Major Depressive Disorder Diagnosis and Treatment Plan Case Study

Referred by: No referral

Informant/Support person: Patient

Date: 02/18/18

Demographics: This is a 32 years old African American female who currently lives in the outskirt of a north eastern state of this country.  She lives with her husband, and three children in a two-bedroom government house. Patient has Medicaid insurance; her primary language is English. Patient is of Catholic faith and currently unemployed. Information was obtained by face to face interview with the patient, and review of medical record.

Thinking about the Diagnosis and treatment plan: The demographic introduce the patient to the Psychiatric Mental Nurse Practitioner (PMHNP). Patient information is elementary, and can be use to initiate possible diagnosis, and treatment options for the patient.

NIMH estimates that in the United States, 16 million adults had at least one major depressive episode in 2012. That’s 6.9 percent of the population. According to the World Health

Organization (WHO), 350 million people worldwide suffer from depression. It is a leading cause of disability.  Pietrangelo, A. (2015, January 28). Anxietydisorders are the most common mental illness in the U.S., affecting 40 million adults in the United States age 18 and older, or 18.1% of the population every year. Anxiety disorders are highly treatable, yet only 36.9% of those suffering receive treatment.   Folk, J. (2017, April 25).

Thinking about Diagnosis and treatment plan

Patient has no strength, unemployed, homeless, and husband is jobless with children, culture aspect of care, patient brother and mother are not supportive.  Family therapy might be needed.

Cultural aspect will be discussed below.

Chief Complaint:  Patient reports that “I have been feeling depressed, anxious, and under stress”.

Thinking about the diagnosis and treatment:

The patient stated “I have been feeling depressed, anxious and under stress” depression need to be considered as potential diagnosis, the other diagnosis generalized anxiety, and sleep apnea disorder due to excessive daytime sleepiness, awakening SOB, frequent arousals, and fatigue. Although the patient has obstructive apnea, the reason she does not sleep much at night is to care for her child. She does have CPAP machine that she uses at night for sleep. This will require further consideration. Patient has been depressed since she was 16 yrs old and has been on Wellbutrin and Cymbalta: Some medication adjustment followed by family therapy will be effective for treating depression (Pietrangelo, A. (2015, January 28)).

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History of Present Illness: Patient’s depression started when she was a teenager. Patient reports being irritable and having occasional crying spells. She frequently has a problem with motivation. She has trouble remembering things and has poor energy level. Appetite has been very poor without any weight change. She has obstructive sleep apnea, and a child who does not sleep at night due to medical condition. Due to caring for her child at night, her CPAP machine monitor often indicates that she is not using it as needed and she may deem not to need it by the insurance company. She denies any suicidal ideations or thoughts. Patient reports going into “panic mode” where she feels that her whole body will explode. During this period of panic mode, she becomes tachycardic, has difficulty taking deep breath, elevated blood pressure and sense of impending doom. She reports that these feelings may last about 3 hours and has on two occasions lasted about 3 days. This panic mode she reports comes after periods of not able to pay her monthly bills. She came to the clinic today because she is becoming more irritable and anxious than normal.

Thinking about the diagnosis and treatment

The history of present illness supports a diagnosis of Major depressive disorder. The DSM-V criteria were met in the above. Further discussion will be presented in the differential diagnosis section. Patient exhibit some anxiety, as she mentioned of been anxious and stress. Patient goes into panic attack due to inability to pay her bills, and husband is also jobless. Other support measure will be discussed further. Treatment measures will address depression and anxiety, and family situation will be considered. Folk, J. (2017, April 25).

Psychiatric History: Patient reports that when she was 16 years old, she cut her wrists because of a relationship with her boyfriend.  The relationship ended because she moved to another state. She admitted it was an unwise decision when she was taken to the hospital for treatment and was not admitted. No history of psychiatric hospitalization. At about 17 years old, she saw a psychologist briefly due to some issues in her life that was not fully revealed. She has used Cymbalta up to 60 mg and Wellbutrin up to 200 mg twice daily at various times. The Cymbalta did help a little but then another physician switched her to Wellbutrin hoping it would help her in quitting smoking. She reports that the depression has been poorly controlled, but tobacco usage has been tapered down. She denies any treatment with a psychiatrist or psychiatrist nurse practitioner.

Thinking about the diagnosis and treatment

The patient suffered psychiatric damages due to her relationship ending. She was taken to the hospital for her damaged skin but not admitted because of the shallow cut. She probably saw a psychologist because she previously had a suicide or self-harm experience. She now smokes.  Patient has had no prior history of psychiatric hospitalization but, has seen a psychologist briefly due to some issues in her life that she not reveals. Teaching will be required for all aspect of treatment plan, which includes: medication, therapy, and diagnosis tools Pietrangelo, A. (2015, January 28).

