in patients with hypertension and glaucoma (Kato et al., 2018).

    Most people struggle with insomnia at some point in their lives.  For many people, poor sleep hygiene can be a component.  Additionally, studies show that 50% of people endorsing insomnia have an underlying untreated mental health condition (Winkelman, 2015).  Insomnia has different components such as difficulty falling asleep, difficulty staying asleep, and early morning awakening.  Cognitive behavioral therapy with improved sleep hygiene are the first line treatments for insomnia.  However, many people also require temporary pharmacological interventions.

    JM, a 42-year-old female, with poor sleep hygiene, in conjunction with depression, is endorsing continued insomnia despite her current regimen of temazepam 30 mg at bedtime.  JM should be counseled regarding the poor lifestyle choices that she is making, such as high caffeine intake, lack of exercise, and high emotional stress levels.  While a pharmacological intervention should be initiated, if JM does not make lifestyle changes and seek CBT, the interventions will not be as effective.  As JM is endorsing depression as well as insomnia, an addition of trazodone or low dose quetiapine before bed would be beneficial (Winkelman, 2015). Temazepam should be considered only as a short-term hypnotic for sleep and be discontinued.  As JM is struggling with daytime alertness and depression, she would be a good candidate for bupropion (Cipriani et al., 2018).

     

    References

    Abejuela, H., & Osser, D. N. (2016). The psychopharmacology algorithm project at the harvard south shore program. Harvard Review of Psychiatry24(4), 243–256. https://doi.org/10.1097/hrp.0000000000000098

    Cipriani, A., Furukawa, T. A., Salanti, G., Chaimani, A., Atkinson, L. Z., Ogawa, Y., Leucht, S., Ruhe, H. G., Turner, E. H., Higgins, J. T., Egger, M., Takeshima, N., Hayasaka, Y., Imai, H., Shinohara, K., Tajika, A., Ioannidis, J. A., & Geddes, J. R. (2018). Comparative efficacy and acceptability of 21 antidepressant drugs for the acute treatment of adults with major depressive disorder: A systematic review and network meta-analysis. The Lancet391(10128), 1357–1366. https://doi.org/10.1016/s0140-6736(17)32802-7

    Depression. (n.d.). Retrieved September 22, 2020, from https://www.nimh.nih.gov/health/topics/depression/index.shtml

    Kato, T., Furukawa, T. A., Mantani, A., Kurata, K., Kubouchi, H., Hirota, S., Sato, H., Sugishita, K., Chino, B., Itoh, K., Ikeda, Y., Shinagawa, Y., Kondo, M., Okamoto, Y., Fujita, H., Suga, M., Yasumoto, S., Tsujino, N., Inoue, T.,…Guyatt, G. H. (2018). Optimising first- and second-line treatment strategies for untreated major depressive disorder — the sun☺d study: A pragmatic, multi-centre, assessor-blinded randomised controlled trial. BMC Medicine16(1). https://doi.org/10.1186/s12916-018-1096-5

    Sharp, R. (2015). The hamilton rating scale for depression. Occupational Medicine65(4), 340–340. https://doi.org/10.1093/occmed/kqv043

    Soyka, M. (2017). Treatment of benzodiazepine dependence. New England Journal of Medicine376(12), 1147–1157. https://doi.org/10.1056/nejmra1611832

    Spitzer, R. L., Kroenke, K., Williams, J. W., & Löwe, B. (2006). A brief measure for assessing generalized anxiety disorder. Archives of Internal Medicine166(10), 1092. https://doi.org/10.1001/archinte.166.10.1092

    Stein, M. B., & Sareen, J. (2015). Generalized anxiety disorder. New England Journal of Medicine373(21), 2059–2068. https://doi.org/10.1056/nejmcp1502514

    Winkelman, J. W. (2015). Insomnia disorder. New England Journal of Medicine373(15), 1437–1444. https://doi.org/10.1056/nejmcp1412740

     

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    Augusta Ibeh posted Sep 23, 2020 4:15 PM

     

    Generalized anxiety disorder (GAD) is one of the most common psychiatric disorders in primary care, although it is often underrecognized and undertreated Davidson, Feltner, & Dugar (2010). Generalized anxiety disorder is chronic, disabling and is linked with many order disorders or health issues. GAD criteria include these list of symptoms (restlessness, irritability, difficulty concentrating, muscle tension, sleep disturbance and being easily fatigued) Davidson et al. (2010) and duration of the disorder last up to 6 months. GAD onset is usually gradual but progresses to be recurrent and chronic and complete recovery are low.

    KT is worried about her academics and if she is going to graduate with her friends. This is stressing her and causing her to experience poor concentration in her academics. The cause of GAD is not well known, but it is linked with genetic, environment reaction Davidson et al. (2010). Individuals with GAD always say that are worried about things extremely that they conceived are dangerous or threats without any evidence.

