Please respond to each classmate with at least 125 words and reference.
Classmate 1:
Major depressive disorder (MDD) is characterized by persistently low or depressed mood, the inability to feel pleasure or decreased interest in pleasurable activities, feelings of guilt, lack of energy, poor concentration, appetite changes, psychomotor retardation or agitation, sleep disturbances, or suicidal thoughts experienced by an individual. The individual must have at least four symptoms in at least two weeks (Bains & Abdijadid, 2023)
The hallmark symptoms of catatonia include stuporousness, blunted affect, extreme withdrawal, negativism, and marked psychomotor retardation. Cyclothymia is characterized by episodes consisting of hypomanic and depressive symptoms that do not meet the full criteria for bipolar or major depressive disorder during the first 2 years of the disturbance. The criteria also require the more or less constant presence of symptoms for two years (or one year for children and adolescents).
The mean age of onset for major depressive disorder is about 40 years, with 50 percent of all patients having an onset between the ages of 20 and 50 years. Major depressive disorder can also begin in childhood or old age. The prevalence rate is almost double in women than in men. The female-to-male ratio in cyclothymic disorder is about 3 to 2, and 50 to 75 percent of all patients have an onset between ages 15 and 25 years. Families of persons with cyclothymic disorder often contain members with substance-related disorders.
The pathophysiologic mechanisms of the disorder.
MDD is caused by abnormalities in neurotransmitters, especially serotonin, norepinephrine, and dopamine. Also, abnormality of GABA, an inhibitory neurotransmitter, and glutamate and glycine can result in MDD.
Emergencies
Medical emergencies are situations where the individual is at risk of imminent death; thus, they require immediate intervention. The conditions include severe self-neglect, self-harm, suicidal behavior, severe depressive episodes, and severely impaired judgment.
General treatment plan
The evidence-based treatment for depression includes pharmacological, psychotherapeutic, interventional, and lifestyle modifications. The first line of treatment for major depressive disorder is the initial treatment of MDD, which includes medications and psychotherapy. The initial treatments of depression are psychotherapeutic ( Cognitive behavioral therapy (CBT) and Interpersonal Therapy) and pharmacological interventions. Psychotherapy intervention includes cognitive behavioral therapy and interpersonal therapy. CBT is a structured therapeutic intervention that focuses on helping the client identify and modify maladaptive thinking and change behavior patterns. It helps the patient find a way to replace faulty negative attitudes about themselves, the world, and the future with a new way of thinking. The effectiveness of CBT depends on the patient’s capacity to observe and change their beliefs and behaviors(Karrouri et al., 2021). The goal of Interpersonal Therapy is to determine what triggers depression symptoms. It is also designed to improve the client’s social functioning and interpersonal relationship quality. Interpersonal therapy lasts for about 12 to 16 weekly sessions and can be combined with antidepressant medication. Regular physical activity is recommended as part of the treatment for depressed patients to alleviate symptoms and prevent relapses. Exercise also improves one’s quality of life in general; it should be considered an adjunct to other anti-depressive treatments(Karrouri et al., 2021). Selective serotonin reuptake inhibitors (SSRIs) are the first-line treatment gold-standard treatment for depression. These include fluoxetine, sertraline, citalopram, escitalopram, paroxetine, and fluvoxamine. other treatment options include tricyclic antidepressants [TCAs], serotonin-norepinephrine reuptake inhibitors [SNRIs], and monoamine oxidase inhibitors [MAOIs])(Bains & Abdijadid, 2023).
Treatment for cyclothymic disorder: The first line of treatment for patients with cyclothymic disorder includes mood stabilizers and antimanic drugs. Psychotherapy for patients with cyclothymic disorder is best directed toward increasing patients’ awareness of their condition and helping them develop coping mechanisms for their mood swings.
Ethical Responsibility
The clinician’s ethical responsibility is to do no harm and treat the patients diagnosed. The 4 main ethical principles, that is beneficence, nonmaleficence, autonomy, and justice (Varkey, 2020). The ethical obligations posed by the clinician’s responsibility to provide care that will benefit the patient, avoid or minimize harm, and respect the patient’s values and preferences. This must be managed in terms of capacity to consent, the use of mandated treatment or hospitalization, discussion of comorbidities, and communication with the patient of the benefits and risks of treatments when the benefits are not well known and confirmed (Boland et al., 2022).