Medical History:

Allergies:  Penicillin 

No known environmental or food allergies

Childhood illness: Reports having usual childhood illnesses but cannot recall specific ones.

Surgery:  Bilateral tubal ligation in 2007 and partial hysterectomy in 2004 for menorrhagia. She has had several miscarriages.

Immunizations: All childhood immunizations were completed; immunizations are current including hepatitis A & B series.

Medical diagnoses: Hypertension, Obstructive Sleep Apnea, Gastric Esophageal Reflux

Disease, Diabetes Mellitus, Chronic back pain, Obesity, Hypercholesterolemia.

Psychiatric diagnosis: depression

Last menstrual period: 10/22/14

Last Pap smear: June 2013. Result was negative

Recommended mammogram:  Not appropriate age.  No family history. Patient reports seeing her OBGYN regularly for preventive care and perform self- breast examination at least five times a week

Medications:  Wellbutrin 200 mg b.i.d. (depression)

Cymbalta 30 mg PO daily (pain)

L-thyroxin 100mcg PO daily (hypothyroidism)

Lisinopril 20mg PO daily (hypertension)

Hydrochlorothiazide 25mg PO daily (hypertension)

Metformin 800mg PO BID (Diabetes)

Zocor 20mg PO daily (cholesterol)

Ultram 75mg PO PRN q6hrs for pain

Prevacid 15mg PO daily for GERD

Over-the-counter: Multivitamins.

Herbal: Denied.

Thinking about the diagnosis and treatment: 

Patient sees OBGYN regularly for preventive care and perform self care breast exam 5 times a week, also has her last pap smear done in 2013. No known major medical problem during patient childhood age.

Endocrine Disorders: Endocrinology disorders involving the hypothalamic pituitary adrenal axis or thyroid are especially likely to produce changes in mood. These include Addison disease, Cushing syndrome, hyperthyroidism, hypothyroidism, and hyperparathyroidism. Endocrine disorder must be rule out because the patient has hypothyroidism. However, her recent thyroid tests were normal. The symptoms the patient is exhibiting that may be related to hypothyroid problem include fatigue, difficulty taking deep breath, poor memory, and weight change (Sadock, Sadock, & Ruiz, 2015).  

Developmental History: The patient reported to the best of her ability that she was born full term, vaginally, after a normal pregnancy. She walked around the furniture at 9 months of age and started walking without assistance at 12 months old.

Thinking about the diagnosis and treatment

Patient was born by a normal pregnancy, reported by the best of her ability. She started walking without assistance at 12 months old. Patient has no evidence of development delays or issue from birth. Patient was born in the southern part of the country, patient has past young adult hood still her mental health problems are affecting her ability to secure a job, which is a major developmental focus. Functional impairment is common in depression; this may persist more than symptoms. It needs to be assessed. (Culpepper, 2016)

Education History: She quit high school twice, the second time being before the last semester of her senior year. She later earned a GED after getting married. She never fails any grade and attended regular school.

Thinking about the diagnosis and treatment plan

Patient quit high school twice. This may have interacted with her depression. She quit for good right before her last semester of her senior year. She got her GED after getting married.  Patient will require learn a trade or continue education in adulthood, if diagnoses are well managed.

Substance use history:

Caffeine: The patient has two or three drinks per day of coffee. She started drinking at age 14. Still drinks coffee

Tobacco: She consumes about a pack of cigarettes a week given that she started Wellbutrin and before that time she had been smoking one-half pack per day. Her first smoking experience was at age 15.

Alcohol: Denied. It is important to know if the patient drinks alcohol because a lot of psychoactive medications can have negative interaction with alcohol.

Illicit drugs: Denied.

Thinking about the Diagnosis and treatment plan:

This patient has no history of illicit drugs, she also denies the use of alcohol, but smokes a pack of cigarettes a week, patient also have 2-3 drinks per day. Patient will be encouraged to attend a rehabilitation session to assist with smoking, also reduce the intake of caffeine.

Personal/Social History: The patient was born in southern part of the country. She and her husband moved to Baltimore in 2005 because her husband had lost his trucking job and they had become homeless. They moved here to stay with family members but had to be evicted because the house was sold.  She has a 10-year-old daughter, and 7-year-old twins (one boy, one girl). She has been married for 11 years. She is presently unemployed but plans to go on a job interview at Safeway supermarket next week. She is of Catholic faith, but only occasionally attends church. She and her family have had some major difficulties with their church of choice. At one point, the pastor accused her husband of larceny of his laptop computer and a credit card; even though, it was later shed to light that one of the young people in the church had been the culprit and no apology was ever given to her husband. Later, they were assisting the pastor with a yard sale, and someone stole the proceeds from the sale, as well as some discount cards. Her husband was again accused, but it was later learned through tracing the discount cards who that the thief was. They felt that the people in the church have viewed them suspiciously and have not apologized for the false accusations.