    To meet up KT problems and issues, appropriate assessments are required with the use of: Generalized anxiety disorder 7-items. This assessment tool which assessments patient in 7 different areas within for 2 weeks rating it from: 0 for Not at all, 1 for several days, 2for more than half the days and 3 nearly every day. This tool looks at individual’s:

    1.Feeling nervous, anxious or at edge

    2.Not being able to stop or control worrying

    3. Worrying too much about different things

    4. Trouble relaxing

    5. Being so restless that it is hard to sit still

    6. Becoming easily annoyed or irritable

    7. Feeling afraid as if something awful might happen.

    Reviewing KT chief complaint, She fell into the 7-assessment tool, she is worried that she might not graduate with her friends. As a practitioner, more histories must be obtained, her family history, how she hands stress, sleep pattern and her coping skills. Coping skills include what she does to relax, recreational activities etc. KT could be started on Buspirone (Buspar), which is antianxiety at a scheduled dosage at a low dose and monitor patient two weekly. Follow up after initiating treatment to assess for adverse side effects. Encourage to take medication and attend to therapy as recommended. Therapeutic effects of Buspar is up to 2-4 weeks Wilson & Tripp (2020). There is no risk of dependency or withdrawal due to lack of effects on GABA receptors (neurotransmitter gamma-aminobutyric acid) Wilson and Tripp (2020) and has been approved by Food and Drug Administration (FDA) for the treatment of GAD both short and long-term basis. Patient will be referred counselling with a psychotherapist that will help her regulate her emotions Edmund (n.d.).

    Benzodiazepines are among the moat prescribed drugs globally Guina, & Merrill, (2018). Benzodiazepines are sedative-hypnotic and are also used to relief anxiety rapidly. These group of medications are addictive in nature and have withdrawal effects. Evidence use of benzodiazepines are in the short term (2-4 weeks) treatments of panic disorder, general anxiety disorder, social anxiety disorder and insomnia. Evidence is against the use of benzodiazepines for patients with comorbid conditions for a long period without trying other first and second line of drugs Guina, & Merrill, (2018). Contra-indications for the use of benzodiazepines are depression, suicide ideation, psychosis, neurogenic disorders including traumatic brain injury etc.

    Patients with cardiovascular disease (CVD) and affective disorders are common Mavrides, & Nemeroff, (2015). The prevalence of depression is between 17% and 47% in CVD patients Mavrides, & Nemeroff, (2015). Depression may make individual’s health condition worse due its effects on the proinflammatory factors, hypothalamic-pituitary axis, nervous system, and metabolic factors. It can lead to inactivity, overweight, smoking and poor adherence to medical treatments Katon (2011).

    It is very important to treat WD 49 years old to reduce comorbidities resulting from Myocardial infarction and major depressive disorder to prove his lifestyle and reduce disabilities. Usually Clinicians should consider using psychotherapy, pharmacotherapy as it will suit the patient Cruz, Chionglo, Tran (2019).  Depression screening, blood pressure monitoring, AIC levels, and measure patient’s weight and BMI.  Antidepressants are made up Selective serotonin reuptake inhibitors (SSRIs), serotonin and norepinephrine reuptake inhibitors (SNRIs), tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs).The TCAs are linked with arrhythmogenic activity which may be a result from the potent blockade of cardiac sodium and potassium channels and affect cardiac contractility and have even been associated to worsening of ischemic heart disease and sudden cardiac death, and thus should be avoided completely in patients at risk of a serious arrhythmia Pragle (2018). Studies have shown that the use SSRIs such as Zoloft, Lexapro, Prozac are safe and effective to be used on patients with heart diseases    in the treatment for MDD.

     

     

    Insomnia is defined as difficulty with sleep initiation, duration, quality or consolidation, which results in impairment of daytime functioning. Insomnia is usually a chronic condition lasting from 1 year to 3 years Heesch (2014). Some of the benzodiazepine receptor agonists are approved by the Federal Drug Administrator, such as temazepam, estazolam, triazolam, quazepam and the non-benzodiazepine are zaleplon, zolpidem and eszopiclone Heesch (2014).  Restoril is a sedative-hypnotic drug that is used for the treatment of insomnia but is addictive and it acts on the central nervous system causing depression, individuals build tolerance and dependent to its uses.

    Caffeine is an adenosine-receptor antagonist and affects the A1 and A2A receptors, which in turn are related to functions of the brain linked with sleep, arousal, and cognition O’Callaghan, Muurlink and Reid (2018). JM should be advised to gradually reduce the consumption of coffee.

