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RESPONSE TO DISCUSSIONS

RESPONSE TO DISCUSSIONS

CC (chief complaint): Patient states “I am very depressed and very anxious”.

HPI; Patient k.k is a 17-year-old African American female who visited with her mother.  She is alert and oriented to time, place, person and situation. She reports she has been having feelings of depression for the past couple of months now as a result of gender identity issues and being gay. She reports symptoms like unprovoked crying spells, sadness, low self-esteem, feelings of hopelessness, worthlessness, lack of motivation and loss of interest, lack of concentration in school, decreased appetite, poor sleep, irritability, self-isolation. She reports she worries about everything from worrying how she would be accepted by her peers and extended family due to her gender identity issues. She also reports symptoms of anxiety such as restlessness,  sweating palms,  difficulty swallowing, racing thoughts and difficulty sleeping. She reports she sleeps for 3-4hours and her sleep is not restful and she has early morning awakening. She reports recently having impulsivity and poor judgement. She denies history of trauma, she denies thoughts of hurting self or others. Patient’s mother report her daughter is very sad and she tries to encourage her to feel better about herself.

Substance Current Use: No substance use by patient.

Medical History: Patient has no medical history.

 

· Current Medications: Zoloft 50mg 1 tab daily.

· Allergies: NKDA

· Reproductive Hx: Patient has no children at this time.

 

ROS:

· GENERAL; Patient is alert, oriented to time, place, situation and person. Well groomed and appropriately dressed. No weight loss, fever, chills or weakness noted.

· HEENT: Patient report no fall or head trauma, no headache. Denies eye pain, no blurry vision, no drainage from eyes. No ear pain, no loss of hearing and no drainage from ears. Neck supple. no throat pain and no problem swallowing.

· SKIN: skin intact, warm and dry to touch. No rash to skin and no itching noted.

· CARDIOVASCULAR: Patient denies heart palpitation or irregular heart beat.  No report of chest pain.

· RESPIRATORY: Patient repiration even and unlabored,  no cough, wheezing or congestion. Denies dyspnea on exersion.

· GASTROINTESTINAL: Patient denies abdominal pain. No nausea, vomiting, constipation. Patient report regular bowel pattern.

· GENITOURINARY: Patient has no abdominal pain, denies burning on urination, urgency or hematauria.

· NEUROLOGICAL: Patient denies hx of syncope, dizziness, ataxia or paralysis. No problem with balance and coordination.

· MUSCULOSKELETAL: Patient denies muscle, joint or back pain. Gait and ambulation normal. No joint stiffness or limitation in motion.

· HEMATOLOGIC: Patient denies hx of anemia. No report of  bleeding or bruising.

· LYMPHATICS: No swelling to lymph nodes.

· ENDOCRINOLOGIC: Patient denies cold or heat intolerance, no polyuria or polydipsia.

Objective: Patient is alert and oriented to time, situation, person and place. she is neatly dressed and appropriate for the weather. Ambulation and gait was non remarkable. Her speech is normal rate, tone, volume and flow. Patient noted with sad facial expression with teary eyes during session. Her mood is congruent with his affect. she was able to answer question accurately and made eye contact during session. Her  intellectual functioning is adequate.

Subjective: She reports she has been having feelings of depression for the past few months now as a result of gender identity issues and being gay. She reports symptoms like unprovoked crying spells, sadness, low self-esteem, feelings of hopelessness, worthlessness, lack of motivation and loss of interest, lack of concentration in school, decreased appetite, poor sleep, irritability, self-isolation. She reports she worries about everything from worrying how she would be accepted by her peers and extended family due to her gender identity issues. She also reports symptoms of anxiety such as restlessness,  sweating palms, difficulty swallowing, racing thoughts and difficulty sleeping. She reports she sleeps for 3-4hours and her sleep is not restful and she has early morning awakening. She reports recently having impulsivity and poor judgement. She denies history of trauma, she denies thoughts of hurting self or others. Patient’s mother reports her daughter is very sad and she tries to encourage her to feel better about herself.

Diagnostic results: Patient PH-Q9 result after assessment for depression indicate patient scored 18/27 showing that patient is severly depressed.

                                                                                                                 

 Assessment

Mental Status Examination: Patient alert to time, place, person and situation. Patient is well dressed and appropriately groomed. Her speech is normal rate, flow, tone and volume.Patient looks sad and her mood is congruent with her affect. Able to make eye contact during session. Her thought process is logical, goal-directed and she is able to have abstract thoughts. Her thought perception is lucid. Patient has intact recent and remote memory. Judgement and insight is good. No psychomotor agitation or retardation noted.