Thinking about the Diagnosis and the treatment plan:

Her personal and social history has proved that patient lack good functional ability, which is consistent with depression. Patient has been raising her twice 7yrs olds and a 10yr olds daughter, patient has not worked for a long time, her husband worked up until, he lost his job. Patient will require learning a skill, by attending a trade school. (Culpupper, L (2016)).

Family History: Patient reports that her mother was adopted. Her mother has depression, and possibly bipolar disorder. Mother has had substance abuse problems, mainly cannabis and alcohol. Her great grandmother on paternal side had Alzheimer’s disease, died in 2008 at age 82. Patient’s son has ADHD. Her aunt on maternal side has hypothyroidism.  Diabetes and hypertension are present on both family sides. Her father does not have psychiatric history. Patient reported that she loves her children and will do anything for them.  Patient has one brother that lives in another state. He does not have any psychiatric illness.

Thinking about the diagnosis and treatment plan

Family history shows that mother was depressed with history of substance abuse, but father and brother have no psychiatric problem. Grandmother has Alzheimer’s disease, Diabetes and hypertensions are on both families, maternal aunty has history of hypothyroidism. The Hamilton Depression Rating Scale and the Beck Depression Inventory (BDI) are using to measure severity of depression and patient symptoms. Early screening will help with diagnosis and treatment modalities.

Cultural History:  Patient said that she is a family-oriented person but due current problem she is having, her brother and mother are not supportive. She said that there are not any specific cultural issues in her family. She does not feel discriminated against in the neighborhood they live. She expressed that her husband has been supportive, but it has been tough on him as well. Thinking about the Diagnosis and the treatment plan: 

Patient is family oriented however because of her current problem of her mental health; her brother and mother are not supportive. She does not feel discriminated against in her neighborhood though she does not feel like an outsider. Her husband has been supportive even though things have been rough. No known cultural issues in her family. (Pietrangelo, A. (2015, January 28)). 

Review of Systems: 

General Health: patient reportsno recent fever or sweats.She statesher last physical exam was October 2013.

Thinking process: The patient seems to be in good physical health since she reports no recent fever or sweats.

HEENT: The patient states that she needs eye glasses but cannot afford to buy them.  Last eye exam was two years ago. She has no blurred vision, eye pain, redness or diplopia. She reports no problem with hearing, no discharge from ear.  She denies hearing or seeing things that others do not see or hear. She has no nasal congestion, epistaxis. Has complete set of own teeth. She does not wear dentures and visited dentist two years ago. She denies throat pain or hoarseness.   She denies neck stiffness or neck pain.

Thinking process

The patient needs eye glasses but cannot afford them.  Her eyes are fine. She suffered from no blurred vision, eye pain, redness or diplopia. She has no nasal congestion. Her last dentist appointment was two years ago. No throat pain and denies any neck pain. Patient will be referred to an ophthalmologist and a dentist for further evaluations. Those with migraines about 25% of them report to having depression.

(Harvard Health Publications (2016))

Cardiovascular: Patient denies chest pain or palpitations. She reports having increase heart rate when she is under stress.

Thinking Process: Patient denies any chest pain.

Respiratory:  Shedenies difficulty breathinghowever, when she starts having panic attack, it is difficult to breathe.

Thinking Process:  Patient only has difficulty breathing when having panic attacks.

Gastrointestinal: She reportsrecurrent epigastric pain, relieved with prevacid. No history of liver disease. She denies nausea, vomiting or diarrhea. She denies any blood in stool or black tarry stool

Thinking Process: Patient reports recurrent epigastric pain that is relieved with prevacid. Since the patient has no history of liver disease, denies nausea, vomiting, and no blooding stool.  Endocrine: Patient reports she has hypothyroidism. She states no current tenderness or enlargement of thyroid glands.

Thinking Process: Although patient reports hypothyroidism, she has no current enlargement of thyroid glands. Hypothyroidism has been found with patient with depressive disorder.

Genitourinary: She reportsstress incontinence. Patient denies hesitancy, burning on urination or hematuria. Patient reports last gynecological examination was in 2013.

Thinking Process; she reports stress incontinence however she also patient denies hesitancy or burning on urination or hematuria

Dermatological: she denies any rash, dryness, color change or abnormalities of hair and nails

Thinking Process: She denies any rashes, dryness, color change or abnormalities of hair and nails. The patient has no rashes or dryness or skin.

