When referring to Benzodiazepines, they are often prescribed however, they are recommended to be used for short term use for anxiety. They have a potential for dependence and abuse. They will have a sedative effect on the patient and can cause amnesia. While in an acute situation, a Benzodiazepine may be warranted but care must be taken to provide interventions that can be given long term if needed. In the elderly population, it should not be used long term as they may not be able to metabolize the medication hence it will stay in their system longer and can be detrimental. It can also cause safety risks by way of falls with the potential for fractures as well as skin breakdown due to the sedative effects that may not allow them to change positions on their own. Prolonged use is associated with the development of dependence, tolerance and adverse reactions, including cognitive impairment, dementia, falls and consequent fractures, (Fulone et al., 2018).
Benzodiazepines act fast and can be effective for acute situations. Alprazolam, clonazepam, and lorazepam are among the 10 most commonly prescribed psychotropic medications in the United States, (Lembke et al., 2018). A common problem with this is that those who use illicit drugs combined with this are at greater risk for addiction and untoward events. Benzodiazepines have proven utility when they are used intermittently and for less than 1 month at a time. When they are used for extended periods, the benefits of benzodiazepines diminish and the risks associated with their use increase, (Lembke et al., 2018).
When speaking with KT regarding her general anxiety disorder, it is important to assess her physically to determine if there are any physiological reasons or perhaps other medications that she is taking that could be the reason for her anxiety. After this is ruled out, it would be important to determine what, if any coping mechanisms she has to deal with the many concerns she has being a new student and coping with her various obligations. Therapy would be the initial course of action. If therapy is being utilized and it is not effective, then medications can be prescribed at its lowest dose. A selective serotonin reuptake inhibitor (SSRI) would be started in combination with therapy to treat her symptoms and coping mechanisms will be taught. She would be advised that the medication may take some time to have its greatest effect before she may see some improvement.
WD may meet the criterion for Major Depressive Disorder as he had a major health event that one can consider life changing. Major depressive disorder is the most prevalent and disabling form of depression, affecting more than 32 million Americans. In any given year, nearly 7% of the American adult population has an episode of major depressive disorder, (Amick et al., 2015). With his past medical history, the first course of treatment would be intensive counseling. A meta‑analysis showed that patients who received psychosocial treatment had significant reductions in psychological distress and systolic BP (SBP), (Seyedhosseini et al., 2016). Refractory hypertension, being hard to treat may have caused his depression. The inherent complexity of psychological distress may in fact raise the blood pressure. The most common cardiovascular-related side effects of SSRIs include mild bradycardia and hypotension, mild QRS prolongation, and first-degree cardiac block, (Nezafati et al., 2016). Behavioral modification would be the first line of defense however, if this is not sufficient, medications would be introduced. The provider must assess the willingness of the patient to be compliant with the prescribed medications as all medications have some sort of side effects. Regardless of which treatment patients prefer, some evidence suggests that patients who receive their treatment of choice fare better than those whose treatment is incongruous with their preferences, (Amick et al., 2015). When starting medications, again the use of SSRIs is considered. To initiate antidepressant treatment, modern guidelines recommend new generation antidepressants and in particular (SSRIs), (Kato et al., 2018).
When prescribing medication for WD, it is important to note that SSRIs are thought to contribute to glaucoma so care must be taken in his circumstance. It has been hypothesized that SSRIs may increase intraocular pressure via serotonergic effects on ciliary body muscle activation and pupil dilation, (Chen et al., 2017). Serotonin has been shown to play a critical role in lens transparency, and, thus, it is postulated that increased levels of serotonin may be associated with lens opacity in human eyes, (Karaküçük et al., 2019). The effect on the body may make their eyes dry and gritty so this should be considered when prescribing medications.
In addition to the above, SSRIs can potentially induce Diabetes. SSRIs are potential inducers of insulin resistance, and its role may be to act as a direct inhibitor of the insulin signaling cascade in β-cells, (Yao et al., 2018). The effect of comorbid diabetes and depression on decrements in health has been shown to be interactive, suggesting a negative effect on health beyond that expected by adding the effect of the two disorders, (Berge & Riise, 2015).
When assessing JW, it is important to note that she has significant concerns that are causing her to have anxiety and depression based on her situation. Her immediate safety needs to be addressed wherever possible and resources for job preparedness and training should be referred. Again, counseling should be incorporated first in her treatment plan and coping mechanisms should be taught prior to medication administration. In patients with conditions such as pain, cancer or depression, treatment focused on relieving the primary disorder, (Geiger-Brown et al., 2015). Her primary disorder are the burdens that she deals with on a daily basis. Most likely she is thinking too much of her current situation which is leading to her insomnia. At some point, the body is forcing her to sleep and she finds herself sleeping for extended periods of time on Sunday. Sleep is an important aspect of health and is restorative in nature. The lack of sleep can cause numerous problems both psychologically and physiologically. Sleep problems can be addressed through simple precautions, such as sleep hygiene, relaxation techniques, and behavioral therapy, before recommending medication, (Duman & Timur Taşhan, 2018).
Alternative, nonpharmacological approaches should be explored such as warm milk, providing a warm quiet environment absent of television or other stimulants prior to the hour of sleep. Late night exercising may prevent her from sleeping as her energy levels may increase however, for some, it can help them sleep better so it advisable to discuss with JW how she feels after exercise. Listening to white noise and calming sounds may prove to be effective. Additionally, avoiding the use of anything that contains caffeine would be advisable.
JW is noted to be taking a benzodiazepine for sleep. While effective for sleep, it does not have an effect on the reason why she is not getting enough sleep. Temazepam has a longer half life than other benzodiazepines and with continued use will not be effective at the same dose. I would opt to try a more natural approach in addition to nonpharmacological treatments for her insomnia.
References
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