Comprehensive Psychiatric Evaluation – Patient Major Depressive Disorder

Comprehensive Psychiatric Evaluation – Patient Major Depressive Disorder

Subjective:

CC (chief complaint): The patient presented with complaints of suicidal ideations. She has been thinking of jumping off a bridge but changes her mind at the last minute.

HPI: K.P. is a 25-year-old female presenting to the office with complaints of suicidal ideation. She started experiencing these thoughts three months ago after a breakup with her boyfriend and the abrupt death of her mother. For the past two weeks, she has been thinking of jumping off a bridge but changes her mind at the last minute. The patient has also reported feeling lonely, experiencing loss of appetite, and having trouble sleeping at night with subsequent daytime sleepiness. The patient recognizes her situation and is seeking care.

Substance Use History: The patient started using methamphetamine one week ago and has been using it till the day before visiting the clinic.

Current Medications: The patient is not on any medications currently. She has never been initiated on any psychotropic agents as well.

Allergies: The patient has no known allergies.

Reproductive Hx: The patient’s reproductive history is negative for pregnancy, contraceptive use, and type of intercourse. Additionally, no information was provided on her menstrual history.

ROS:

GENERAL: The patient is a 25-year-old female. She has no weight loss, body weakness, chills, or fever.

HEENT: The patient has a negative history of eye disorders or deformities. No visual loss, double vision, blurred vision, or discharge was reported. Also, no hearing loss, ear and nasal discharge, sneezing, nasal congestion, or sore throat was reported on the patient.

SKIN: No skin lesion, rash, reddening, or inflammation reported.

CARDIOVASCULAR: Negative report of chest pain or any chest discomfort, palpitations, or edema.

RESPIRATORY: Negative report of dyspnea, cough, or sputum production on cough.

GASTROINTESTINAL: No abdominal pain, melena stool, diarrhea, anorexia, nausea, or vomiting were reported.

GENITOURINARY: No dysuria, polyuria, urinary urgency, or frequency was reported. Additionally, no urinary discoloration, hesitancy, or odd odor was reported.

NEUROLOGICAL: No dizziness, seizures, tremors, headaches, numbness, or weakness of extremities was reported. Additionally, there were no reports of ataxia, syncope, and changes in bladder and bowel control.

MUSCULOSKELETAL: No back pain, joint stiffness, joint pain, joint swelling, and neck pain reported.

HEMATOLOGIC: Negative report of bruising, anemia, issues of clot or bleeding reported. Negative history of any blood thinning medications.

LYMPHATICS: The patient’s history is negative history of splenectomy lymphedema reported.

ENDOCRINOLOGIC: No reports of oligomenorrhea or amenorrhea, sweats, heat or cold intolerance. The patient’s history is also negative for contraceptive pill use or changes in libido.

Objective:

Diagnostic results: The Patient Health Questionnaire-9 (PHQ-9) revealed that the patient had severe depression. This diagnostic tool rates patients on a nine-item scale, with each item corresponding to depressive manifestations listed in the DSM-V manual (Ford et al., 2020). The patient in the case scored highly on suicidal ideation and tendencies, as well as on items such as trouble sleeping, fatigue, and loss of concentration.

Assessment:

Mental Status Examination: The patient is a 25-year-old female. She is alert and oriented to place, time, and event. She appears withdrawn and is observed staring out of the window with minimal interactions and no eye contact. She is responsive and dressed to the occasion. Her judgment is also intact, logical, and goal-driven. She reports feeling sad and lonely. Additionally, she was observed crying during the assessment. The patient admits that she would harm herself when allowed to leave the office. She denies having any auditory or visual hallucinations or delusional thoughts. She reported having difficulties concentrating.

Differential Diagnosis

The differentials in this case include bipolar disorder and prolonged grief disorder.

• Major Depressive Disorder

Major depressive disorder is a chronic mental health illness characterized by persistently low mood, lack of concentration, suicidal tendencies or ideation, loss of interest in pleasurable things, and others. Per the DSM-V diagnostic criteria, a positive diagnosis of major depressive disorder is made in the presence of these symptoms (Karrouri et al., 2021). A positive diagnosis is made upon ruling out manic or hypomanic presentations. The patient, in this case, presented with symptoms of loneliness, loss of concentration, suicidal ideation, insomnia, and loss of appetite. These manifestations are suggestive of major depressive disorder.

