Evaluate Clients for Treatment of Mental Health Disorders.

Practicum: Decision Tree
For this Assignment, as you examine the client case study in this week’s Learning Resources, consider how you might assess and treat adult and older adult clients presenting symptoms of a mental health disorder.Evaluate Clients for Treatment of Mental Health Disorders.

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Learning Objectives
Students will:
Evaluate clients for treatment of mental health disorders
Analyze decisions made throughout diagnosis and treatment of clients with mental health disorders
Examine Case 2: You will be asked to make three decisions concerning the diagnosis and treatment for this client. Be sure to consider co-morbid physical, as well as mental factors that might impact the client’s diagnosis and treatment.Evaluate Clients for Treatment of Mental Health Disorders.

At each Decision Point stop to complete the following:

Decision #1: Differential Diagnosis
Which Decision did you select?
Why did you select this Decision? Support your response with evidence and references to the Learning Resources.
What were you hoping to achieve by making this Decision? Support your response with evidence and references to the Learning Resources.
Explain any difference between what you expected to achieve with Decision #1 and the results of the Decision. Why were they different?
Decision #2: Treatment Plan for Psychotherapy
Why did you select this Decision? Support your response with evidence and references to the Learning Resources.
What were you hoping to achieve by making this Decision? Support your response with evidence and references to the Learning Resources.
Explain any difference between what you expected to achieve with Decision #2 and the results of the Decision. Why were they different?
Decision #3: Treatment Plan for Psychopharmacology
Why did you select this Decision? Support your response with evidence and references to the Learning Resources.
What were you hoping to achieve by making this Decision? Support your response with evidence and references to the Learning Resources.
Explain any difference between what you expected to achieve with Decision #3 and the results of the decision. Why were they different?
Also include how ethical considerations might impact your treatment plan and communication with clients and their family.

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

// A young woman with Depression
Case #2
A young woman with Depression

SUBJECTIVE
Stefanie is a 32-year-old female from Puerto Rico who presents to your office today with complaints of difficulty sleeping. You learn that Stefanie can go for a few days with minimal sleep (about 3 hours/night), but does not seem to be fatigued the next day. Stefanie explains that after 3 days with minimal sleep, she “crashes” and has a good night’s sleep. She states that sleep will be “alright” for a few days, even a few weeks, and then she will have a similar issue with sleep.
You learn throughout the assessment process that Stefanie has had this problem for years. She noticed that it began in college and thought it was just because of the workload and academic demands. However, she found that it persisted after college. She also notices that she has periods where she will engage in increased amounts of goal-directed activity. She states that things will just “pile up” at work and she gets this burst of energy to “make everything right.” She states that these bursts will last most of the day. She states that these periods show up probably every 2 to 3 weeks.
Stefanie also confesses to problems with being “down in the dumps.” She states that when she has her episodes in which she endeavors to “make everything right,” she feels fantastic and on top of the world. However, when these periods of energy end, she reports that she feels “depressed”—but then states: “well, maybe not depressed, but I definitely feel sad and empty.” She also endorses feelings of fatigue and a decreased ability to concentrate when she is feeling sad. She finally tells you: “I have lived with this for so long, I have to admit that it is finally a relief to tell someone how I feel!” Evaluate Clients for Treatment of Mental Health Disorders.

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

MENTAL STATUS EXAM
Stefanie is alert and oriented × 4 spheres. Her speech is clear, coherent, goal directed, and spontaneous. Self-reported mood is “sad.” Affect does appear consistent with dysphoria. Eye contact is normal. Speech is clear, coherent, and goal directed. She denies visual or auditory hallucinations. No overt evidence of paranoid or delusional thought processes noted. She denies suicidal or homicidal ideation and is future oriented.
At this point, please discuss any additional diagnostic tests you would perform on Stefanie.
Decision Point One
BASED ON THE INFORMATION PROVIDED IN THE SCENARIO ABOVE, WHICH OF THE FOLLOWING DIAGNOSES WOULD THE PSYCHIATRIC/MENTAL HEALTH NURSE PRACTITIONER (PMHNP) GIVE TO STEFANIE?
In your write-up of this case, be certain to link specific symptoms presented in the case to DSM–5 criteria to support your diagnosis.