Musculoskeletal: Reports having chronic back pain. Patient reports having nerve ablation but thinks that the nerves have been growing back which has made the pain worse. Patient also has right knee pain usually relieved by taking cymbalta.

Thinking Process: due to patient chronic back pain, patient is on cymbalta, a SNRI antidepressant used for treating depression, anxiety, and pain

Neurologic: reports no history of seizures. She reports having migraine headaches and has been diagnosed with restless leg syndrome. Patient reports that when she was little, she fell on brick blocks and hit her head, losing consciousness. Her brother accidentally hit her on the head one day when they were playing in the yard during second grade but did not lose consciousness.

Thinking Process: With no history of seizures the patient just has reports having migraines and diagnosed with restless leg syndrome. When she was little she fell on brick

Hematological: patient reports no known hematological disorder (Seidel, 2015).

Thinking Process: She has reported no known hematological disorder (Seidel,2015)

Mental Status Exam:

General appearance: Dressed appropriately for season. Grooming is good. Appears older than stated age.

Thinking Process: Patient dressed appropriately for the season

Behavior during interview: Arrived on time. Cooperative, alert, and pleasant.

Thinking Process: During the interview patient was cooperative, alert, and pleasant. Let it be noted that she also arrived on time

Social skills: Had good eye contact. Reports reduced socialization.

Thinking process: patient maintained good eye contact.

Orientation:  Aware of person, place and time.

Thinking Process: Patient is within a reasonable range of self-aware

Memory: Memory is good for immediate recall of interviewer’s name.

Thinking process: Able to spell the word “twitter” in forward and backward directions correctly. Patient can recall last four presidents of the country.  

Speech patterns: Very circumstantial and tangential with normal rate and tone.

Thinking Process:   Patient speech patterns seem normal.       

Thought clarity: Clear.

Thought content: She denies auditory or visual hallucinations. She denies suicidal and homicidal ideation.

Thought process: No overt sign of psychosis, goal directed.

Mood: Depressed, anxiety level is moderate.

Affect: Consistent with mood

Thinking process: Patient has clarity. Patient denies suicidal and homicidal ideation.

Insight and Judgment: Appropriate. Able to explain what she will do if when she gets to a stop sign while driving, she responded “I will stop”. She states that she needs help with her mental health.

Intellectual functioning: Intelligence is average.  She can complete initial interview and consent forms.

Abstract thinking: She can interpret the proverb “make hay while the sun shines” means to work hard while you are able to and save up for the future (Keltner, Bostrom & McGuiness,

2011).

Neurological Exam:

Height: 5’4”

Weight: 250lbs

Blood pressure: 132/88

Pulse: 82

Respiration: 18

Cranial nerves:

1. Olfactory function is tested easily by having the patient smell common objects such as coffee or perfume
2. Peripheral vision tested by asking patient to cover one eye and to look at interviewer’s nose. Interviewer wiggles simultaneously both index fingers of right and left hands. In the superior fields. Patient was able to state correctly the side that moved. Acuity is tested by using the Snellen chart (near and distant vision). Visual fields tested by means of confrontation. III, IV, VI –   Pupils are equal and reactive to light and accommodation. For lateral and vertical gaze, patient was asked follow interviewer’s finger horizontally and vertically. Patient was able to state how many fingers she saw. There is no nystagmus noted
3. The cheek is touch lightly with a wisp of cotton with eyes closed. She was able to feel the sensation.
4. Patient was asked to smile, there is no weakness noted on either side of face.
5. The Weber test involves holding a vibrating tuning fork against the forehead in the midline. The vibrations are normally perceived equally in both ears because bone conduction is equal. In conductive hearing loss, the sound is louder in the abnormal ear than in the normal ear. In sensorineural hearing loss, lateralization occurs to the normal ear. To perform the Rinne test, the vibrating tuning fork is placed over the mastoid region until the sound is no longer heard. It is then held at the opening of the ear canal on the same side. A patient with normal hearing should continue to hear the sound. In conductive hearing loss, the patient does not continue to hear the sound, since bone conduction in that case is better than air conduction. In sensorineural hearing loss, both air conduction and bone conduction are decreased to a similar extent, the tongue was depressed with tongue blade.  The soft palate was touched and gag reflex was noticed. Both soft palates retract symmetrically.
6. Patient was asked to raise her shoulders against the manual resistance of the interviewer. Able to shrug both shoulders symmetrically.
7. To test the hypoglossal nerve, the patient was asked to protrude the tongue, no deviation of tongue noted.