    The non-pharmacological treatments JM are cognitive behavioral therapy for insomnia (CBTI). This therapy aims at reducing factors that reduce sleep, adopt sleep hygiene, relaxation training and these last 4 to 8 sessions by a therapist. Using a diary to record number of hours of sleep. Awakening, and naps Siebern, Suh, and Nowakowski (2012).

    • Sleep restriction: This limits the amount of sleep in bed. Sleep restriction therapy is effective because it strengthens sleep and wake system that is controlled by the endogenous circadian pacemaker Siebern, Suh, and Nowakowski (2012).
    • Stimulus control is used is used to reduce the number hours one spends awake in bed. That patient goes to bed when sleepy i.e., using bed for sleep and sexual activities Siebern, Suh, and Nowakowski (2012).
    • Relaxation technique during the day or before bedtime such as deep breathing exercises, watching relaxing movie, tensing and relaxation exercises Siebern, Suh, and Nowakowski (2012).
    • Pharmacological drug that should be added to the non-pharmacological treatment for JM should be Trazodone. Start JM on a low dosage from 50mg to 100mg at night. Trazodone is an antidepressant but is widely used as a sleep aid. It an antagonist to serotonin type 2 (5-HT2) receptors Jaffer et al. (20170.

    Reference

    Aimee Pragle (2018) Depression and CAD. Retrieved from https://www.acc.org/latest-in-            cardiology/articles/2018/09/28/08/08/depression-and-cad

    Austin De La Cruz, Alyssa Marie Chionglo, Thao Tran (2019) Current Updates Regarding             Antidepressant Prescribing in Cardiovascular Dysfunction. (n.d.). Retrieved from             https://www.acc.org/latest-in- cardiology/articles/2019 current-updates-regarding- antidepressant-prescribing-in-cv-dysfunction

    Davidson, J. R., Feltner, D. E., & Dugar, A. (2010). Management of generalized anxiety disorder in primary care: identifying the challenges and unmet needs. Primary care companion to the Journal of clinical psychiatry12(2), PCC.09r00772.      https://doi.org/10.4088/PCC.09r00772blu

    Generalized Anxiety Disorder 7-item (GAD-7). (n.d.). Retrieved from             https://www.hiv.uw.edu/page/mental-health-screening/gad-7

    Guina, J., & Merrill, B. (2018). Benzodiazepines I: Upping the Care on Downers: The Evidence of Risks, Benefits and Alternatives. Journal of clinical medicine7(2), 17.     https://doi.org/10.3390/jcm7020017

    Jaffer, K. Y., Chang, T., Vanle, B., Dang, J., Steiner, A. J., Loera, N., Abdelmesseh, M.,   Danovitch, I., &             Ishak, W. W. (2017). Trazodone for Insomnia: A Systematic           Review. Innovations in clinical             neuroscience14(7-8), 24–34.

    Katon W. J. (2011). Epidemiology and treatment of depression in patients with chronic medical             illness. Dialogues in clinical neuroscience13(1), 7–23.

    Mavrides, N., & Nemeroff, C. B. (2015). Treatment of affective disorders in cardiac         disease. Dialogues in         clinical neuroscience17(2), 127–140.

    O’Callaghan, F., Muurlink, O., & Reid, N. (2018, December 07). Effects of caffeine on sleep       quality and             daytime functioning. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6292246/

    Sara J. Edmund is a clinical assistant professor at the University of Arizona. (n.d.). The challenge            of generalized anxiety disorder in primary…: The Nurse Practitioner. Retrieved from             https://journals.lww.com/tnpj/FullText/2018/04000/The_challenge_of_generalized_anxie            ty_disorder_in.3.aspx

    Siebern, A. T., Suh, S., & Nowakowski, S. (2012, October). Non-pharmacological treatment of    insomnia. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3480569/

    Wilson TK, Tripp J. Buspirone. [Updated 2020]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from:          https://www.ncbi.nlm.nih.gov/books/NBK531477/

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    Kathryn Mosholder posted Sep 23, 2020 10:48 PM

    The 24yr old female, she is suffering from GAD, the first thing I would do is a full physical assessment to ensure that she is physically stable. A medication review to ensure that medication is not contributing to her anxiety. Secondly, I would get her scheduled with a psychologist for therapy secondary to medication. Women are more likely to have anxiety disorders than men (Chisholm-Burns et al., 2019). Some of the signs and symptoms exhibited with GAD are difficulty controlling worrying,  anxiety, easily fatigued, low concentration or mind going blank, irritability, muscle tension, insomnia, significant distress not caused by any medical condition(Chisholm-Burns et al., 2019). Anxiety disorders are due to higher levels of stress and can be due to several outside factors such as school, relationships, disability, or illness (Andres et al., 2018). Unfortunately, only about 50% of those with anxiety disorders seek help (Andres et al., 2018). Of that, 50% on about a third receive the care and treatment that is appropriate (Andres et al., 2018). “Anxiety disorders, like all mental disorders, lie on dimensions that extend from transient symptoms to symptoms that are severe, disabling and persist for years” (Andres et al., 2018, para. 2).

