Provide two different examples of how research uses hypothesis testing, and describe the criteria for rejecting the null hypothesis. Discuss why this is important in your practice and with patient interactions.

Psychiatric Care and Mental Health in the Community

Read chapter 24 of the class textbook and review the attached PowerPoint presentation.  Once done answer the following questions;

1. Explain and give some examples of the concepts of community mental health and discuss the importance of community mental health promotion in special populations.
2. Describe the biological, social, and political factors associated with mental illness.
3. Describe different types of evidence-based treatment for mental disorders, including the use of psychotropic medication management, community case management, and crisis intervention.  Give at least one example.
4. Describe the role of mental health nurses in the community.

INSTRUCTIONS:

As stated in the syllabus present your assignment in an APA format word document, Arial 12 font attached to the forum in the discussion tab of the blackboard titled “Week 14 discussion questions” and the SafeAssign exercise in the assignment tab of the blackboard(which is mandatory).  A minimum of 3 evidence-based references besides the class textbook no older than 5 years must be used and quoted according to APA guidelines.  You must post two replies to any of your peers sustained with the proper references no older than 5 years in two different days to verify attendance and as well make sure the references are properly quoted and mention to whom you are replying to.  The reply is a comment to your peer, not an extension of what you posted in your assignment.  What I mean is that you can’t post in your replies the same that you posted in your assignment.   A minimum of 800 words is required.  Please make sure to follow the instructions as given and use either spell-check or Grammarly before you post your assignment.  I will also pay close attention to spelling and/or grammar.  Please review the rubric attached to the lecture.  You must present the assignment according to how it is posted, answering the questions by number and essay-style assignments will not be accepted unless otherwise specified.

Topic 2

Search the South University Online Library for information about caregiver role strain.

• What is the most important factor that causes caregiver role strain?
• How do you assess for caregiver strain?
• What can be done to prevent or decrease caregiver role strain?

The Case:

The sleepy woman with anxiety

This week’s discussion presents a case study involving a 44-year old woman with a chief complaint of anxiety beginning at age 15 years old. She has a long history of mental illness and continued therapies. The purpose of this discussion is to analyze her case history to determine medication and treatment effectiveness.

Client Questions

Question 1. Are you having feelings of harming yourself or harming someone else?

Rationale: This is a possibly uncomfortable yet important set of questions to ask each client. Primary care providers may be in a unique position to prevent suicide due to their frequent interactions with suicidal patients. Reviews suggest that among patients who committed suicide, 80 percent had contact with primary care clinicians within one year of their death, whereas only 25 to 30 percent of decedents had contact with psychiatric clinicians within the year of their death (Stene-Lars & Reneflot, 2017).

Question 2. What was happening in your life as a teenager when the anxiety started and you began to self-medicate?

Rationale: Per our report, this patient began suffering signs and symptoms of anxiety at 15-years old. Asking these types of questions we may gain insight into an underlying cause or triggering event. Anxiety disorders are the most common psychiatric disorders with onset in childhood, with prevalence estimates ranging from 10 to 30 percent. Nearly 37 percent of behaviorally inhibited preschool-age children had social anxiety disorder at age 15, compared with 15 percent of non- behaviorally inhibited children. Children with anxiety disorders are more likely to have persistent anxiety disorders into adulthood. (Rapee, 2014).

Question 3. What was happening in your life a year ago when these symptoms returned and became debilitating? Let’s discuss what the triggering events may have been.

Rationale: Self-discovery of triggering events may help the client to come to terms with the determinants of her anxiety and depression. Studies have shown that specific types of stressors were found to differentially predict increases in specific facets of anxiety sensitivity; health-related stressors predicted increases in disease-related concerns and fear of mental incapacitation, whereas stressors related to family discord predicted increases in fear of feeling unsteady, fear of mental incapacitation, and fear of having publicly observable symptoms of anxiety (McLaughlin & Hatzenbuehler, 2009).

Support System

The support system as reported by our client is her husband. She states he is supportive and has little to no contact with the family of origin. She has a few friends and a few outside interests. As PMHNP, discussing relationships with the client is one avenue to gain insight into anxiety patterns and coping mechanisms as seen by outside support. With the client’s permission, speaking to her husband may assist us in this situation. Learning how the patient functions at home, what critical changes have occurred with this recent bout of depression and what coping mechanisms are utilized by the couple may assist us in reaching a state of remission. In addition, these disorders are associated with significant decreases in patient well-being and social functioning and can cause considerable pain and suffering, not only for affected individuals but for their family and friends as well. Despite the availability of proven treatments, both disorders remain underrecognized and undertreated (Ballenger, 2000).

1. Are you aware of when your wife is entering a state of anxiety or depression?
2. What have you noticed happening in your lives when this occurs?
3. When these events occur, what response does that create for you?
4. What coping mechanisms do you utilize for yourself and your relationship when these events occur?

