psychotherapy.
Provide one alternative therapeutic approach to the following. Explain why you suggest this alternative and support your suggestion with evidence-based literature. (Not sure it attached)
Treatment Plan for the older adult-Initial post
This 69 y/o AA male, widowed, has one child and six grandchildren. He was self-referred with depression and anxiety after encouragement by son. His father, who he describes as his support, is dying. He doesn’t enjoy being with his family and doesn’t do volunteer work anymore. His physical complaints are insomnia and feeling tired. This year he was diagnosed with prostate cancer. He has a history of anxiety treatment, denial of the illness’s severity, and end-of-life issues associated with this diagnosis. Currently, his symptomology is guilt and rumination consistent with depression. Also, he is taking a benzodiazepine for several years for anxiety. He took Effexor, Prozac, Lexapro, and duloxetine in the past, and he reported that they were ineffective. Only his mother had a mental health history, depression. The information given to the student states there are no cognitive or physical deficits. His current medical history includes GERD, obesity, hypertension, and hyperlipidemia, but there are no medications for treating these disorders.
Diagnosis: GAD with a comorbidity of Adjustment Disorder with mixed anxiety and depressed mood.
This patient apparently has some kind of anxiety disorder. He may have developed GAD from improperly treated separation anxiety disorder or adjustment disorder with mixed anxiety and depressed mood. This patient lost his wife and is retired. He was prescribed Effexor, Prozac, Zoloft, Lexapro, and Duloxetine but is still taking Lorazepam for several years. According to Wheeler, the elderly with mental health issues, who go to a primary care setting for medical care, are often misdiagnosed or undertreated for these problems (2014).
His GAD and Adjustment Disorder have exacerbated because he was not only diagnosed with prostate cancer this year, but he also has recently learned his father is dying, who he describes as his support system. His symptoms for GAD are anxiety for several years and recently have increased fatigue and sleep disturbances. His anxiety is causing impairment in social and other important areas of functioning. He doesn’t enjoy being with his family, and he doesn’t do volunteer work anymore. His symptoms for Adjustment disorder with mixed anxiety and depressed mood are the development of emotional and behavioral symptoms in response to his recent prostate cancer diagnosis and knowledge of his father’s impending death. The symptoms are a significant impairment in social and other important areas of functioning. He complains of feeling tired, doesn’t enjoy being with his family, and doesn’t do volunteer work anymore. Also, he fears losing his father. He has expressed that he has anxiety and depression.
DSM-V Coding for diagnosis
1) GAD: 300.02
Differential Diagnosis:
1) Anxiety disorder due to anther medical condition
2) Depressive Disorder
2) Adjustment Disorder with mixed anxiety and depressed mood: 309.28 (F43.23).
This adjustment disorder may be acute versus persistent. The acute diagnosis is because of the client’s recent learning that his father will soon be dying. This current knowledge and encouragement by his son caused this client to seek help, not the one-year-old diagnosis of prostate cancer.
Differential Diagnosis:
1) Normative stress reactions
What tests or tools should be considered to help identify the correct diagnosis?
Diagnostic Tests
1) Blood test: TSH, T4 and T3C to rule out hyperthyroidism and hypothyroidism which could cause anxiety or depressive symptoms (Mayoclinic.org, n. d-1.), (Mayoclinic.org, n. d-2).
2) Liver functions test: Hepatic disease can affect the pharmacokinetics and pharmacodynamics of many antidepressants and anxiolytic medications (Telles-Correia, D., et al., 2017).
3) EKG-To get a baseline reading of the electro conductivity of the heart because some antidepressants can prolong the conductivity of the heart (Mayoclinic.org, n. d-2.).
4) To assess my patient’s functional status before and after treatment, I would use the following clinical rating scales:
Global Assessment of Functioning (GAF), Geriatric Depression Scale (GDS), Geriatric Anxiety Inventory (GAI), Interpersonal Relationship Inventory (IPRI), Brief Resilient Coping Scale, and Quality of Life Scale (QOL). The Overt Aggression Scale-Modified (OAS-M), and the WHO Spirituality, Religiousness and Personal Beliefs (SRPS) would be done before treatment has started (APA.org, n. d.), (Wheeler, K. 2014).
What Treatment Strategy would you recommend?
I would recommend a holistic, multidisciplinary treatment plan that includes psychiatric services and medical services for medical problems, social services for social problems for this client, and psychiatric and social services for the caregivers. According to Wheeler, understanding an individual, their family, and their systemic issues collectively improves psychotherapy outcomes for older adults with mental health issues. Also, collaboration with other services is EBPs for more successful and long-lasting therapy outcomes with older adults (2014).
What treatment would you prescribe and what is the rationale?
According to Wheeler, Cognitive Behavioral Therapy (CBT), relaxation training, interpersonal psychotherapy (ITP), reminiscence therapy (RT), and life review therapy (LRT) are evidenced-based, best treatments (EBTs) for this client (2014).
Safety
According to Wheeler, suicide risk factors include depression, loss of loved one, social isolation and loneliness, physical illness, and fear of a long illness, all of which this patient has. Also, anxiety, not treated, can negatively impact current functioning and life and increase depression and suicide risk. The severity of the anxiety positively correlates with the risk of suicide for this patient. To decrease suicidal risk factors, treatment recommendations for the APPN must include helping this client with the relief of these symptoms, helping him with his complex grief, finding meaning in his life, and maintaining his social connections (2014).