    After careful assessment, I would prescribe an SSRI to assist with her acute anxiety and return for evaluation in two to four weeks to see if she felt any better and then reevaluate. Drugs of choice are sertraline and fluoxetine (Chisholm-Burns et al., 2019). Patient education on side effects is significantly essential.  The most common are diarrhea, sweating, decreased libido, anorgasmia, and asthenia (Chisholm-Burns et al., 2019).

    A 49-year-old male discharged status post myocardial infarction one week ago with hypertension, diabetes mellitus, and severe uncontrolled narrow-angle glaucoma and is now showing signs of depression. The first step is to complete a physical, medication review, and a full medical history. Research has shown links comorbidities are related to depression.  People with diabetes are prone to depression, and diabetics are three times more likely to have depression than non-diabetic patients (Gershenwald et al., 2017). Further research also indicates that depression can be associated directly with cardiac, cerebrovascular, and peripheral diseases (Gershenwald et al., 2017). However, how it is all linked still needs to be further researched. When treating this patient, it is essential to consider that he also has glaucoma. SSRIs treat depression; however, there has been significant research that warns against long term treatment causing glaucoma to develop or become more severe over time. SSRIs should be limited to patients that are “younger than 65 yrs old and without diabetes, hypertension, or hypercholesterolemia” (Chen et al., 2017). The antidepressant I would recommend, along with therapy, would be a benzodiazepine such as alprazolam. It is important to remember to educate the patient on the side effects of alprazolam and medications contraindicated with benzodiazepines and re-assess them in two weeks of starting antidepressants.

    The third case study is a 42 yr old female that struggles from insomnia. She recently has increased her dose of Temazepam from 15mg to 30mg. Temazepam is a benzodiazepine with side effects of insomnia for some patients and causes unusual excitement, nervousness, restlessness, mood or mental changes, or irritability (Gebara et al., 2018). Additionally, this patient has poor sleep hygiene, is in an abusive relationship,  does not have a healthy diet, and consumes 6-8 cups of coffee a day. Insomnia patients can be prescribed benzodiazepines, antidepressants, melatonin receptor agents, and orexin receptor inhibitors.  The first intervention would be to encourage this patient to see a psychologist and encourage group sessions for depression and abusive relationships. Secondly, I would have this patient stop taking her Temazepam and change her to a different antidepressant such as Escitalopram to assist with her depression and mood. I would also encourage a regular bedtime, ask her to consider removing the TV from her bedroom and help the patient in a diet and exercise. It is not uncommon to see insomnia and depression (Gebara et al., 2018). Futher evaluation and research is warranted for the relationship between insomnia and depression (Gebara et al., 2018).

     

    References

    Andrews, G., Bell, C., Boyce, P., Gale, C., Lampe, L., Marwat, O., … Wilkins, G. (2018). Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for treating panic disorder, social anxiety disorder, and generalised anxiety disorder. Australian & New Zealand Journal of Psychiatry52(12), 1109–1172. https://doi.org/10.1177/0004867418799453

    Chen, V. C.-H., Ng, M.-H., Chiu, W.-C., Mcintyre, R. S., Lee, Y., Lin, T.-Y., … Hsu, C.-Y. (2017). Effects of selective serotonin reuptake inhibitors on glaucoma: A nationwide population-based study. Plos One12(3). https://doi.org/10.1371/journal.pone.0173005

    Gebara, M. A., Siripong, N., Dinapoli, E. A., Maree, R. D., Germain, A., Reynolds, C. F., … Karp, J. F. (2018). Effect of insomnia treatments on depression: A systematic review and meta-analysis. Depression and Anxiety35(8), 717–731. https://doi.org/10.1002/da.22776

    Gershenwald, J. E., Scolyer, R. A., Hess, K. R., Sondak, V. K., Long, G. V., Ross, M. I., … Thompson, J. F. (2017). Melanoma staging: Evidence-based changes in the American Joint Committee on Cancer eighth edition cancer staging manual. CA: A Cancer Journal for Clinicians67(6), 472–492. https://doi.org/10.3322/caac.21409

    Iglay, K., Radican, L., & Rajpathak, S. (2017). Comorbid depression and diabetes — How can we improve adherence? Journal of Diabetes and Its Complications31(7), 1077–1078. https://doi.org/10.1016/j.jdiacomp.2017.04.014

     

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    Dianne Cohen posted Sep 23, 2020 4:27 PM

