Sleep/Wake Disorders assignment help

1. Have you had any thoughts of suicide or causing harm to yourself or others in the past month? I am asking this question because if the client has major depressive disorder and the client is currently taking Paxil which can increase the risk for suicide in adults (Wiese, 2011).
2. How would you describe your sleeping patterns? The client stated she was abused as a child, therefore I want to establish if she is having nightmares or trouble sleeping related to the memories and flashbacks. This question can also help me establish if the client may have a sleeping disorder as well.
3. Do you have friends or close family members that you spend time with? Or friends that you go out with? Depression can have an impact on the client’s daily lifestyle which means she may not participate in her usual activities. The client may also withdraw from social activities and become uninterested in spending time with people.

Identify People in the client’s life I need to speak to
The client’s family history includes having family members with major depressive disorder (MDD) which means that her family members are the first people to interview to gain better insight about her behavior and patterns. The interviews can focus on past psychiatric history and if they are aware of anything she may have left out from her statements or medical history. I think it may be beneficial to interview the attending physician to see if he has something to add to her initial evaluation notes. The primary care physician can help if she has pre-existing conditions that may contribute to her current psychiatric symptoms. The client also mentioned attending psychotherapy sessions. I would want to interview the therapists to know if the patient is compliant with therapy goals and medication regimen during treatment. The purpose of the interviews it to develop an effective treatment plan for the client.
Diagnostic Tests and Physical Exams
The client has a history of substance abuse and has been attending support groups but it is still important to get a urine drug screen. The thyroid stimulating hormone (TSH) levels should be checked due to the thyroid gland being linked to having an influence on the brain with impacting the mood (Pilhatsch, Marxen, Winter, Smolka, & Bauer, 2011). The client should also receive a mental health examination considering we are trying to rule out different diagnosis and it is our first time with the client. The mental health examination will help establish a baseline like an annual physical.
Differential Diagnosis

1. Post-Traumatic Stress Disorder – According to the American Psychiatric Association (2013) PTSD involves exposure and serious injury which client experienced abuse as a child. The client reported having nightmares and flashbacks. PTSD symptoms also exist with other conditions such as the client’s history of alcohol and substance abuse (National Alliance on Mental Illness, 2017). I feel that the client mostly identifies with this diagnosis.
2. Major Depressive Disorder – The client’s PTSD and agitation are causing her to be depressed. Her depression is secondary and triggered by her nightmares. A persistent feeling of sadness and loss of interest that interferes with the client’s daily functioning.
3. Substance Use Disorder – The client has used alcohol and other substances to cope with her PTSD symptoms. The use of alcohol and other substances is commonly seen with individual’s that experience PTSD symptoms as a coping mechanism. Half of the individuals seeking treatment for SUD have symptoms of PTSD (Berenz, 2012).

Two Pharmacologic Agents
Sertraline – The medication is indicated for use with major depression disorder and posttraumatic stress disorder. The medication should be started at 25mg orally daily and then re-evaluated at the follow up appointment in 4 weeks. One of the side effects is weight gain so the client would need diet and exercise counseling as well.
Wellbutrin – This medication would be good to add as an augmenting agent to be taken in the morning daily. The extended release tablet can be started at 150mg. The client should be able to report a decrease in insomnia symptoms. The preferred combination treatment by some clinicians is to use Wellbutrin and Zoloft together to improve symptoms (Stahl, 2013).
Follow up checkpoints
I believe the client would have benefited from Sertraline and received a more positive outcome at the follow up visits. Sertraline combined with the Wellbutrin would have been more effective with treating the depressive symptoms and PTSD.  The follow up appointments revealed that the client’s appetite was curved and there were no problems with weight gain. The medication was also treating her depressive symptoms. The client should still be monitored for suicidal thoughts because she is always at risk for suicide while having depressive episodes and taking antidepressant medications.
Lesson Learned
Client safety is always the goal when prescribing medications for treatment. The PMHNP should fully understand that monotherapy may not be effective to treat the symptoms and to consider combination therapy for certain clients. The client has more than one disorder showing that polypharmacy may be indicated for more effective results in treatment. The treatment plan should be revisited at every follow up appointment and make the necessary changes as needed dependent on how the client is responding to the current treatment. The PMHNP will take into consideration how the client feels and any decisions she may have about her treatment.
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
Berenz, E. (2012). Treatment of co-occurring posttraumatic stress disorder and substance use disorders. Current Psychiatry Reports, 14(5), 469-477. doi: 10.1007/s11920-012-0300-0
National Alliance on Mental Illness. (2017). Posttraumatic Stress Disorder. Retrieved from https://www.nami.org/learn-more/mental-health-conditions/posttraumatic-stress-disorder
Pilhatsch, M., Marxen, M., Winter, C., Smolka, M., & Bauer, M. (2011). Hypothyroidism and mood disorders: Integrating novel insights from brain imaging techiniques. Thyroid Research, 4(S3). Retrieved from https://thyroidresearchjournal.biomedcentral.com/articles/10.1186/1756-6614-4-S1-S3
Stahl, S. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applicatons (4th ed.). New York, NY: Cambridge University Press.
Wiese, B. (2011). Geriatric depression: The use of antidepressants in the elderly. BC Medical Journal, 53(47), 341-347. Retrieved from https://www.bcmj.org/articles/geriatric-depression-use-antidepressants-elderly