Assessment tools: 

The Hamilton Depression Rating Scale is the most widely used interview scale, developed in 1960 to measure severity of depression in an inpatient population. Many versions have been tailored, including well thought-out interview guides, introspective forms, and computerized versions. In the original clinician-administered scale, the first 17 topics are tallied for the total score, while topics 18-21 are used to further qualify the depression. The scale takes 20-30 minutes to administer. Scores of 0-7 are considered standard, and scores more than or equal to 20 signify moderately severe depression. Each topic either is scored on a 5-point scale, representing absent, mild, moderate, or severe symptoms, or on a 3-point scale, representing absent, slight or doubtful, and clearly present symptoms (Heslop, 2014).

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The Beck Depression Inventory (BDI) is the most widely used self-rating scale, developed in 1961 by Aaron Beck based on symptoms he observed to be common among depressed patients. The BDI consists of 21 items of emotional, behavioral, and somatic symptoms that takes 5-10 minutes to administer. The items are scored from 0 to 3 and measure mood, pessimism, sense of failure, lack of satisfaction, guilty feelings, sense of punishment, self hate, self accusations, self-punitive wishes, crying spells, irritability, social withdrawal, indecisiveness, body image, work inhibition, sleep disturbance, fatigability, loss of appetite, weight loss, somatic preoccupation, and loss of libido. Scores of 10-18 indicate mild depression, 19-29 indicate moderate depression, and greater than 30 indicate severe depression (American Psychiatric Association, 2013).

Lab/ Diagnostic Tests:

Glucose: 98. Within Normal Limit.

Thyroid: Free T4 (1.27ng/dL), TSH (3.41mU/L)

Cholesterol: 168mg.dL

Triglycerides: 74mg/dL

HDL: 55mg/dL

LDL: 110mg/dL

Albumin: 4.5. All patients’ labs are within normal limit (Fischbach& Dunning, 2009). The labs were done to determine if some of the symptoms the patient is experiencing are related to her medical condition. Some medical conditions have psychiatric symptoms when not treated.

Differential Diagnosis:

Generalized Anxiety Disorder (GAD): Patient reports a time when she goes into panic mode, where she feels her body is going to explode. DSM V criteria for GAD include excessive anxiety and worry, restlessness or feeling keyed up or on edge, irritability, sleep disturbance, difficulty concentrating or feeling of impending doom (American Psychiatric Association, 2013).

Sleep Disorder: of the various sleep disorders, obstructive sleep apnea can cause significant medical and psychiatric symptoms and is often missed as a diagnosis. Patients should be interviewed regarding their sleep quality, daytime sleepiness, and snoring.  DSM V criteria for sleep disorder include excessive daytime sleepiness, awakening SOB, frequent arousals, and fatigue. Although the patient has obstructive apnea, the reason she does not sleep much at night is care for her child. She does have CPAP machine that she uses at night for sleep.

Major Depressive Disorder (MDD): The patient had history of depression which has been poorly controlled with Wellbutrin. However, based on the symptoms she is presenting, recurrent depression must be ruled out. DSM- V criteria for major depressive disorder include;

• Depressed Mood,
• Loss of interest and enjoyment in usual activities
• Reduced energy and decreased activity
• Reduced self-esteem and confidence
• Ideas of guilt and unworthiness
• Pessimistic thoughts
• Disturbed sleep
• Diminished appetite
• Ideas of self-harm

DSM 5 DIAGNOSIS:

F33.2– Major Depressive Disorder (MDD): Depression is a common and complicated

illness. The lifetime prevalence of major depressive disorder in the United State is about 16% (Amanda et.al. 2009).  The study endorsed at least 2 current symptoms of depression found that current major depressive disorder was present in 66% cases. The annual prevalence rate is up to 25% in patient with chronic medical illness. Risk factors are multifactorial and include genetics, medical, social and environmental factors. Initial patient presentation of major depression can include a variety of physical symptoms including headache, musculoskeletal pain, abdominal/pelvic pain, mood symptoms and cognitive changes. Depression is highly recurrent. In a study conducted by Bentley, Pagalilauan & Simpson (2014), of 200 patients who have recovered from an episode of major depressive disorder, 64% experienced at least 1 additional episode of major depression with the greatest risk of recurrence in the first month after recovery. A history of recurrent episodes is the most predictive factor for additional episodes of major depressive disorder, and each recurrence increases the risk of experiencing another episode by 16%.

Many symptoms of major depression are shared by other medical illness and complicating diagnosis. Anyone in whom depression is suspected must be screened for substance dependence including marijuana, prescription drug diversion, and especially alcohol. Substance dependence is common among patients with depression, may induce or exacerbate depressed mood and associated risk. The patient denied use of alcohol or substance. Many medical conditions cause depressive symptoms like fatigue, changes in eating and sleeping pattern, and even hyper/hypo activity, but these medical illnesses are less likely to induce cognitive distortions typical of major depression, such as low mood.