    KT is 24 which puts her on the lower end of the age range for generalized anxiety disorder (GAD) (Chisholm-Burns et al., 2019). First I would review her medical and social history along with a medical workup including labs. Also, according to Rutter and Brown, it is beneficial for the patient to complete a GAD-7 questionnaire which assists the clinician in determining her level of anxiety (2017). Further investigation into the source of her anxiety is necessary. Possibly she has a positive family history of GAD. Is there a history of alcohol abuse, mitral valve prolapse, hyperthyroidism, anemia, or asthma? All of which can predispose her to anxiety (Locke et al., 2015). Also, due to her age and demographic, is a relationship change the source of her anxiety? Equally important, I would ask her, questions about her level of anxiety, fright, panic, and avoidance of situations in the last two weeks in order to determine her risk of suicide (Chisholm-Burns et al., 2019). In the absence of any underlying conditions, I would recommend lifestyle changes including self-help groups, regular exercise, and avoidance of caffeine products. As well, a few sessions of cognitive behavior treatment may teach her effective techniques to manage anxiety (Locke et al., 2015). If all of the above methods fail, I would begin an SSRI such as Citalopram 10mg. Careful monitoring is suggested for four weeks before a dose increase and discontinue sooner if not tolerated well before trying another SSRI. Lastly, if the SSRI’s were ineffective, I would move on to an SNRI such as Duloxetine 30mg daily (Rao et al., 2017).

    WD has experienced a major debilitating life event one week ago that can cause major depressive symptoms (Stanton et al., 2019). For this reason, I would investigate when did his depression begin? Was it before his heart attack and if so for how long? This information is important since the diagnosis of MDD is based upon the presence of one or more major depressive episodes in a person’s lifetime (Chisholm-Burns et al., 2019). In addition, he has chronic health conditions that predispose him to a higher rate of depression. For example, patients with diabetes, and cardiovascular disease according to Stanton et al., have higher rates of MDD than in healthier populations (2019). Also, does the patient consume excessive alcohol which is also a known cause of MDD (Stanton et al., 2019). Next, I would conduct a physical exam and draw labs to detect any underlying imbalances that also contribute to depression (Han et al., 2019). I would recommend interpersonal or cognitive-behavioral therapy (CBT) since its use is supported by evidence-based research. In fact, alternative therapies according to Gartlehner and Gaynes, are equally effective as medication with potentially longer-lasting improvements (2016). Also, he would benefit from lifestyle changes such as joining a support group and engaging in regular exercise. Since WD has several complex underlying conditions including glaucoma and diabetes which rule out most antidepressant therapy, I would not recommend the use of pharmacotherapy. I would only advise careful use of a natural herb such as St. John’s wort along with low dose doses of omega-3 fatty acids which in some studies have shown mild patient improvement (Chisholm-Burns et al., 2019).

    JM’s care should include a thorough history and physical that includes labs. Also, I would investigate deeper into possible causes of her insomnia. According to Townsend, there are several underlying medical conditions that if left untreated can result in sleep disturbances, such as overactive thyroid, anemia, and gastroesophageal reflux disease (GERD)(2107). Furthermore, is Restless Leg Syndrom (RLS) suspected? If so, I would order nocturnal polysomnography (NPSG) to confirm the presence of RLS (Chisholm-Burns et al., 2019).
    Additionally, over the counter medication use should be investigated for stimulants that may also unknowingly contribute to insomnia. My first suggestion based on her history is to decrease coffee consumption and only consume caffeine products early in the day. She would also benefit from sleep hygiene education. According to Jansonn-Frojmark et al., this includes not consuming food directly before retiring or in bed and not watching television in bed (2019). I would suggest joining a support group or counseling to learn effective coping measures since she the stress of an abusive relationship may also cause insomnia. She may benefit from using internet insomnia apps that track symptoms and also help alleviate symptoms (Dooley, 2018). Lastly, Restoril may cause daytime drowsiness and a hangover feeling (Chisholm-Burns et al., 2019).
    Since she recently had a dose increase with worsening symptoms, I would decrease the dose to 15mg and monitor for symptom improvement. If symptoms do not improve, I would consider switching to a benzodiazepine receptor agonist (BZDRA) such as Ambien since it is considered a first-line medication treatment of insomnia and sleep maintenance problems.

