Chronic Health Case Study-A 42-Year-Old Caucasian Male

Chronic Health Case Study-A 42-Year-Old Caucasian Male

A 42-year-old Caucasian male was referred to the clinic for the management of depressive flare-ups. Depression is a mood disorder characterized by a loss of interest and persistent feelings of sadness. The hallmark features of depressive presentations are the feeling of emptiness, low self-worth and hopelessness, irritable mood, excessive guilt, suicidal ideations and tendencies, and altered concentration. Somatic manifestations such as weight loss or weight gain, insomnia, and fatigue may also accompany this disorder (Karrouri et al., 2021). Notwithstanding, depression is a major cause of morbidity and mortality across the globe. In the U.S., this disorder affects over 17 million Americans. Depression has a multi-factorial etiology. An interplay of both genetic and environmental factors is evident in the pathophysiologic development of the disorder. Comprehensive management of depression utilizes psychotherapeutic and pharmacotherapeutic modalities. This paper analyzes the case presented with emphasis on the available therapeutic modalities available for the client.

Setting and Social Dynamics

The setting is a psychiatric clinic. The presenting client is accompanied by his wife to the clinic. He is responsive to care and ready to comply with therapeutic recommendations given to him by his caregivers. His wife is also aware of his disease and is willing to help him through his illness.

Subjective Information

The patient was referred to the clinic for the management of a depressive flare-up. He reported that he experienced suicidal ideation three times in the past three weeks. He also noted that he has increasingly been feeling hopeless and guilty about his current situation in life. Collaborative history from the wife revealed that his depressive flare-ups began after the loss of their daughter and brother in a car accident. She also reported that he kept blaming himself for not fixing a tire, which led to the car accident. His wife also noted that he had a failed suicidal attempt after the incident.

The patient’s past medical history revealed that he has been battling depression for the past seven years and has been on and off medications. At the time of his presentation, he had stopped taking medications. He is a known hypertensive. He has been hospitalized once for a road accident injury. His psychiatric history revealed that he was diagnosed with substance abuse disorder three years ago. He has a negative history of head injuries or surgeries. His family history is positive for major depressive disorder. His elder brother committed suicide after a stint of depressive episodes. His mother was also diagnosed with late-onset depression and has since been on medications.

The patient is a physician. He currently works at a local healthcare facility. He is a smoker and occasional drinker. He started smoking and taking alcohol during his undergraduate studies but stopped briefly when he was diagnosed with substance abuse disorder. He is married and had four children before losing one in a road accident. The client’s family is well-off. They have access to all of their basic needs and luxuries. Their health-seeking behavior is also excellent, as demonstrated by their vaccination status and participation in community health promotion programs. Further, the review of systems is negative except for the cardiovascular and psychiatric systems. Assessment of the cardiovascular system revealed palpitations. The psychiatric evaluation revealed difficulty in concentration, withdrawal, and fatigue.

Objective Information

The patient has a temperature of 37 degrees Celsius, blood pressure of 140/90mmHg, pulse rate of 91 beats per minute, and a respiratory rate of 20 breaths per minute. He was dressed appropriately for the occasion, event, and weather. However, he looked fatigued and disoriented. He also demonstrated diminished facial expressions and gestures and a loss of interest in his surrounding.

Medical Decision-Making and Clinical Impression

The patient’s presentation, along with the subjective and objective findings, are essential in making a clinical diagnosis. His manifestations, family history of depression, environmental factors such as a history of grief, and positive history of depression all point to the major depressive disorder diagnosis. The client was diagnosed with major depressive disorder. Major depressive disorder is a prevalent psychiatric illness with a lifetime prevalence of 5 to 17 percent (Abdoli et al., 2022). It is a major cause of suffering and deterioration in the quality of life among many individuals. This warrants comprehensive management of the disorder.