Interdisciplinary team
An interdisciplinary approach is essential for the effective and successful treatment of MDD. Primary care physicians, psychiatrists, nurses, therapists, social workers, and case managers are integral to these collaborated services. PCPs are the first providers to whom individuals with MDD present mainly with somatic complaints. Regular screening of patients using depression rating scales such as PHQ-9 can be beneficial in the early diagnosis and intervention, thus improving the overall outcome of MDD. Psychoeducation plays a significant role in improving patient compliance and medication adherence. Therapists and psychologists can ensure the environment is safe and supportive and encourage patients to describe their symptoms and communicate psychosocial stressors.
References
Bains, N., & Abdijadid, S. (2023, April 10). Major depressive disorder. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK559078/Links to an external site.
Baldaçara, L., da Silva, A. G., Pereira, L. A., Malloy-Diniz, L., & Tung, T. C. (2021). The management of psychiatric emergencies in situations of public calamity. Frontiers in Psychiatry, 12. https://doi.org/10.3389/fpsyt.2021.556792Links to an external site.
Bielecki, J. E., & Gupta, V. (2020). Cyclothymic Disorder. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK557877/Links to an external site.
Karrouri, R., Hammani, Z., Benjelloun, R., & Otheman, Y. (2021). Major depressive disorder: Validated treatments and future challenges. World Journal of Clinical Cases, 9(31), 9350–9367. https://doi.org/10.12998/wjcc.v9.i31.9350Links to an external site.
Varkey, B. (2020). Principles of clinical ethics and their application to practice. Medical Principles and Practice, 30(1), 17–28. https://doi.org/10.1159/000509119Links to an external site.
Classmate 2:
Compare/contrast Major Depressive Disorder with Cyclothymic Disorder in terms of the following parameters:
Age-appropriate, culturally responsive, comprehensive assessment.
The diagnostic criteria for Major Depressive Disorder (MDD) outlined by the American Psychiatric Association (2022), specify the presence of a two-week period with more days than not of persistently low or depressed mood, anhedonia, feelings of guilt or worthlessness, lack of energy, poor concentration, appetite changes, psychomotor retardation or agitation, sleep disturbances, or suicidal thoughts. The etiology of MDD is believed to be multifactorial, influenced by biological, genetic, environmental, and psychosocial factors. Evidence suggests that an imbalance in serotonin, norepinephrine, GABA, glutamate, and dopamine contributes to the development of MDD (Bains & Abdijadid, 2023). Depressed patients have been found to have lower plasma, CSF, and brain GABA levels. GABA, an inhibitory neurotransmitter, as well as glutamate and glycine, which are major excitatory neurotransmitters, are thought to be involved in the etiology of depression. GABA is considered to exert its antidepressant effect by inhibiting specific brain pathways, including the mesocortical and mesolimbic systems. Furthermore, research has explored the potential antidepressant properties of drugs that antagonize NMDA receptors.
In contrast, Cyclothymic Disorder causes distress but differs from MDD in the duration of symptoms. An individual with Cyclothymic Disorder will have experienced cycles of nearly meeting the criteria for either disorder for a period of 2 years (1 year if a child or adolescent), with no more than 2 months without symptoms, without meeting the criteria for an MDD episode or a hypomanic episode (APA, 2022). Cyclothymia is a primary mood disorder that is characterized by significant ambiguity and controversy. The disorder’s diagnostic complexity stems from its overlapping symptoms with various other disorders. It is characterized by episodes featuring hypomanic and depressive symptoms that do not fully align with the criteria for bipolar or major depressive disorder. Typically, cyclothymia emerges early in life, evident through mood reactivity and dysregulation. The intricacies of the disorder make it challenging to identify in clinical practice. In the DSM-5, it is categorized under bipolar mood disorders. Cyclothymia shares similarities with personality disorders, as its onset is early, its course is chronic and pervasive. Misconceptions often arise, as it is frequently confused with cluster-B personality disorders due to overlapping diagnostic criteria, leading to potential misdiagnoses. Similar to other psychiatric disorders, cyclothymia can lead to dysfunction and distress. While many psychiatric disorders may co-occur with cyclothymic disorder, the reverse is not true. For instance, despite its frequent comorbidity with substance use disorders, cyclothymia is not induced by substance use, as defined.
Hypomania is characterized by a period of abnormally elevated, expansive, or irritable mood lasting for four or more days, along with three or more symptoms such as increased self-esteem, needing 3 hours or less of sleep, being talkative, experiencing a flight of ideas, being easily distracted, engaging in goal-directed activity or showing signs of agitation, or displaying risky behavior (APA, 2022).