    References
    Chisholm-Burns, M. A., Schwinghammer, T. L., Malone, P. M., Kolesar, J. M., Lee, Kelly, C.L., & Bookstaver, P. B. (2019). Pharmacotherapy Principles & Practice. McGraw-Hill.
    DOOLEY YOUNG, K. (2018). App tied to reducing insomnia, depression in adults. Chest Physician, 13(10), 40.
    Gartlehner, G., and Gaynes, B. (2016). Comparative Benefits and Harms of Antidepressant, Psychological, Complementary, and Exercise Treatments for Major Depression: An Evidence Report for a Clinical Practice Guideline From the American College of Physicians. Annals of Internal Medicine, https://doi-org.wilkes.idm.oclc.org/10.7326/M15-1813
    Han, K.-M., Kim, M. S., Kim, A., Paik, J.-W., Lee, J., & Ham, B.-J. (2019). Chronic medical conditions and metabolic syndrome as risk factors for the incidence of major depressive disorder: A longitudinal study based on 4.7 million adults in South Korea. Journal of Affective Disorders, 257, 486–494. https://doi-org.ezproxy.fau.edu/10.1016/j.jad.2019.07.00

    Jansson-Fröjmark, M., Evander, J., & Alfonsson, S. (2019). Are sleep hygiene practices related to the incidence, persistence, and remission of insomnia? Findings from a prospective community study. Journal of Behavioral Medicine, 42(1), 128–138. https://doi-org.ezproxy.fau.edu/10.1007/s10865-018-9949-0

    Locke, A. B., Kirst, N., & Shultz, C. G. (2015). Diagnosis and management of generalized anxiety disorder and panic disorder in adults. American Family Physician, 91(9), 617–624.
    Rao, T. S. S., Manohar J., S., Raman, R., Darshan, M. S., Tandon, A., K. N., K., N., S., Das, K., G. T., H., Kunkeri, S. P., & Andrade, C. (2017). The prospective, 24-week assessment of cost-efficacy of and compliance to antidepressant medications in a rural setting (PACECAR) study. Indian Journal of Psychiatry, 59(2), 157–163. https://doi-org.ezproxy.fau.edu/10.4103/psychiatry.IndianJPsychiatry_202_17
    Rutter, L., & Brown, T. (2017). Psychometric Properties of the Generalized Anxiety Disorder Scale-7 (GAD-7) in Outpatients with Anxiety and Mood Disorders. Journal of Psychopathology & Behavioral Assessment, 39(1), 140–146. https://doi-org.ezproxy.fau.edu/10.1007/s10862-016-9571-9
    Stanton, R., Rosenbaum, S., Rebar, A., & Happell, B. (2019). Prevalence of Chronic Health Conditions in Australian Adults with Depression and/or Anxiety. Issues in Mental Health Nursing, 40(10), 902–907. https://doi-org.wilkes.idm.oclc.org/10.1080/01612840.2019.1613701

    Townsend, D., Kazaglis, L., Savik, K., Smerud, A., & Iber, C. (2017). A brief tool to differentiate factors contributing to insomnia complaints. Health Psychology, 36(3), 291–297. https://doi-org.ezproxy.fau.edu/10.1037/hea0000442

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    Karen Halter posted Sep 21, 2020 9:31 PM

    Pharm Module 4

    Benzodiazepines have been prescribed for decades, but recent changes to prescribing information is taking a hard look at the safety, efficacy, and overuse of this class of drugs. Pennsylvania prescribing guidelines state that they are not a first line treatment for anxiety and are not effective in the long term use.(Huet, 2016) The guidelines list cognitive behavioral therapy (CBT) and the use of SSRI antidepressants as safer options. Benzodiazepines have had a 320% increase in prescribing and a 500% increase in deaths due to overuse.(Huet, 2016) I would be very cautious in prescribing these medications especially to anyone with a substance abuse history or the elderly.

    With regard to KT, mental health issues among college age students is common due to a rapid time of change and often precipitates first onset of mental health issues.(College Students: Mental Health Problems and Treatment Considerations, n.d.)If KT meets the criteria of a GAD diagnosis and if a thorough history reveals no substance abuse issues I would start her on a low dose SSRI. Because the antianxiety effect is delayed by 2-4 weeks I would also consider a low dose benzodiazepine for short term relief of symptoms. (Chisholm-burns et al., 2019, pp. 622–623)  I would monitor her closely and advise CBT therapy.

    WD is not alone in his new onset depression. Circulation reported in 2017 that “Depression among patients with acute myocardial infarction (AMI) is prevalent and associated with an adverse quality of life and prognosis.” (Smolderen et al., 2017) Due to his diagnosis of closed angle glaucoma and diabetes, I would suggest CBT and a support group. Because of his severe narrow angle glaucoma, I would not prescribe an antidepressant at this time until is determined that psychotherapy is not working.

    JM needs a lot of education and counseling on sleep hygiene. The habits that she reports are probably the reason that she has insomnia. Caffeine, poor dietary habits, and depression need to be countered by relaxation training, better sleep hygiene, and stimulus control.(Chisholm-burns et al., 2019, p. 638) I would also begin a slow wean of her restoril. Restoril is a benzodiazepine which only has a recommended use of 4 weeks.(Temazepam, 2019) I would monitor her progress and encourage her to develop better sleeping habits.