Introduction of EBP and Peer-Reviewed Treatment

Comprehensive management of major depressive disorder utilizes pharmacotherapeutic and psychotherapeutic modalities, lifestyle modifications, and interventional modalities in lessening depressive symptoms. Psychotherapeutic interventions maintain effectiveness in the management of major depressive disorders. Commonly used interventions are cognitive behavioral therapy (CBT) and interpersonal therapy. These modalities include supportive counseling, life-review therapy, behavioral activation therapy, interpersonal psychotherapy, and psychodynamic therapy. They reduce depressive relapses and can be used in isolation in the management of mild to moderate depression (Cuijpers et al., 2021). The client in the case presented can benefit from this treatment option.

Pharmacotherapeutic management of major depression is one of the main options for managing the disorder. This treatment modality utilizes antidepressant medications to lessen the severity of depressive symptoms and ensure that individuals diagnosed with the disorder return to their normal lives. Karrouri et al. (2021) report that pharmacotherapy with antidepressants during the acute phase of the disorder helps patients reach the remission state and return to their baseline functioning. The gold standard in antidepressant pharmacotherapy is selective serotonin reuptake inhibitors. Medications under this category include paroxetine, escitalopram, citalopram, fluoxetine, and sertraline. These medications maintain superiority in managing depression due to their high efficacy and tolerability. Other medication classes include monoamine oxidase inhibitors such as iproniazid, tricyclic antidepressants (TCAs) such as imipramine, and amitriptyline, Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs), such as venlafaxine and duloxetine, and others. The choice of medication to use will depend on the client’s response and other patient factors that may affect the pharmacokinetics and the pharmacodynamics of either medication.

Guidelines for the Chosen Diagnosis

The client was diagnosed with major depressive disorder. This diagnosis was guided by the Diagnostic and Statistical Manual for Mental Health Disorders (DSM-V). As per this diagnostic manual, a positive diagnosis of major depressive disorder is made in the presence of anhedonia and any other four depressive symptoms upon ruling out a history of hypomanic and manic presentations. The client in the case presented met the criteria set in the DSM-V. He had a persistent depressed mood, feelings of hopelessness, loss of self-worth, suicidal ideations and attempts, and feelings of sadness. These manifestations are suggestive of depression. Subjective findings on the client also revealed a predilection for major depressive disorder. His family history was positive for depressive disorders, as his brother and mother were diagnosed with the disorder. Sall et al. (2021) report that individuals with close family members with depression are up to three times more likely to develop depression. The negative history of manic or hypomanic manifestations further affirmed the diagnosis of major depressive disorder.

Comparing and Contrasting Psychotherapy and Pharmacotherapy of MDD

Psychotherapeutic and pharmacotherapeutic interventions are treatment modalities available in the comprehensive management of depression. Both therapeutic modalities are effective in lessening depressive symptoms and can be used either alone or adjunctively to manage this disorder (Karrouri et al., 2021). These modalities are integral in managing depression and are part of the evidence-based practice recommendations for managing the disorder.

Despite their effectiveness in alleviating depressive symptoms, both modalities require clients to stick to the therapeutic regimen for positive outcomes to be attained. Pedrosa-Naudín et al. (2022) report that non-compliance with the therapeutic modalities available for the management of major depressive disorder is the major cause of depressive relapse, flare-ups, and complications. This reinforces the need to adhere to the set regimen.

Psychotherapy may, however, differ from pharmacotherapy on several fronts. Psychotherapy utilizes psychological methods to help clients attain behavior change. This treatment method is targeted at helping clients identify and alter troublesome thoughts, emotions, and behaviors. Conversely, pharmacotherapy is centered on biogenic psychophysiology principles and utilizes agents that alter neurotransmitters’ homeostasis in the brain. Such agents include SSRIs, TCAs, SNRIs, and others. These agents are effective in lowering and eliminating depressive episodes.

Psychotherapy also differs from pharmacotherapy in its mode of administration and onset of action. Psychotherapeutic modalities often employ talk therapies in their attempt to attain behavior change. They may take a long to attain the desired physiologic effects and may not be favorable for sole use in severe depression. Pharmacotherapy, on the other hand, is administered systemically and can help alleviate depressive episodes rapidly. This intervention is thus essential in severe and acute depression, where quick relief of depressive symptoms is required.