Descriiption of postulated pathophysiologic mechanisms of the disorder- these should be linked to common symptoms observed in clients who present with this illness.
Precision psychiatry becomes possible through an understanding of the pathophysiologic mechanisms of a disorder. According to a study by De Menezes Galvão et al. (2021), increased severity of depressive symptoms and poor sleep quality are linked to low levels of serum cortisol and salivary cortisol awakening response, as well as high levels of serum mature brain-derived neurotrophic factor in Major Depressive Disorder (MDD). While it used to be believed that the major players in depression were the monoamine systems in the brain – particularly serotonin, norepinephrine, and dopamine (Nemeroff, 2020) – ongoing research is broadening our comprehension.
Because Cyclothymic Disorder seems similar to Bipolar II Disorder, it’s important to consider some findings regarding bipolar disorder. An article by Vidya et al. (2022) suggests that the prefrontal cortex, anterior cingulate cortex, hippocampus, and amygdala regulate emotion control, response conditioning, and reactionary behavior. In bipolar disorder, it is postulated that dopamine, serotonin, and norepinephrine are among the deregulatory neurotransmitters. Additionally, adrenocortical hyperactivity is associated with mania, and chronic stress is believed to inhibit neurogenesis and neuroplasticity by lowering brain-derived neurotrophic factor.
What behaviors on the part of the client (with either condition) would lead you to believe that they may be experiencing a psychiatric emergency?
As discussed in an article by Pompili et al. (2022), a psychiatric emergency related to MDD may involve a person presenting with both suicidal ideation and intent. A patient expressing thoughts of self-harm and possessing the means to carry it out is at a heightened risk of suicide and constitutes a psychiatric emergency. It is crucial to use standardized screening tools, such as the Columbia-Suicide Severity Rating Scale (C-SSRS), to assess the level of risk the patient presents. Higher risks necessitate vigilant interventions. Therefore, a patient deemed an immediate threat to themselves should be placed under one-to-one observation, and someone should always be keeping an eye on them. Additionally, the clinician must pay attention to subtle statements or behaviors to ascertain suicide risks, as not all individuals with an intent to harm themselves are vocal about it. Consideration of the person’s history, including any previous suicide attempts, is essential, among other signs. A history of a failed suicide attempt further increases the risk (Pompili et al. 2022).
Develop a general treatment plan for either disorder- what evidence-based psychotherapies would you plan to include? What evidence-based psychopharmacologic approaches (if any) would be appropriate?
Major depressive disorder (MDD) can be managed through various treatment methods, including medication, psychotherapy, intervention, and lifestyle adjustments. The initial treatment for MDD typically involves medication and/or psychotherapy
FDA-approved medications for MDD treatment include (Bains & Abdijadid, 2023):
Selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine, sertraline, citalopram, escitalopram, paroxetine, and fluvoxamine. These are often the first line of treatment and are widely prescribed.
Serotonin-norepinephrine reuptake inhibitors (SNRIs) like venlafaxine, duloxetine, desvenlafaxine, levomilnacipran, and milnacipran. They are often used for depressed patients with comorbid pain disorders.
Serotonin modulators, which include trazodone, vilazodone, and vortioxetine.
Atypical antidepressants (bupropion and mirtazapine) are frequently prescribed as standalone treatments or as supplement agents when patients experience sexual side effects from SSRIs or SNRIs.
Tricyclic antidepressants (TCAs) such as amitriptyline, imipramine, clomipramine, doxepin, nortriptyline, and desipramine.
Monoamine oxidase inhibitors (MAOIs) like tranylcypromine, phenelzine, selegiline, and isocarboxazid, although these are not commonly used due to high side effects and lethality in overdose.
Other medications like mood stabilizers and antipsychotics, which may be added to enhance antidepressant effects.
Psychotherapy approaches include (Bains & Abdijadid, 2023):
Cognitive behavioral therapy (CBT) focuses on changing the automatic negative thoughts that can contribute to and worsen our emotional difficulties, depression, and anxiety. These spontaneous negative thoughts also have a detrimental influence on our mood.
Interpersonal psychotherapy (IPT) focuses on improving problematic relationships and circumstances closely linked to the current depressive episode.
Psychodynamic therapy (PT) centers on unconscious thoughts, early experiences, and the therapeutic relationship to understand current challenges, improve self-awareness, and support the patient in developing more adaptive patterns of functioning.
Supportive therapy (ST) focuses on helping individuals explore and understand their experience in their current situation. It aims to strengthen a person’s ability to make choices that help them cope effectively with various life stressors, from a stance of genuine empathy and supportive listening.