     

     

    References

    Chisholm-burns, M. A., Schwinghammer, T. L., Malone, P. M., Kolesar, J. M., Lee, K. C., & Bookstaver, P. B. (2019). Pharmacotherapy principles and practice, fifth edition (5th ed.). Mcgraw-hill Education / Medical.

    College students: Mental health problems and treatment considerations. (n.d.). PubMed Central (PMC). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4527955/

    Huet, E. (2016). Benzo-for-anxiety-and-insomnia-final-002 [PDF]. http://www.overdosefreepa.pitt.edu/wp-content/uploads/2016/10/Benzo-for-anxiety-and-insomnia-FINAL-002.pdf

    Smolderen, K. G., Buchanan, D. M., Gosch, K., Whooley, M., Chan, P. S., Vaccarino, V., Parashar, S., Shah, A. J., Ho, P., & Spertus, J. A. (2017). Depression treatment and 1-year mortality after acute myocardial infarction. Circulation135(18), 1681–1689. https://doi.org/10.1161/circulationaha.116.025140

    Temazepam. (2019). nhs.uk. https://www.nhs.uk/medicines/temazepam/

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    Last post Sep 22, 2020 10:34 PM by Anna McMullen
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    Robin Morgan posted Sep 21, 2020 9:49 PM

    Module IV: Psychiatric Disorders ( Depression, Anxiety, Sleep) Discussion

    Benzodiazepines are relatively safe for short term use. It can be used in patients with many different illnesses, and overdose is almost never lethal. The most common side effect is drowsiness. Short acting Benzos may cause rebound insomnia the night after taking. Some benzos can impair memory and the ability to learn new things. The elderly are more susceptible to these side effects. It is best to avoid alcohol and opioids with Benzos due to alcohol potentiating the effects of these sedatives. Combining opioids and benzodiazepines can be unsafe because both types of drugs sedate patients and decrease respirations. Both prescription opioids and benzodiazepines have a black box warning on the label to warn of the dangers of using these drugs together.

    Side effects to note when considering prescribing benzos to patients would be sedation, dizziness, weakness, unsteadiness, depression, loss of orientation, headache, sleep disturbance, confusion, irritability, aggression, excitement, memory impairment(Ansari & Osser, 2020). One must be mindful of the patients they are prescribing for, are they at risk for falls? Do they already become aggressive due to dementia? Are they suffering from depression?

    Benzodiazepines sedative and calming effect will help anxiety and sleep for most patients in the short term. Its good to remember these drugs are for severe anxiety or insomnia that is disabling and causing distress. Benzos taken regularly for more than a few weeks and at higher doses, or taken by patient with a history of drug abuse are at a higher risk of becoming addicted(Hamzelou, 2019). While clinicians are prescribing fewer opioid pain relievers, prescriptions for anti-anxiety drugs are going up.  Doctors overestimate the benefits of benzodiazepines, as long-term use can not only cause dependance it can actually make insomnia, mood, and anxiety worse.

    Benzos have their place in treating anxiety and insomnia as a short-term medication until the underlying cause can be fixed. The use of Benzos should be short term, or used just when really needed for severe attacks. Clinicians should avoid prescribing benzodiazepines and opiates together.

    General anxiety disorder (GAD) is an anxiety disorder characterized by being in a chronic state of agitation and worry for at least 6 months without any outside reason for the agitation, and the anxiety is not caused by a medical condition, medication, or substances.

    It has been determined that 24-year-old KT has GAD, and has presented to the clinic for treatment options. I would start KT on an antidepressant that will help her anxiety disorder. The three types of antidepressants are Tricyclics, SSR’s, and SNRIs. This drug can take weeks if not months to become fully effective. If KT is having distress that she feels can not wait for antidepressants to take effect, I would order a short-term benzo such as Ativan to help until the antidepressant began to be effective. I would suggest KT also try psychotherapy and cognitive behavioral therapy. Exercise and a good support system are also important to good mental health.

    WD has been diagnosed with major depressive disorder and needs to start treatment. Do to WD having severe uncontrolled narrow angle glaucoma I would be very cautious in what I ordered for him. SSRIs and Tricyclic antidepressants can worsen narrow angle glaucoma(“Risk of Angle-closure Glaucoma with Antidepressants,” 2016). I might consider and older MAOI antidepressant such as Nardil or Parnate. I would also avoid Effexor as it can raise WD’s blood pressure further.

    JM is having difficulty sleeping as well as depression related to an abusive relationship. Non-pharmacological treatment recommendations would be, decreasing caffeine intake especially later in the day, exercising earlier in the day, and stop eating at least 2 hours before bedtime. I would suggest winding down an hour or so before bedtime with a warm bath, and decreasing stimuli in the bedroom in order to fall asleep easier. I would increase the Restoril but only to 22.5 mg to see if it affective at that dose. Restoril is a drug that allows users to fall asleep faster and stay asleep longer(Jackson et al., 2018), so it would be a good choice for JM.