The patient assessment revealed that she has insomnia, poor appetite, crying spells, and irritable which are consistent with diagnoses of depression. The patient has been depressed since teenage years and based on the stressors in her life (unemployment, sick child, medical problems, and inability to pay bills have worsened the depression. Based of all these stressors, the symptoms the patient present with, and DSM V criteria, the diagnoses of major depression without psychotic features was chosen.

INDIVIDUALIZED TREATMENT PLAN

Cultural Accommodations:     

The patient is African American and practices Catholic faith. Patient belief that her illness is not permanent and prayer to a higher being will help her through the ordeal. Religion and religious behaviors are integral part of the African-American community. African Americans take their religion seriously, and they expect to receive a message in preaching that helps them in their daily lives (Purnell, 2013). African Americans believe strongly in use of prayer for all situations they may encounter, prayer reflect the trust and faith one has in God. Spiritual practices are source of comfort, coping, and support which are most effective ways to influence healing. God is responsible for physical and spiritual health, and the doctor is perceived as God’s instrument in the healing process.

Low educational level among African Americans may limit their access to information about etiology and treatment of mental illness. Some African Americans hold a stigma against mental illness. They belief that anyone diagnosed with mental illness is “crazy”.  Such a person may not fit into the society, and when they make decisions, it is irrational or irrelevant.  The high frequency of misdiagnosis among African Americans contributes to their reluctance to trust mental health professionals (Purnell, 2013). When caring for patients from diverse cultures, the Psychiatric Mental Health Practitioner (PMHP) should become aware of cultural differences and worldviews. A PMHP should acknowledge his or her biases regarding different views and should have a basic understanding of the cultural areas that should be assessed during interaction with patients (Drake, 2013).

The patient could express her view of her cultural belief during the interview. Although she had said that she does not attend church regularly, she claims to pray daily with her children and husband. She is family oriented but due to circumstances she did not explain, she had distance herself from her sibling and mother.

Medications /Medications Adjustments:

The patient will continue with Wellbutrin 200mg twice daily for depression. Wellbutrin is a norepinephrine dopamine reuptake inhibitor (NDRI) and an efficacious antidepressant.It selectively inhibits neuronal reuptake of dopamine. Its antidepressant effect is related to CNS stimulant effects. Wellbutrin is metabolized to several active metabolites, some of which are not only more potent norepinephrine transporter (NET) than wellbutrin itself and equally potent dopamine transporter inhibitor (DAT) but are also concentrated in the brain. Wellbutrin is both an active drug and a precursor for another active drug. The fact that Wellbutrin is not known to be particularly abusable, is not a scheduled substance, yet it has proven to be effective in treating nicotine addiction, which is consistent with the possibility that it is occupying DATs in the striatum and nucleus accumbens in a manner sufficient to mitigate craving but not sufficient to cause abuse (Stahl, 2013).

Clinical observation of depressed patients with DAT and NET inhibition as the mechanism of wellbutrin, since this agent appears especially useful in targeting the symptoms of “reduced positive effect” within the affective spectrum, including improvement in the symptoms of loss of happiness, joy, interest, pleasure, energy, enthusiasm, alertness, and self confidence.

Since the patient wants to quit smoking, wellbutrin can help, although another option of quitting will be discussed further with patient below. When Wellbutrin is administered, a little bit of dopamine is released in the nucleus accumbens, making the craving less but usually not eliminating it (Stahl, 2013). This medication was chosen because it will help with patient’s depression and assist with reducing the craving for smoking (patient smokes one pack of cigarette daily).  

The patient will also continue with Cymblata 30mg daily for symptoms of generalized anxiety disorder and chronic back pain. Cymbalta (duloxetine) is a selective serotonin and norepinephrine reuptake inhibitor (SNRI) used for treating depression, anxiety disorder and pain associated with diabetic peripheral neuropathy or fibromyalgia (Tran & Castle, 2012). Not only does cymbalta relieve depression in the absence of pain, but also relieves pain in the absence of depression. Cymblata not only boost serotonin and norepinephrine throughout the brain, it also boosts dopamine specifically in the prefrontal cortex. This medication was chosen because it will help with patient’s unexplained chronic back pain and symptoms of generalized anxiety disorder.