Since psychotherapy targets behavior change, it can be used in preventing depressive relapses. Cuijpers et al. (2021) note that CBT and other forms of psychotherapy equip clients with coping mechanisms that can help them handle situations that predispose them to depression. Contrarily, relapses are common in the pharmacotherapeutic management of depression, especially when patients fail to stick to the treatment regimen.

Assessment and Analysis of the Merits and Soundness of Research

Several studies have been conducted on the efficacy and therapeutic benefits of applying psychotherapy and pharmacotherapy in the comprehensive management of depression. There is a consensus on their effectiveness in alleviating depressive symptoms and improving the quality of life of individuals with these illnesses. However, more robust and elaborate studies have been conducted on pharmacotherapeutic interventions than psychotherapeutic interventions. This may, in part, be due to their widespread applicability and use of Westernized medical interventions and the presence of diverse parameters of pharmacotherapy that can be interrogated through research (Machmutow et al., 2019). In contemporary medicine, pharmacotherapeutic interventions are more widespread, with many treatment guidelines recommending their application in managing depression. This affirms the robustness of research conducted in this field.

Treatment Chosen for the Patient Scenario

The patient was treated with a combination of psychodynamic therapy and fluoxetine. SSRIs remain the first line in the management of major depressive disorder. Essentially, they maintain effectiveness in alleviating depressed mood and lessening the severity of depressive symptoms (Kern et al., 2020). They are also fairly tolerable in most patients. Its once-daily dosing makes this intervention favorable to the client as he has a history of non-compliance with medications. Psychodynamic therapy, a form of psychotherapy, focuses on the unconscious processes that facilitate understanding deeper thoughts and emotions (Leichsenring et al., 2021). In this case, the patient can benefit from this intervention as it will help him understand the emotions and thoughts that contributed to his depression flare-ups. Adjunctive management of depression using pharmacotherapy and psychotherapy maintains superiority in alleviating depressive symptoms over either agent when used alone. In severe depression and depressive relapse, this combination helps ensure quick symptomatic relief and prevent depressive relapses (Karrouri et al., 2021). It is for these reasons that this modality was selected.

Specific Interventions, Recommendations, Education, Health Promotion, and Follow-Up

The client was started on 20mg of fluoxetine once daily. He was also scheduled for a psychotherapeutic session twice a week, with each session lasting an hour. During these sessions, the client was engaged in open-ended discussions guided by his psychotherapists. The patient was educated on the significance of complying with his medication regimen and the recommended psychotherapy for optimal clinical outcomes. The patient’s wife and other family members were also advised to provide the necessary support required by the client, for instance, by reminding him to take his medications, accompanying him to the clinic, and monitoring his progress during the continuum of care at home. As a health promotion strategy, all the family members were educated on aspects of depression, including its symptoms, to enhance their understanding of the disorder and their excellence in monitoring and caring for their ill member. The client was advised to return to the clinic after two weeks for follow-ups.

Cultural and Socioeconomic Considerations

The client in the case is a Caucasian male married to an African American woman. Diversities in cultures are thus apparent in the case and may influence the therapeutic outcomes of the patient. For this reason, caregivers should incorporate the family in managing the patient. This will include defining the illness to them, explaining the available therapeutic options, and explaining why the selected intervention is best suited for the patient. As Sichimba et al. (2022) report, incorporating family members in cross-culture patient treatment plans may help eliminate stereotypic reasoning and influence that may affect therapeutic choices and, consequently, the treatment outcomes. Managing depression fetches considerable healthcare costs due to the chronic nature of this illness. In this regard, the client should be educated on the financial implications of the therapeutic options of choice and the available alternatives. In this case, the patient has active insurance coverage and can meet his basic and medical needs. Notwithstanding, he was made aware of the financial implications of the selected therapeutic intervention.