    References

    Ansari, A., & Osser, D. N. (2020). Anti-anxiety medicines and hypnotics. In Psychopharmacology (pp. 85–120). Oxford University Press. https://doi.org/10.1093/med/9780197537046.003.0003

    Hamzelou, J. (2019). The trouble with benzos. New Scientist243(3250), 18–19. https://doi.org/10.1016/s0262-4079(19)31862-7

    Jackson, E. A., Cardoni, A. A., McElnay, J. C., Jones, M. E., & Alexander, B. (2018). Temazepam (restoril, sandoz pharmaceuticals). Drug Intelligence & Clinical Pharmacy16(9), 650–656. https://doi.org/10.1177/106002808201600902

    Risk of angle-closure glaucoma with antidepressants. (2016). Reactions Weekly1616(1), 6–6. https://doi.org/10.1007/s40278-016-20623-7

     

     

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    Last post Sep 22, 2020 9:44 AM by Kelly Miskovsky
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    Carlita Lockett posted Sep 19, 2020 8:58 PM

              In the case of KT experiencing anxiety related to school and life experiences, I would not prescribe her any benzodiazepines due to their addictive nature and the level of anxiety she presents with. I would prescribe a selective serotonin reuptake inhibitor (SSRI), like sertraline. First, potentially adequate pharmacological treatments were defined as receiving a first-line, second-line, and third-line agent for generalized anxiety disorder (GAD) at an adequate dosage; plus at least 3 consultations with a general practitioner or psychiatrist (Bocti et al., 2015). Meeting with the general practitioner or psychiatrist will help her with her coping skills while on the medication.
    The diagnosis of major depressive disorder (MDD) can be treated with a variety of medications. For WD, I would become familiar with his past medical history to ensure that he has minimal complications with the treatment regimen. I would prescribe an anti-depressant as well as have him seek professional counseling. The medications would help him to improve his energy and mood, while the counselor will help him discuss new limitations and lifestyle changes that have occurred since his new diagnosis. A significantly greater therapeutic response has been shown for males than females for the tricyclic antidepressant (TCA) imipramine (Cutler, 2015, p.449). The research shows that imipramine would be more effective to treat a male with depressive disorder, but due to WD’s recent heart attack and history of type II diabetes mellitus, the medication is contraindicated. I would choose an SSRI because it would not interact negatively with his hypertension or diabetes. WD would need to notify his provider if he notices any changes in his glaucoma because the SSRI could potentially increase the eye pressure.
    As a form of non-pharmacological therapy, I would suggest JM attend cognitive-behavioral therapy (CBT). More recently, CBT has included a more trans-diagnostic/process-based and personalized approach, with the ultimate goal of linking the therapeutic technique to the process and the individual client (Cristea et al., 2016). CBT will help her improve her mental health by allowing her to discuss her feelings about her abusive relationship and lack of employment. This therapy will also help address the connection between her eating habits and her depression. Meta-analyses lend support for the superior effectiveness of combined psychosocial and pharmacological treatments with chronic depression (Carey, 2015). As a pharmacological therapy, I would continue the Restoril. I would request JM to stop drinking more than 1-2 cups of coffee per day and become more aware of her diet. This may help reverse the paradoxical effect it looks like she is having with Restoril. If the reduction in caffeine doesn’t help her insomnia, I would add a non-addictive SSRI like Trazadone to her regimen.

    References:
    Bocti, C., Duhoux, A., Fournier, L., Luc, M., Normand-Lauziere, F., Roberge, P., & Tanguay-

    Bernard, M. (2015). Generalized anxiety disorder in primary care: Mental health services

    use and treatment adequacy. BioMed Central Family Practice, 16 (146), 1-11.

              https://doi.org/10.1186/s12875-015-0358-y

    Carey, S., Craighead, W.E., Dunlop, B.W., & Johnson, B.N. (2015). Psychological treatments

    for major depressive disorder. In P.E. Nathan & J.M. Gorman (Eds.), A guide to

    treatments that work (p.381-408). Oxford University Press.

    Cristea, I., David, D., & Hoffman, S.G. (2016). Why cognitive behavioral therapy is the current

    gold standard of psychotherapy. Frontiers in Psychiatry, 9(4), 1-3.

              https://doi.org/10.3389/fpsyt.2018.00004

    Cutler, N.R., Murphy, M.F., Sramek, J.J. (2016). Sex differences in the psychopharmacological

    treatment of depression. Dialogues in Clinical Neuroscience, 18(4), 447-457.