Electroconvulsive therapy has been found to be more effective than any other form of treatment for severe major depression (Bains & Abdijadid, 2023).
Discuss any legal/ethical issues inherent in the care of the individual with either condition (Major Depressive Disorder or Other Specified Depressive Disorder).
The treatment of patients with either disorder involves addressing various legal and ethical considerations such as respect for the law, beneficence, compassion, non-maleficence, justice, veracity, confidentiality, fidelity, altruism, autonomy, and integrity (Rogol, 2020). Ethical deliberations become particularly crucial due to the multitude of depressive symptoms and the extensive array of available treatment options. While patients have the right to privacy and autonomy, these rights may be compromised in situations where the level of danger supersedes privacy and individual rights. In some cases, a patient’s capacity to make decisions for themselves may be overridden by a psychiatrist and a judge, resulting in involuntary hospitalization and a loss of autonomy if the patient lacks the mental capacity to make independent decisions (Bipeta, 2019).
How would you know if the care of this client (either in an acute episode or chronic care) exceeded your clinical competence? How would you proceed with the client’s care in this case?
If the client did not display significant improvement, I would acknowledge that my clinical abilities may not be sufficient for their care. Since nurse practitioners cannot work independently in Georgia, my first step would be to consult with my colleagues or supervising psychiatrist to benefit from their clinical expertise. According to Boland et al. (2021), it is recommended that students in training should recognize their limitations and seek supervision when necessary. If, even after consulting with them, I still felt that the client’s care was beyond my scope of practice, I would then involve my supervising provider or refer the client to a more suitable healthcare provider. It is crucial for professionals to recognize their limitations in terms of clinical competence.
What other professionals would you consider including in the care/treatment of this client, and why?
Individuals with Major Depressive Disorder (MDD) require a comprehensive approach for successful treatment. Primary care physicians are essential for screening and managing side effects through blood work and other diagnostics, while therapists provide interpersonal and cognitive behavioral therapy, and psychiatrists offer psychoeducation and medication management. Additionally, case managers and social workers play a valuable role in patient care (Bains & Gupta, 2023). Family support is also crucial for understanding and assisting in the care of these individuals.
References
American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). Author. ISBN-13: 978-0890425763
Bains N, Abdijadid S. Major Depressive Disorder.(2023, Apr 10). StatPearls Publishing.
https://www.ncbi.nlm.nih.gov/books/NBK559078/Links to an external site.
Bipeta, R. (2019). Legal and ethical aspects of mental health care. Indian Journal of Psychiatry Medicine; 4 (12): 108-112. Retrieved from http://www.ncbi.min.nih.gov
Boland, R., Verduin, M., & Ruiz, P. (2021). Kaplan and Sadock’s synopsis of psychiatry: Behavioral sciences/clinical psychiatry (12th ed.). Wolters Kluwer Health.
De Menezes Galvão, A. C., De Almeida, R. N., De Sousa, G. M., Leocadio-Miguel, M. A., Palhano-Fontes, F., De Araújo, D. B., Lobão-Soares, B., Maia‐de‐Oliveira, J. P., Nunes, E. A., Hallak, J. E. C., Schuch, F. B., Sarris, J., & Galvão-Coelho, N. L. (2021). Pathophysiology of Major Depression by clinical stages. Frontiers in Psychology, 12. https://doi.org/10.3389/fpsyg.2021.541779Links to an external site.
Nemeroff C. B. (2020). The State of our understanding of the pathophysiology and optimal treatment of depression: Glass half full or half empty? The American Journal of Psychiatry, 177(8), 671–685. https://doi.org/10.1176/appi.ajp.2020.20060845Links to an external site.
Pompili, M., Sarli, G., Erbuto, D., Manfredi, G., & Comparelli, A. (2022). Clinical experiences with intranasal esketamine for major depressive disorder resistant to treatment and with a psychiatric emergency: Case presentations. International Clinical Psychopharmacology, 38(3), 195–200. https://doi.org/10.1097/yic.0000000000000455Links to an external site.
Vidya, N., Begum, S., Rani, S., & Shaik, A. (2022). Pathophysiology, diagnosis and treatment of I & II bipolar disorder – A DETAILED REVIEW. ResearchGate. https://www.researchgate.net/publication/359634990_PATHOPHYSIOLOGY_DIAGNOSIS_AND_TREATMENT_OF_I_II_BIPOLAR_DISORDERS_-A_DETAILED_REVIEW