Bipolar I, current phase, depressed

Bipolar II, current phase, hypomanic

Cyclothymic disorder

Decision Point One

Bipolar I, current phase, depressed
Bipolar I, current phase, depressed
Decision Point Two
BASED ON THIS DIAGNOSIS, SELECT YOUR CHOICE OF ACTIONS:

 

Begin Latuda 40 mg orally daily

Lamictal 100 mg orally daily

Begin psychotherapy using a psychodynamic approach

Decision Point One

BipBipolar II, current phase, hypomanic
olar II, current phase, hypomanic
Decision Point Two
BASED ON THIS DIAGNOSIS, SELECT YOUR CHOICE OF ACTIONS:

 

Begin Lithium 300 mg orally twice a day

Begin Olanzapine 10 mg orally at bedtime

Begin Abilify 10 mg orally daily

 

Cyclothymic disorder

 

Cyclothymic disorder

Decision Point Two
BASED ON THIS DIAGNOSIS, SELECT YOUR CHOICE OF ACTIONS:

 

Begin Depakote 250 mg orally three times daily

Begin Abilify 10 mg orally daily

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

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Practicum: Decision Tree

Introduction

This case study presents a 32-year-old client who presented and reported complaints regarding sleep problems. The client also reported being sad, fatigued, empty, and concentration problems. According to the client, she would sometimes feel completely alright and full of energy while other times she would be sad, fatigued and a feeling of emptiness. The purpose of this assignment is, therefore, to make a decision about the diagnosis for this client and then make two decisions regarding her treatment choices. Finally, the ethical factors that could impact her treatment plan will be discussed .Evaluate Clients for Treatment of Mental Health Disorders.

Decision Point One

From the symptoms the client reported, the diagnosis is cyclothymic disorder. The reason for selecting this decision is because the symptoms the client presents meet the diagnostic criteria for cyclothymic disorder. The DSM-5 diagnostic criteria outline clinical symptoms for cyclothymic disorder to be events of depressive and hypomanic episodes although the depressive symptoms do not meet the criteria for hypomania or major depressive disorder. Additionally, the person is not supposed to have a history of hypomanic, manic or depressive episode; symptoms should not be as a result of psychotic disorder or substance abuse; and the symptoms lead to notable distress to the individual where the occupational and social functioning of the person get impaired (American Psychiatric Association, 2013). Additionally, for the diagnosis of cyclothymic disorder, the person should experience mood changes for over two years.

The client in this case study presents symptoms comparable to cyclothymic disorder like erratic sleep problems; periods of the feeling of emptiness and sadness; and episodes of high-energy and over-activity, while other times she feels low and fatigued. Her affect is consistent with dysphoria. The client has experienced these symptoms for over two years and thus her symptoms fit the diagnostic criteria for cyclothymic disorder.

The expected outcome for this decision is that a further mental status exam would reveal additional symptoms of cyclothymic disorder. No difference between the expected outcomes and the actual outcomes since the client exhibits symptoms of cyclothymic disorder such as mood changes that fluctuate between hypomania and depression; fatigue; sadness; sleep problems; concentration problems; and periods of high energy (American Psychiatric Association, 2013).

Decision Point Two

The selected second decision is for the client to begin Abilify 10 mg orally daily. This decision was selected since evidence indicates that Abilify is the appropriate first-line drug in the treatment of depressive mood and hypomanic or manic episodes in individuals with cyclothymic disorder or bipolar 1 (Muneer, 2016). Accordingly, the medication will be effective in improving depressive and hypomania symptoms in this client. Abilify works by balancing the level of dopamine and serotonin within the brain. This leads to improvement in terms of mood, thinking pattern and emotions of a person (Bartolomeis et al, 2015). Secondly, Abilify was selected since evidence indicates that the medication has a good safety profile and thus minimal side effects and also people with mood disorders have shown good tolerability of the medication (Muneer, 2016).Evaluate Clients for Treatment of Mental Health Disorders.