Conclusion

The case presented was of a Caucasian male with major depressive disorder. Comprehensive management of depression utilizes psychotherapy, pharmacotherapy, and lifestyle modification to alleviate depressive symptoms and help patients return to baseline physiologic and psychological functioning. Combination therapy utilizing psychotherapeutic modalities and pharmacotherapy maintains superiority in alleviating these symptoms than either agent alone. The patient in the case benefited from the combined use of psychodynamic therapy and pharmacotherapy with fluoxetine. When managing patients with depression, several considerations should be made. The patient’s cultural and socioeconomic status plays a role in their management and eventual clinical outcomes. In the resolve to better their clinical outcomes, the available healthcare options and their financial implications should be explained to the patients and their families. Notably, this helps eliminate cultural influences in the definition of mental health illnesses and health-seeking behavior.

 References

Abdoli, N., Salari, N., Darvishi, N., Jafarpour, S., Solaymani, M., Mohammadi, M., & Shohaimi, S. (2022). The global prevalence of major depressive disorder (MDD) among the elderly: A systematic review and meta-analysis. Neuroscience & Biobehavioral Reviews, 132, 1067–1073. https://doi.org/10.1016/j.neubiorev.2021.10.041

Cuijpers, P., Quero, S., Noma, H., Ciharova, M., Miguel, C., Karyotaki, E., Cipriani, A., Cristea, I. A., & Furukawa, T. A. (2021). Psychotherapies for depression: A network meta‐analysis covering efficacy, acceptability and long‐term outcomes of all main treatment types. World Psychiatry, 20(2), 283–293. https://doi.org/10.1002/wps.20860

Karrouri, R., Hammani, Z., Benjelloun, R., & Otheman, Y. (2021). Major depressive disorder: Validated treatments and future challenges. World Journal of Clinical Cases, 9(31), 9350–9367. https://doi.org/10.12998/wjcc.v9.i31.9350

Kern, D. M., Cepeda, M. S., Defalco, F., & Etropolski, M. (2020). Treatment patterns and sequences of pharmacotherapy for patients diagnosed with depression in the United States: 2014 through 2019. BMC Psychiatry, 20(1). https://doi.org/10.1186/s12888-019-2418-7

Leichsenring, F., Luyten, P., Abbass, A., & Steinert, C. (2021). Psychodynamic therapy of depression. Australian & New Zealand Journal of Psychiatry, 55(12), 1202–1203. https://doi.org/10.1177/00048674211031481

Machmutow, K., Meister, R., Jansen, A., Kriston, L., Watzke, B., Härter, M. C., & Liebherz, S. (2019). Comparative effectiveness of continuation and maintenance treatments for persistent depressive disorder in adults. Cochrane Database of Systematic Reviews, 2019(5). https://doi.org/10.1002/14651858.cd012855.pub2

Pedrosa-Naudín, M. A., Gutiérrez-Abejón, E., Herrera-Gómez, F., Fernández-Lázaro, D., & Álvarez, F. J. (2022). Non-Adherence to antidepressant treatment and related factors in a region of Spain: A population-based registry study. Pharmaceutics, 14(12), 2696. https://doi.org/10.3390/pharmaceutics14122696

Sall, S., Thompson, W., Santos, A., & Dwyer, D. S. (2021). Analysis of major depression risk genes reveals evolutionary conservation, shared phenotypes, and extensive genetic interactions. Frontiers in Psychiatry, 12. https://doi.org/10.3389/fpsyt.2021.698029

Sichimba, F., Janlöv, A. C., & Khalaf, A. (2022). Family caregivers’ perspectives of cultural beliefs and practices towards mental illness in Zambia: An Interview-based qualitative study. Scientific Reports, 12(1). https://doi.org/10.1038/s41598-022-25985-7

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For your signature assignment, you will write a scholarly case study that will compare and contrast two possible ways of treating a chronic health condition.
Select a chronic health issue you may have encountered in your clinical rotations. You may either recall a real patient you saw with this condition, or you may create a fictitious patient for the paper. You will write a paper about this patient where you will compare and contrast two different ways of treating the problem, both with published peer-reviewed literature to support the treatment plans.

After analyzing the options, you will choose the most appropriate plan for the patient’s scenario, based on their unique and individual health needs and desires. A SOAP note is not required and should not be submitted as an appendix. To support your progression in master’s level writing, you will integrate subjective and objective information into the paper to create a scholarly case study in third-person language worthy of publication.