• Bipolar Disorder

Bipolar disorder is a mood disorder characterized by alternating episodes of mania and depression. As per the DSM-V manual provisions, a positive diagnosis of bipolar disorder is in the presence of at least one episode of a manic phase, preceded or preceded by depressive episodes (Baldessarini et al., 2020). While the patient in the case experienced severe manifestations of depression, manic or hypomanic manifestations were absent. This ruled out the bipolar diagnosis.

• Prolonged Grief Disorder

Prolonged grief disorder is a disorder characterized by persistent and intense grief following the death of a loved one. The psychological distress that often accompanies the loss of a loved one may resemble those seen in major depression (Szuhany et al., 2021). Per the DSM-V provisions, a positive diagnosis of prolonged grief disorder is made when the loss of a loved one has occurred at least a year ago for adults. Symptoms such as identity disruptions, intense loneliness, purposelessness, and loneliness may accompany this disorder. In the case presented, the patient had lost a loved one. This may have perpetuated her suffering and led to her developing a prolonged grief disorder. This differential was, however, excluded due to the presence of other manifestations not included in its diagnostic criterion.

Diagnostic Impression: 

The patient in the case had a major depressive disorder. Assessment findings on the patients revealed features consistent with those of this disorder. The patient’s symptoms met the diagnostic criteria for major depressive disorder defined in the DSM-V. Additionally, her diagnostic results revealed high scores, further confirming this diagnosis. The other differentials were excluded because they did not meet the criteria for diagnosing the disorder.

Reflections:

Reflection of the case revealed features consistent with those of major depressive disorder. I, therefore, agree with my preceptor’s assessment and diagnostic impression of the patient. The patient’s manifestations, such as feelings of loneliness, loss of appetite, insomnia, suicidal ideations, feelings of sadness, and frequent crying, are consistent with the diagnostic criterion for major depressive disorder. The assessment findings also ruled out any manic manifestations that may have suggested a bipolar diagnosis. The case gave me insight into how to assess and diagnose depressive disorders. It emphasized the criticality of the DSM-V tool in distinguishing mental health disorders.

A legal consideration apparent in the case is the application of the Baker Act. The involuntary Baker Act allows individuals to be taken in for treatment in a receiving facility upon determination that they are mentally ill, refused voluntary examination, or unable to determine for themselves the necessity for examination. In the case presented, the patient was admitted for psychiatric care because she met the provisions of the act. As evident in the case, she admitted that she would harm herself when allowed to leave the office. In the spirit of beneficence and non-maleficence, the caregivers were ethically right to invoke the Baker Act.

Patients with mental health illnesses are sometimes subject to neglect in society. The problem is especially pronounced in ethnic minority groups. In the resolve to better mental healthcare for these patients, expanding access to mental healthcare facilities and educating them on mental health illnesses is necessary (Singh et al., 2022). Health promotion targeted at expanding the knowledge of these communities on mental healthcare is thus warranted in these communities. In this case, a point of education when engaging the patient is to notify her of the significance of a positive mental health-seeking behavior. This will not only better her mental health but also help in lessening the traditional health inequities and disparities apparent in universal mental healthcare. Integral to these engagements is the use of culturally sensitive language. This can increase the adoption of various available mental healthcare resources and better the health-seeking behavior of individuals in these communities.

Case Formulation and Treatment Plan

The patient was diagnosed with major depressive disorder. This patient can benefit from psychotherapeutic and pharmacotherapeutic interventions. Karrouri et al. (2021) note that adjunctive management of major depressive disorder using both psychotherapy and pharmacotherapy is more effective than using either agent alone to alleviate depressive symptoms. Before the initiation of therapy, a comprehensive metabolic panel, urinalysis, and toxicological screening will have to be done to rule out any systemic involvement. The patient will then be referred to a psychotherapist for initiation of therapy. Pharmacological management of major depressive disorder utilizes antidepressant medications. All antidepressants are equally effective in managing the disorder. Selective serotonin inhibitors are, however, preferred as the first line due to their high safety profile. The patient will scheduled for follow-up two weeks after the initiation of therapy to ascertain the effectiveness of the medications used.