Laboratory/diagnostic with rationales: 

Depression and anxiety are clinical diagnosis, based on the history and physical findings from the patient. “No diagnostic laboratory tests are available to diagnose major depressive disorder or anxiety disorder, but focused laboratory studies may be useful to exclude possible medical illnesses that may present as major depressive disorder and anxiety disorder. These laboratory studies might include the following: Vitamin B-12, HIV test, Electrolytes, including calcium, phosphate, and magnesium levels, Blood urea nitrogen (BUN) and creatinine, Liver function tests (LFTs), and Blood alcohol level (Sadock, Sadock & Ruiz, 2015). In HIV patients, anxiety disorder and depression are a significant problem. Major depression is a risk factor for HIV by its impact on behavior, intensification of substance abuse, and exacerbation of self destructive behavior. Thyroid function is most commonly monitored through thyroid stimulating hormone (TSH). Low levels (hypothyroidism) can mimic symptoms of mental illnesses or exasperate the symptoms of mental illness. Lithium can include hypothyroidism. Low B12 levels can impersonate symptoms of mental illnesses” (Sadock, Sadcok & Ruiz, 2015).

Neuroimaging can help clarify the nature of the neurologic illness that may produce psychiatric symptoms, but these studies are costly and may be of questionable value in patients without discrete neurologic deficits. Computed tomography (CT) scanning or magnetic resonance imaging (MRI) of the brain should be considered if organic brain syndrome or hypopituitarism is included in the differential diagnosis (Sadock, Sadcok & Ruiz, 2015). Because the patient complains of occasional headache, suggesting MRI may be an option.  Positron emission tomography (PET) imaging provides the means for the study of receptor binding of certain ligands and the effect a compound may have on receptors. However, PET scanning is problematic for use because it requires complex equipment and uses radiation.

Assessment tools with rationales:

Although no tool was used during psychiatric assessment of the above patient, there are tools that could have been used to help with psychiatric diagnosis of the patient. One of the tools is the Abnormal Involuntary Movement Scale (AIMS).  It is imperative to assess the patient using the AIMS tool because the patient has been prescribed psychoactive medications. The AIMS record the amount of tardive dyskinesia (TD) in patients getting neuroleptic medications.

The AIMS test is used to distinguish TD and to follow the severity of a patient’s TD over time.

The AIMS is a 12-item anchored scale that is clinician given and scored on rate of 0-4 (0 = none, 4=severe) based on assessment. The AIMS is a global rating method. The AIMS require the raters to compare the observed movements to the average movement disturbance seen in person with TD. Such relative judgments may differ among raters with diverse backgrounds and knowledge (American Psychiatric Association, 2013). The patient will score 0 after administering this tool because she showed no abnormal movement or sign of TD.

Another tool that can be used for assessing the patient is the PHQ-9 patient depression questionnaire (PHQ-9). The PHQ-9 was developed to assist clinicians with diagnosis of depressive disorder and to monitor the severity overtime for newly diagnosed patients or patients in current treatment for depression. Since the patient has been diagnosed with depression as a teenager, using the PHQ-9 questionnaire will be appropriate. There are 10 questions with rating scale of 0-3 (0= not at all, 3=nearly everyday) that shows how often the patient experience any depressive symptoms over the last two weeks. Once the patient completes the questionnaire by checking the appropriate box, the score is calculated (1-4= minimal depression, 20-27 = severe depression). Based on the score, a definitive diagnosis is made on clinical grounds, considering how well the patient understood the questionnaire, as well as other relevant information from the patient. The patients may complete the PHQ-9 questionnaire at baseline and at regular intervals at home and bring them in at their next appointment for scoring (American Psychiatric

Association, 2013).

Referral with rationales:

The patient will be referred to a community job enrichment program to assist her with getting a job.  As such, she can have additional income to support her monthly bills. She can attend with her husband if needed. Also, the patient will be referred to home heath agencies in the community that can provide supportive care to her child at night so that she can sleep, thus preventing exacerbation of her obstructive sleep apnea (OSA). The patient will be referred to her primary care physician to discuss how to better manage her medical conditions. A study conducted by Sampaio, Pereira & Winck (2011) finds indirect physical and psychological complications associated with OSA. Such complications include hypertension, hear disease, heart failure, stroke, impairment in neurocognitive functioning, and elevated psychological symptoms. Direct effect that OSA can cause includes daytime fatigue, disturbed sleep, irritability, memory problems, and decreased quality of life. The patient did report some of these symptoms when giving history of present illness. Although the patient has continuous positive airway pressure (CPAP) machine at home, it is not used effectively because she must care for her child at night. Intervention studies have demonstrated that treatment of OSA via CPAP use resulted in improvement in depressive symptoms and panic attacks (Sampaio, Pereira & Winck, 2011).   