Psychopharmacology
For this client, I would wean this patient off the benzodiazepine and start him on vortioxetine. According to findings by Crocco, E. A., antidepressants are considered the first line treatment for anxiety disorders in the elderly. This new, well tolerated, antidepressant with anxiolytic effects is a serotonin modulator and stimulator. It enhances serotonin activity, and increases norepinephrine and dopamine, which causes improvements in cognition, and in depressive disorders. Other SSRIs and SNRIs, although effective, have increase adverse effects on the elderly such as hepatotoxicity, drug-drug interactions and increased endocrine and cardiac risks. In comparison, Benzodiazepines are recommended for short term and as adjunctive treatment with antidepressants. Because they can lead to falls and cognitive impairment in the elderly, their use should be avoided (2017).
Psychotherapy
According to Wheeler, individual psychotherapy is effective when the therapies are adapted to meet the physical and cognitive requirements of the client (2014). From the information given, this client has high levels of physical and cognitive functioning. Therefore his therapy would focus on strengthening his coping strategies and promotion of meaningful activities, social engagement and social support.
Psychoeducation
According to Wheeler, repeated discussions and written materials are recommended for elderly clients. Also, because older client are not as comfortable with psychotherapy, education on psychotherapy, the therapeutic process, conduct in the therapy session, the number and cost of the therapy sessions, projected outcomes from therapy, and information to support informed decision making and confidentiality are recommended. This education will not only aid in the development of the therapeutic relationship, but it will also normalize the therapy process. This normalization will assist the therapist and client with problems in living, goal and priority setting for therapy (2014).
What standard guidelines would you use to treat or assess this patient?
For this client, I would use the American Psychiatric Association practice guidelines for the psychiatric evaluation of adults and clinical practice guidelines for treatment of GAD and Depression (Psychiatryonline.org, n. d-1.), (Psychiatryonline.org, n. d-2). This client’s psychiatric symptoms, trauma history, psychiatric treatment history, substance use, suicide risk, medical health, were reviewed and that information was documented. Aggressive behaviors, cultural factors, quantitative assessment, (ie, qualitative measures of symptoms, level of functioning and quality of life), involvement of the patient in treatment decision making would need to be done with the tools previously mentioned to assess functioning. In compliance with the APA guidelines, a review of all available evidence will be done so that selection of an appropriate treatment will be made by the therapist and patient.
Clinical Note: Is depression a normal part of aging?
Depression is not a natural aspect of aging. Wheeler reported that according to the Depression and Bipolar Support Alliance, because elderly patients with mental health issues commonly use the primary care setting for treatment, mood disorders are under-recognized, inadequately treated and underserviced. Because this depression in the elderly population is under-recognition and inadequately treated, it worsens and leads to decreases in cognitive function, functional impairment, poorer well-being and increased risk of completed suicides and death (2014). Therefore appropriate diagnosis and timely treatment is critical.
Treatments for Depression and Anxiety
This client has mild to moderate depression. EBPs include Individual Psychotherapy, CBT, RT, LRT, problem-solving therapy, IPT, and antidepressant medications. According to Wheeler, CBT and RT are reported to prevent depression in the elderly, who are at risk for depression, bereavement, and sleep disturbances. Also, CBTs, such as learning cognitive skills to change negative thinking, social skills to improve problem-solving communication, homework, which includes weekly activity schedules and journaling, along with motivation interviewing techniques to help the elderly patient overcome reluctance to do homework are all EBPs for treating anxiety. Also, modular interventions, such as exposure in vivo, relaxation therapies, mindfulness training, has been proven to be effective treatments for individuals, who don’t want medication for the treatment of anxiety. Also, these treatments are the first in treatment for depression. Also, RT is especially effective for late in life anxiety. Also, IPT, which is important for reflection and resolution of roles and relationships, with a focus on social relationships is a good choice of therapy for individuals, who are cognitively intact with mild to moderate depression, and anxiety associated with loss, grief, and interpersonal conflicts. RT and LRT are effective in treating depression and anxiety. It is the process of recalling their life and events, and in the process of talking about their lives, the clients come to an understanding of who they are as a whole person. Finally, pharmacotherapy appears to be effective for treating depression and anxiety. Medication with IPT is especially effective in treating recurrent major depression.
To offer a holistic, multidisciplinary approach to treating this client’s depression and anxiety, in addition to the above therapies, life style management, self-care management, spiritual support, all which increase wisdom and resiliency, and community services, such as outreach and peer support groups, are encouraged to promote mental health, according to the finding of the MacArthur Study of Successful Aging reported by Wheeler (2014). Also to assist this client with achieving Gerotranscendenc and the development task of integrity versus despair, developed by Erikson’s wife and Erikson respectfully, encouragement of personal growth and development through travel, and engaging in friendships and hobbies that have been neglected are recommended to enhance the quality of life and improve the well being of your client (Wheeler, 2014).
To further provide a holistic, multidisciplinary approach for this patient, family and caregiver support group therapy can be offered to decrease the mental and emotional stress of caring for the older adult on the family. Social services for the family can be offered to decrease the physical and financial stress that caregivers face. Therapy goals for the caregivers would include education, specific problems-solving skills, resource acquisition, long-range planning, emotional support, respite care (Wheeler, 2014).
Finally, termination of psychotherapy will occur with a mutual decision between the APPN and the client, and when the therapy goals are attained. It is recommended that the criteria for termination be discussed early in the therapy session. Identification of options to encourage resiliency, self-care management, and contingency plans, based on what was learned in therapy are discussed in later therapy sessions. Termination also enhances a positive psychotherapy experience for the client and therapist because it fosters a sense of reciprocity, sharing and completion (Wheeler, 2014).
psychotherapy