By selecting the decision for the client to start Abilify, the expectation was that the client would manifest notable symptom improvement regarding depressive symptoms like sadness, concentration problems and sleep problems; and also, manifest improvement in hypomania symptoms such as high energy. Studies indicate the efficacy of Abilify in treating depressive and hypomania symptoms in individuals with cyclothymic disorder, just like Stephanie (Muneer, 2016). Secondly, it is expected that client would manifest good tolerability towards the medication and therefore would not experience any significant side effect. This is because Abilify has been shown to have a good safety profile and people with mood disorders tolerate the medication well, with minimal or no side effects (Sadock et al, 2015).

The actual and expected outcomes are not significantly different. There was notable symptom improvement for this client because during the review clinic after four weeks the client reported that she was no longer feeling sad. This improvement is attributable to the efficacy of Abilify in improving depressive symptoms in people with cyclothymic disorder (Muneer, 2016). Nonetheless, according to the client, on starting Abilify, she started experiencing a feeling of lightheadedness when sitting to a standing position or when lying down. The lightheadedness is one of the side effects of Abilify medication (Stahl, 2017).

Decision Point Three

The third decision is to have the client maintain the current Abilify dose. The reason for selecting this decision is to ensure that the client continues to manifest symptom improvement since she is already manifesting symptom improvement with the current Abilify dose. Abilify has been demonstrated to be effective in leading to symptom improvement in people with cyclothymic disorder. Moreover, the client seems to be tolerating the current dose relatively well because the only reported side effect was lightheadedness (Stahl, 2017).

The decision to maintain the current dose of Abilify hoped that the client will consistently manifest symptom improvement which will result to complete remission of both depressive symptoms and hypomanic symptoms. This is due to the medication’s efficacy in treating and improving depressive and hypomanic symptoms in people having cyclothymic disorder, just like the current client (Muneer, 2016). Secondly, it is hoped that the client would tolerate the current dose of Abilify due to the medication’s good safety profile (Stahl, 2017).

Ethical Considerations

Various ethical aspects could affect the treatment plan for this client. First, there is a need for the PMHNP to seek informed consent from the client before starting any treatment. However, individuals with cyclothymic disorder manifest symptoms like hypomania and such symptoms may impair the judgment of the client. Therefore, the impaired judgment may hinder the ability of the client to make a good treatment decision and also make it a challenge for the client to consent to treatment (Richa et al, 2018). In addition, the issue of autonomy may affect the client’s treatment plan. The hypomanic symptoms may interfere with the client’s judgment and ability to make rational decisions and thus the client may become uncooperative during treatment. Moreover, like grandiosity and aggressiveness during hypomanic episodes can adversely affect the therapeutic relationship, and thus interfering with the treatment plan (Perugi et al, 2017). Finally, the PMHNP should ensure that the confidentiality and privacy of the client are respected. Any information the client reveals during the treatment should not be revealed to any third party unless the client gives consent.Evaluate Clients for Treatment of Mental Health Disorders.

Conclusion

The diagnosis for Stephanie is cyclothymic disorder as she exhibits both depressive and hypomanic symptoms that do not satisfactorily fit the diagnostic criteria for major depressive disorder or hypomanic episodes present in bipolar disorder. The second decision was therefore for Stefanie to begin Abilify since the medication’s efficacy in the treatment of depressive and hypomanic symptoms in individuals with cyclothymic disorder has been demonstrated. Therefore, it was expected that after starting the Abilify 10 mg the client would manifest significant symptom improvement and at the same time tolerate the medication. The client reported significant symptom improvement Abilify 10 mg, with minima side effects. Therefore, the last decision was to maintain the current dose of Abilify. This is because the client manifested impressive symptom improvement and only reported lightheadedness as the side effect. The ethical aspects that could affect the treatment plan for this client include informed consent, autonomy, decision-making ability, and confidentiality/privacy.Evaluate Clients for Treatment of Mental Health Disorders.