 

Diagnostic Impression:

Major Depressive disorder; It is diagnosed when an individual has a persistently low or depressed mood, anhedonia or decreased interest in pleasurable activities, feelings of guilt or worthlessness, lack of energy, poor concentration, appetite changes, psychomotor retardation or agitation, sleep disturbances, or suicidal thoughts.  This patient is a 17yr old  African American female who suffers from gender identity. She is an LGBT but her family and community do not accept her sexual preferences. She also reports symptoms such as sadness, self-isolation, unprovoked crying spells, feeling of hopelessness and worthlessness, lack of motivation, irritability, fluctuating appetite, disrupted sleep. All these symptom reported are consistent with the diagnosis of major depression. According to the DSM-V,  the diagnosis of major depressive disorder includes the presence of at least one of either 1. depressed mood or 2. anhedonia in addition to five or more of the following symptoms listed below for at least 2 weeks, impact social, occupational or cause distress in other important areas of life, not precipitated by drug use. Not be explained by other mental disorders such as schizopherenia or bipolar disorder. These additional symptoms of which 5 must be positive include;

· Depressed mood

· Anhedonia (diminished loss of interest or pleasure in almost all activities)

· Significant weight or appetite disturbance (read more about:  Depression and Weight Gain, Weight Loss )

· Sleep disturbance

· Psychomotor agitation or retardation (a speeding or slowing of muscle movement)

· Loss of energy or fatigue

· Feelings of worthlessness (low self-esteem)

· Diminished ability to think, concentrate and make decisions

· Recurrent thoughts of death, dying or suicide

· Longstanding interpersonal rejection ideation (ie. others would be better off without me); specific suicide plan; suicide attempt. This patient has more than 5 of the above listed symptoms persistently for many months.

· Bipolar II disorder; Bipolar II disorder (pronounced ” bipolar two”) is a form of mental illness characterized by moodsalternating between cycles of depression and hypomania over time.  In bipolar II disorder, the elevated moods states are less intense than and never reach full-blown mania (Rowland, T. A., & Marwaha, S. 2018). This patient is a 17yr old with symptoms suggestive of major depression following a history of emotional and psychological challenges with her family member. She reports symptoms like unprovoked crying spells, sadness, low self-esteem, feelings of hopelessness, worthlessness, lack of motivation and loss of interest, lack of concentration in school, decreased appetite, poor sleep, irritability, self-isolation all of which are suggestive of major depression. However, she recently experienced the new set of symptom such as as restlessness,  sweating palms,  difficulty swallowing, racing thoughts, difficulty sleeping  as well as impulsivity. However, this did not warrant hospital admission. These new symptoms are suggestive of hypomania. Therefore, with all these constellation of symtpoms are suggestive of a diagnosis of bipolar disorder type 2. However, there isn’t enough data to determine the cyclical association between the depressive episodes and hypomania to make this diagnosis.

 

· Generalized anxiety disorder; Generalized anxiety disorder is a mental health disorder that produces fear, worry, and a constant feeling of being overwhelmed. It is characterized by excessive, persistent, and unrealistic worry about everyday things. This patient is a 17yr old lady with symptoms suggestive of major depression in addition to complaints of anxiety such as restlessness,  sweating palms, difficulty swallowing, racing thoughts and difficulty sleeping. She reports she sleeps for 3-4hours and her sleep is not restful and early morning awakening. She is a member of the  LGBTQ community but her family does not respect and accept her sexual choices and preferences resulting in all the distress she is facing.  Generalized anxiety disorder is diagnosed when an individual has excessive anxiety and worry occurring on most days for at least 6mo. The worry is impulsive and difficult to control. In this patient, the anxiety is caused by the the emotional stress, it has a specific cause as opposed to generalized anxiety disorder where individuals just worry about everything. Also generalized anxiety disorder is diagnosed when symptoms persist for at least 6 months while this anxiety has only been present for a couple of months.

                                                                                                                                                           Reflections

This patient’s history was thoroughly taken and the investigations and subsequent diagnosis and treatment were very good. However, there is always a room for improvement. If I had to see this patient again, I would like to elicit if there is a cyclical or alternating pattern between mania and depression. I will also like to know if there is family history of bipolar disorder because studies have shown that there is a strong familial association in bipolar disorder. I will also like to know if there is a history of depression in  the family. Bipolar disorder has also been linked to other mood disorders such as major depressive disorder.she also complained of restlessness and sweaty palms. I would like to rule out all hyperthyroid symptoms such as tremors, brisk reflexes, palpitations, recent weight loss despite hyperphagia, menstrual abnormalities. I will also like to know if she is taking androgenous steroids which could be responsible for her mood disorders. For example if she is trying to be masculine and is on steroids she could be experiencing side effects of the drugs. Lastly, I would like to seek her permission to invite the parents for family therapy. Her stressor is her immediate family being unwilling to accept her for who she is and it will be of great benefit to invite them, explain to them and counsel them all together. I believe that family therapy would be more effective than pharmacotherapy in this patient because it removes the stressor/ aetiology of the condition.