Therapy with rationales

The patient and her husband will benefit from couples’ therapy. The family is the foundation on which most societies are built. Couples and family therapy has demonstrated to have a clear and important role in the treatment of numerous specific psychiatric disorders, often as a component within a multi method treatment (Sadock, Sadock, & Ruiz, 2015). The patient will also be referred to exercise and pulmonary rehabilitation (EPR).  EPR are very important non- pharmacological interventions that can improve physical and psychological well being in patients with OSA. EPR has established itself as a key management strategy in people with chronic respiratory disease, however it does not replace medical treatment but enhances it. The program includes a session of up to three sessions per week of incremental and supervised exercise, along with education and psychosocial support, significantly reduce anxiety and depression more than standard care in patients with OSA (Heslop, 2014).

Cognitive behavioral therapy (CBT) is evidence based psychological talking treatment, which explores the links between situations, thoughts, feelings, physical symptoms, and behavior. One fundamental principle of CBT is that what patient thinks affects how they feel, what they do, and the physical symptoms they experience (Sadock, Sadock & Ruiz, 2015). Patients’ beliefs about the diagnosis, symptoms, severity, duration, and cause of their illness as well as the value or role of medical and other treatments will affect how they make sense of or give meaning to their illness. Another option for the patient is counseling which is a type of talking therapy that allows a person to talk about their problems and feelings in a confidential and dependable environment (Sadock, Sadock & Ruiz, 2015). It can be a great relief to people who may be struggling with a problem to share their worries and fears with someone who acknowledges the feelings they may have and helps explore ways to reach a positive solution. The above therapy options are free for the patient in the community and she will be advised to take advantage of them.

Health Promotion: 

The prevalence of obesity among people with mental illness is approximately 1.5-2.0 times higher than the general population. Several factors have been found to contribute to obesity among people with mental illness. One area that has received considerable clinical attention in recent years is the metabolic effect of second generation antipsychotic medications including weight gain, hyperlipidemia, and hyperglycemia (Mckibbin, Kitchen, Wykes & Lee, 2013).  The above patient will be advised to engage in more physical activity that can help promote weight loss because she currently weighs 250 lbs and it could be detrimental to her health. Also, patient will be referred to community dietician and diabetes educator that will assist patient in planning her diet to make them healthier. Obesity is associated with increase medical expenditure among those with mental illness, even when demographics characteristics and medical comorbidities are controlled. Obesity is leading risk factor for cardiovascular disease which is a number one cause of death among people with mental illness. Additionally, obesity is associated with diabetes, hypertension, and significant reduction in quality of life and health related functioning. By following a healthy diet, and becoming physically active, patient’s medical condition (diabetes, hypertension, and hypercholesterolemia) will be better controlled.

Patient Education:

Systematic transfer of knowledge and power to people with long term conditions to maximize self management and choice is important. This includes ensuring that the patient has appropriate information about how to manage her condition (Heslop, 2014). An important part of education for the patient includes strategies for coping with anxiety and depression. The study conducted by Cairns, Hill, Dark, McPhail & Gray (2012) concluded that poor adherence to prescribed treatment regimens undermines treatment benefits and reduces the predictability of medication action, increasing likelihood of symptoms relapse, longer recovery times, frequency of hospitalization and sustained functional impairment. The negative sequela of medication nonadherence as explained to the patient is that it can result in reduced quality of life for her, her/families and her potential career.

The patient was educated about symptoms of mental illness and available resources. Risk, benefits, and side effects of current medications such as dry mouth, constipation, blurred visions, and risk of toxicity with different medications was discussed. Patient was informed in detail about the risk of diabetes mellitus and hypothyroidism. Also, patient was educated to try nicotine patch as a beginning strategy for smoking cessation and to choose from the above recommended therapy. She was able to ask questions, discuss the side effects in detail and verbalized understanding of the teachings. She said that she will get back to the Practitioner regarding the nicotine patch at next visit.  

Legal issues: 

The patient is currently in outpatient treatment clinic for management of her mental health. There is no indication currently to commit the patient to an inpatient facility, because she is not a danger to herself and others. Upon arrival at the clinic, the patient signed a confidentiality agreement form after brief education regarding how her medical information will be used. Also, a consent form for any medications prescribed was signed by the patient. A copy of the confidentiality agreement and consent form was given to the patient. The patient does not have any legal charges that could impede her treatment regimen at this time.

Discharge planning/follow up:

Patient will return in two weeks to the clinic for follow up visit.  Patient will continue taking medications as prescribed to help manage her anxiety and depression. Patient has been given emergency access phone number to local crisis center and encouraged to call 911 if symptoms becomes severe. Patient will continue with treatment at this clinic.

The study articles that were used to support the notes were graded using Oxford Center for Evidence Based Medicine (OCEBM, 2011). The articles grade of recommendation is “A” and level of evidence is “1b” because they all used randomized control trial, where participants were assigned to groups. This system eliminates participant and researchers’ bias, which can compromise result of the trial. The outcome of the studies suggested that the result of the studies could be applied to clinical setting.

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