References

Baldessarini, R. J., Vázquez, G. H., & Tondo, L. (2020). Bipolar depression: A major unsolved challenge. International Journal of Bipolar Disorders, 8(1). https://doi.org/10.1186/s40345-019-0160-1 

Ford, J., Thomas, F., Byng, R., & McCabe, R. (2020). Use of the Patient Health Questionnaire (PHQ-9) in practice: Interactions between patients and physicians. Qualitative Health Research, 30(13), 2146–2159. https://doi.org/10.1177/1049732320924625

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

Singh, V., Kumar, A., & Gupta, S. (2022). Mental health prevention and promotion—A narrative review. Frontiers in Psychiatry, 13. https://doi.org/10.3389/fpsyt.2022.898009 

Szuhany, K. L., Malgaroli, M., Miron, C. D., & Simon, N. M. (2021). Prolonged grief disorder: Course, diagnosis, assessment, and treatment. FOCUS, 19(2), 161–172. https://doi.org/10.1176/appi.focus.20200052

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Diagnosis:  MDD

A 25-year-old female patient came into the office with a chief complaint of suicidal ideation. The patient stated she has been having thoughts of suicide for the last 3 months but for the past 2 weeks, she has been thinking about jumping off the bridge. She reported a few days ago walking to a bridge to jump off but changed her mind at the last minute. The patient stated it all started when she had a breakup with her boyfriend and the abrupt death of her mother. The patient stated that she has trouble sleeping at night, concentrating, daytime sleepiness, loss of appetite, and loneliness. The patient reported that she recently lost her job of 10 years because of her poor performance. The patient stated that she does not have any family members or a good support system. The patient stated that she started using methamphetamine last week and her last usage was one day ago. Patient is requesting for help because she is losing control over her life and does not like where she at mentally.

A Mental state evaluation was performed, and question was asked. Patient is alert oriented to time, place, and location. Patient observed staring out of the window with no eye contact or minimal interaction. The patient reported feeling sad, lonely, and observed crying throughout the assessment. Patient reported that she does not care for her life. Patient was asked if she would harm herself when leaving the office and she admitted it is a possibility she would. The patient has no known allergies or has any other medical or psychiatric history.

Based on the DSM-V diagnostic criteria, the client is diagnosed with major depressive disorder.

The patient is Baker Act and will be admitted to a psychiatric hospital for further evaluation. Patients have labs drawn in the morning for the start of medication regimen and psychotherapy daily at the psychiatric hospital. Patient agreed to treatment plan, and we will follow up in three days for determination of hold or continuation of outpatient observation.

CC (chief complaint):

HPI:

Past Psychiatric History:

• General Statement:
• Caregivers (if applicable):
• Hospitalizations:
• Medication trials:
• Psychotherapy or Previous Psychiatric Diagnosis:

Substance Current Use and History:

Family Psychiatric/Substance Use History:

Psychosocial History:

Medical History:

• Current Medications:
• Allergies:

• Reproductive Hx:

ROS:

• GENERAL:
• HEENT:
• SKIN:
• CARDIOVASCULAR:
• RESPIRATORY:
• GASTROINTESTINAL:
• GENITOURINARY:
• NEUROLOGICAL:
• MUSCULOSKELETAL:
• HEMATOLOGIC:
• LYMPHATICS:
• ENDOCRINOLOGIC:

Physical exam: if applicable

Diagnostic results:

Assessment

Assessment: What were your differential diagnoses? Provide a minimum of three (3) possible diagnoses. List them from highest to lowest priority. What was your primary diagnosis, and why?

Mental Status Examination:

Differential Diagnoses:

Reflections:

Reflection notes: What would you do differently in a similar patient evaluation? Reflect on one social determinant of health according to the HealthyPeople 2030 (you will need to research) as applied to this case in the realm of psychiatry and mental health.  As a future advanced provider, what are one health promotion activity and one patient education consideration for this patient for improving health disparities and inequities in the realm of psychiatry and mental health? Demonstrate your critical thinking.

 References

Include at least five (5) scholarly resources to support your assessment and diagnostic reasoning.