Question

Ripley Walker is a 57-year-old attorney referred to you by his primary care physician (PCP) for treatment of depression. He has been depressed for approximately eight months, since the death of his wife from breast cancer. He feels the depression is worsening. Ripley reports having problems with decreased appetite, poor sleep, and anhedonia. His PCP prescribed paroxetine three months ago, but Ripley hasn’t noticed much improvement in his symptoms—even at a dose of 50 mg/d.

Ripley reports that he takes tramadol regularly for low back pain. He has had chronic low back pain since an automobile accident 20 years ago. He had taken ibuprofen or naproxen for the back pain with some relief, but he began having epigastric distress about two years ago when using these. At the time, his PCP recommended discontinuing them. Once he stopped taking the NSAIDs, the epigastric distress resolved.

Questions

From your perspective as Ripley’s psychiatric nurse practitioner, answer the following questions in a paper no longer than two double-spaced pages (not including the reference page) and in APA format. Include at least three peer-reviewed, evidence-based references.

1. What assessment questions should you ask Ripley?
2. When you ask about his back pain, Ripley replies that he is willing to talk about it but doesn’t see how it’s relevant to the depression he came in for. How do you respond to Ripley?
3. You decide that a trial of a different antidepressant is indicated. Which would be the best choice? Why?
4. Ripley mentions that, to help him sleep, he had taken diazepam that his wife had been prescribed during her terminal illness. He asked his PCP to prescribe diazepam for him, but she was hesitant and suggested he discuss this with you. How should you proceed?
5. You consider prescribing pain medication. Select a pain medication appropriate for Ripley. What is the mechanism of action of this medication? How does it relieve pain (that is, how does it interact with the function and structure of the nervous system relative to pain)?
6. Select a controlled pain medication appropriate for Ripley (it can be the same as you chose in the prior question). Explain the FDA regulations and legal ramifications of prescribing this controlled pain medication for Ripley.

Answer 1

1)ASSESSMENT QUESTIONS:

• ask Mr. Ripley regarding the dose and duration of the tramadol which he has been taking.
• check his medical history to check for other co morbidities.
• ask if his back pain has increased in these eight months or is it the same?

2) I would explain the patient(Ripley) that depression and pain are interlinked and there are mental illnesses that causes the patients to experience pain and depression. I would also tell him that depression can worsen his pain or vice versa.

3)The best choice is mirtazapine(tetracycline antidepressant) which improves his appetite it is a histamine 1 antagonist causing sedation which is helpful in this patient   as he has trouble sleeping.

4)I would tell him that the diazepam is not   needed for him and his insomnia can be treated by the drug mirtazapine that also helps to treat his depression.

5)I would advise him to stop tramadol and start him on acetaminophen. It works by reducing prostaglandins in brain. It increases the pain threshold.

6)Acetaminophen 650mg three times a day is appropriate for this patient as it is not habit forming unlike tramadol and it does not interact with the antidepressants and also it has less side effects comparatively.

7)FDA advises to start initially with NSAID and increase the dose as required. If not controlled by NSAID then small possible dose of opioid should be prescribed but in this case tramadol cannot be used as it has a major possible interaction between tramadol and mirtazapine or any other antidepressant.

REFERENCES

Pain and depression: is there a link? Article from mayo clinic.

Babu km et al. prevention of opioid overdose. N Engl J Med 2019

Can mental illness cause physical pain article from www.mentalhelp.net.