Physical Exams and Diagnostic Tests

First a complete physical assessment of the patient is required to rule out any underlying medical issues. This would also include a full blood panel with CBC, CMP, TSH and urinalysis and toxicology. Research findings suggest that mood and anxiety symptoms result from a disruption in the balance of impulses from the brain’s limbic system. A 2015 study reported that individuals with comorbid depression and anxiety have increased resting-state functional connectivity of the limbic network when compared with depression or anxiety alone. FK506 binding protein 51 (FKBP5) is a co-chaperone binding protein which modulates the function of glucocorticoid receptors. In a study examining allelic variants of FKBP5, the T allele was more frequent among patients with comorbid depression and anxiety (Pannekoek et al., 2015). Additionally, rating scales have shown good reliability for assessing anxiety and depression. The Depression and Anxiety Stress Scale (DASS) is suitable for assessing clients with co-occurring depression and anxiety.

Differential Diagnoses

1. Post-Traumatic Stress Disorder (PTSD)- This patient could be showing physical manifestations of PTSD. Posttraumatic stress disorder (PTSD) and substance use disorders (SUD) are prevalent and frequently co-occurring psychiatric illnesses that are both highly associated with disturbed sleep. PTSD affects an estimated 5 million people in the U.S. each year and is characterized by an inability to recover from a stress reaction following exposure to a traumatic event (Vandrey et al., 2014).
2. Generalized Anxiety Disorder (GAD)- This patient falls into the DSM-V criteria for anxiety. Generalized anxiety disorder produces fear, worry, and a constant feeling of being overwhelmed. Generalized anxiety disorder is characterized by persistent, excessive, and unrealistic worry about everyday things. This worry could be multifocal such as finance, family, health, and the future. It is excessive, difficult to control, and is often accompanied by many non-specific psychological and physical symptoms (Munir & Takov, 2019).
3. Polypharmacy and (GAD)- This patient may be suffering issues relating to polypharmacy as evidenced by sleep disturbances combined with anxiety disorder. As the number of available medication options increases, so does the potential for polypharmacy, a practice with possible complications. Such complications include a greater number of side effects with the initiation of additional medications and the consequences of drug-drug interactions.

Pharmacologic

This patient does not appear to be a good self-historian regarding medication, compliance and lacks the ability to determine medication effectiveness. It is the thought of the PMHNP that the patients issue with narcolepsy is related to medication and polypharmacy issues. Simplifying the patients eight medications by discontinuing sodium oxybate, pramipaxole and DDAVP seem to improve her daytime sleepiness. This patient was taking several medication relating to sleep, causing other issues including bed-wetting for which she was prescribed DDAVP (Desmopressin), and reports it is not very helpful. By tapering and discontinuing these medications and educating the patient on sleep hygiene and perhaps sleep studies, we can assist this patient into improved sleep at night without excessive daytime sleepiness.

Lessons Learned

This case is an excellent example of long term mental health issues and polypharmacy. This patient seemed to be a good candidate for Vagus Nerve Stimulation (VNS) to which she received relief from sleep disturbances. Many patients with chronic anxiety have a poor quality of life. The education of both the patient and family by the pharmacist, nurse, and provider as a team is important to reduce the high morbidity and addiction problems with treatment medications. Family members should help ensure medication compliance and provide a supportive environment. Unfortunately, despite optimal treatment, relapse rates are high (Dold et al., 2017).

References

Ballenger J. C. (2000). Anxiety and Depression: Optimizing Treatments. Primary care companion to the Journal of clinical psychiatry, 2(3), 71–79. https://doi.org/10.4088/pcc.v02n0301

Dold M, Bartova L, Souery D, Mendlewicz J, Serretti A, Porcelli S, Zohar J, Montgomery S, Kasper S. Clinical characteristics and treatment outcomes of patients with major depressive disorder and comorbid anxiety disorders – results from a European multicenter study. J Psychiatr Res. 2017 Aug;91:1-13.

McLaughlin, K. A., & Hatzenbuehler, M. L. (2009). Stressful life events, anxiety sensitivity, and internalizing symptoms in adolescents. Journal of abnormal psychology, 118(3), 659–669. https://doi.org/10.1037/a0016499

Munir S, Takov V. Generalized Anxiety Disorder (GAD) [Updated 2019 Nov 22]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK441870/

Rapee RM. Preschool environment and temperament as predictors of social and nonsocial anxiety disorders in middle adolescence. J Am Acad Child Adolesc Psychiatry 2014; 53:320.

Stene-Larsen K, Reneflot A. Contact with primary and mental health care prior to suicide: A systematic review of the literature from 2000 to 2017. Scand J Public Health 2019; 47:9.

Pannekoek JN, van der Werff SJ, van Tol MJ, et al. Investigating distinct and common abnormalities of resting-state functional connectivity in depression, anxiety, and their comorbid states. Eur Neuropsychopharmacol 2015; 25:1933.

Vandrey, R., Babson, K. A., Herrmann, E. S., & Bonn-Miller, M. O. (2014). Interactions between disordered sleep, post-traumatic stress disorder, and substance use disorders. International review of psychiatry (Abingdon, England), 26(2), 237–247. https://doi.org/10.3109/09540261.2014.901300