                                                                                                                                                

Case Formulation

Treatment Plan: The treatment plan for patient will be to start patient on an antidepressant.  This antidepressant could be a Selective Serotonin Reuptake Inhbitors (SSRI) or a Serotonin-norepinephrine reuptake inhibitor (SNRI) is the medication of choice for patient with Major depressive disorder (Clevenger et al., 2018).  It is also known that patient with major depressive disorder can be treated with Cognitive Behavioral Therapy in conjuction with an antidepressant to prevent relapse of  Depression in these patient (Clevenger et al., 2018) . There are different factor a health provider must consider before starting patient on medication. Provider must ask if patient is pregnant during assessment before starting patient on any medication. Patient was started on Zoloft (Sertraline) 50mg 1 tab daily for depression. Zoloft is an SSRI and  It works by blocking the target transport involved in the reuptake of serotonin, so as to have adequate amount of serotonin neurotransmitters in the synaptic cleft. This drug of choice is very appropriate for patient because in addition to patient having major depressive disorder, she also has anxiety disorder and this medication can be used to treat both disorder at the same time. Provider must educate patient on the side effect, adverse effect of medication. Also teach patient not to stop  medication abruptly and to inform patient that medication might take 2-4 weeks before they can get positive effect of medication.

Plan for Psychotherapy and alternative therapies; the plan for psychotherapy will be for patient to participate in Cognitive behavaioral thearpy (CBT) either in a group or as individual. Patient with major depressive disorder are known to focus and ruminate on their negative shortcomings, known to have distorted pattern of thinking and in patient’s case she verbalized feelings of hopelessness, worthlessness, self-isolation coupled with her having identity problem and low self-esteem. During CBT, patient’s core beliefs and are explored by the therapist and the therapist will help patient explore her thoughts and explain how her thoughts could affect her feelings and emotions. The therapist will also help patient identify negative rumination and help her change those negative thoughts to positive thoughts and this will ultimately improve patient’s mood (Guantam et al., 2020). In CBT, the therapist teach coping skills such as self motivation and efficacy strengthening, emotion regulation and shifting perspective.

Pharmacological treatment, rationale for use; Pharmacological intervention for patient is to start patient on Zoloft 50mg 1 tab daily. Zoloft works by desensitizing serotonin neurotransmitter, thereby making it more available. Teaching for patient on side effect of Zoloft include tremors, headache, dizziness, dry mouth, nausea(Stahl 2021).

Nonpharmacological treatment and rationale for use; Nonpharmacological treatment for patient will be Cognitive behavioral therapy (CBT) which is know to be effective for patient with major depressive disorder.

 Health promotion activity; one health promotion activivy for patient will be for her to engage in daily exercise. Exercise is known to help patient improve mental and physical energy and it helps patient reduce stress and enhance sleep. Exercise will help patient feel relaxaed and sleep better. Exercise is also know to enhance cardiorespiratory fitness in patients suffering from depression (Belvederi et al., 2019).

 Patient education strategy; Patient education will include imporatance of medication intervention, side effects of medication, when to expect symptoms relief in the case of  Zoloft is between 2-4weeks. Patient is also educated not to stop medication without taking with provider. Patient educated to call provider or call 911 for any active thoughts of hurting self or others.

 

 

QUESTIONS.

1. Mention any three risk factors for Depression?

2. How do social factors affect Depression ?

3. Mention 3 pharmacological treatments for Depression aside from treatment mentioned in case presentation

 

                                                                                                                                             

References

Belvederi Murri, M., Ekkekakis, P., Magagnoli, M., Zampogna, D., Cattedra, S., Capobianco, L., Serafini, G., Calcagno, P., Zanetidou, S., & Amore, M. (2019). Physical Exercise in Major Depression: Reducing the Mortality Gap While Improving Clinical Outcomes. Frontiers in psychiatry9, 762. https://doi.org/10.3389/fpsyt.2018.00762

Clevenger, S. S., Malhotra, D., Dang, J., Vanle, B., & IsHak, W. W. (2018). The role of selective serotonin reuptake inhibitors in preventing relapse of major depressive disorder. Therapeutic advances in psychopharmacology8(1), 49–58.  https://doi.org/10.1177/2045125317737264

Gartlehner, G., Wagner, G., Matyas, N., Titscher, V., Greimel, J., Lux, L., Gaynes, B. N., Viswanathan, M., Patel, S., & Lohr, K. N. (2017). Pharmacological and non-pharmacological treatments for major depressive disorder: review of systematic reviews. BMJ open7(6), e014912. https://doi.org/10.1136/bmjopen-2016-014912

Gautam, M., Tripathi, A., Deshmukh, D., & Gaur, M. (2020). Cognitive Behavioral Therapy for Depression. Indian journal of psychiatry62(Suppl 2), S223–S229.  https://doi.org/10.4103/psychiatry.IndianJPsychiatry_772_19

Rowland, T. A., & Marwaha, S. (2018). Epidemiology and risk factors for bipolar disorder. Therapeutic advances in psychopharmacology8(9), 251–269. https://doi.org/10.1177/2045125318769235

Stahl, S. M. (2021). Essential psychopharmacology: the prescribers guide: Stahl’s essential psychopharmacology (Seventh Edition). Cambridge: Cambridge University Press

Thom, R., Silbersweig, D. A., & Boland, R. J. (2019). Major Depressive Disorder in Medical Illness: A Review of Assessment, Prevalence, and Treatment Options. Psychosomatic medicine81(3), 246–255.  https://doi.org/10.1097/PSY.0000000000000678

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