Suicidal Ideation and Depression in Adolescent

Suicidal Ideation and Depression in Adolescent

Patient Name:  MPS

MRN: XXX

Date of Service:         01-27-2020

Start Time:                10:00               End Time:                  10:54

Billing Code(s):         90213, 90836

Accompanied by: Her mother

CC: Seeking urgent assessment and intervention following suicidal ideation and depression amidst parental marital problems, academic struggles, and a history of Major Depressive Disorder (MDD).

HPI: MPS is a 15-year-old Puerto Rican adolescent recently discharged from inpatient care for her depression and suicidal ideation. She transitioned to partial inpatient care one week ago, including daily individual psychotherapy sessions and extended daily group therapy sessions. Her symptoms include frequent sadness, crying, increased appetite and overeating, guilt, low self-esteem, anxiety, irritability, insomnia, hopelessness, and difficulty concentrating. She also experiences difficulties in her interpersonal relationships, persistent negative thoughts about her appearance and academic abilities, and guilt regarding her parents’ marital problems. MPS has a history of MDD, initially triggered by romantic rejection and recently exacerbated by her parents’ marital issues and academic struggles.

S- The patient’s emotional state is persistently low and accompanied by frequent bouts of sadness and crying. She notes an increased appetite, leading to overeating. Feelings of guilt, low self-esteem, and anxiety are still prevalent, along with irritability and difficulty sleeping. She describes her sleep as disturbed, and she often experiences insomnia. MPS expresses hopelessness and difficulty concentrating, which has had an adverse impact on her academic performance, leading to failing grades. She also mentions ongoing problems in her interpersonal relationships, particularly negative thoughts about her appearance and academic abilities. Additionally, she carries a sense of guilt concerning her parents’ marital problems, contributing to her overall distress. She confides that she sometimes contemplates disappearing from the world, indicating significant suicidal ideation.

Crisis Issues: Maria has expressed ongoing suicidal ideation, mentioning feelings that the world wouldn’t notice if she disappeared. While she has not mentioned a specific suicide plan, these thoughts are concerning and require immediate attention. Additionally, her struggles with depression, academic performance, and family issues have led to significant emotional distress, impacting her daily life and well-being.

Reviewed Allergies: No known drug and food allergies

Current Medications: fluoxetine and Sertraline (no dosage information provided).

ROS: Unremarkable

O-

Vitals: T 96.2, P 72, R 18, BP 110/80

PE: (not always required and performed, especially in psychotherapy-only visits)

Heart- Normoactive precordium, S1, S2 heard, no murmurs

Lungs- Bilateral equal air entry, Vesicular breath sounds

Skin- no hyperpigmentation, rashes or lesions

Labs: FHG, TSH, LFTS, Lipid profile, Metabolic Panel, UECs, Drug Screening (Dwivedi, 2022).

Results of any Psychiatric Clinical Tests: None

MSE:

MPS, a 15-year-old Puerto Rican adolescent, presents with a somewhat disheveled appearance, possibly reflecting her ongoing depressive symptoms, and appears younger than her actual age. During the interview, she frequently expresses sadness and hopelessness, with labile shifts in her affect corresponding to her emotional distress. Her speech is coherent, conveying emotions like guilt, low self-esteem, anxiety, and relationship difficulties. Her thought process centers on depressive ruminations, academic struggles, and her parents’ marital issues, with persistent negative thoughts about her appearance and academic abilities. Of grave concern, MPS discloses thoughts of suicidal ideation, expressing a belief that the world might not notice her absence. While oriented to time and place, she admits to difficulty concentrating, impacting her academic performance, and her insight seems compromised, emphasizing the urgent need for psychiatric evaluation and intervention to address her severe emotional distress and ensure her safety.

A – with (ICD-10 code)

Differential Diagnoses:

Major Depressive Disorder (MDD) F32.9

Adjustment Disorder with Depressed Mood F43.21

Generalized Anxiety Disorder (GAD) F41.1

Definitive Diagnosis:

Major Depressive Disorder (MDD) F32.9

The patient is characterized by persistent sadness, increased appetite, guilt, low self-esteem, anxiety, irritability, insomnia, hopelessness, difficulty concentrating, and a history of prior MDD diagnosis, which aligns closely with the criteria for MDD (Kennedy, 2022). Additionally, her suicidal ideation expressed feelings of despair and emotional distress further support this diagnosis.

P

– Continue with Sertraline

– Continue Fluoxetine.

Continue outpatient counseling: Focus on addressing her depressive symptoms, suicidal ideation, and improving coping mechanisms.

Non-pharmacological Tx: Psychotherapy Modality used:  Interpersonal Therapy (IPT) and Cognitive-Behavioral Therapy (CBT) (Morey-Nase, et al., 2019).

-Promote healthy lifestyle habits, including regular physical activity, a balanced diet, and adequate sleep

Pharmacological Tx: Consider gradually increasing the dosage for Sertraline by 25 mg every 1 to 2 weeks, under close supervision. Consider increasing the Fluoxetine dose to 20mg daily after monitoring for potential side effects.

Education:

-Discuss the importance of recognizing depressive symptoms and seeking help.

-Address coping strategies, stress management, and self-care techniques.

-Emphasize the significance of attending therapy sessions and engaging in treatment actively.

-Inform them about the potential impact of lifestyle factors like sleep, exercise, and nutrition on her mental health (Morey-Nase et al., 2019).

Follow-up: Initially, schedule regular follow-up appointments at least once every two weeks to closely monitor her progress, assess her safety, and adjust the treatment plan as needed. Over time, these appointments can be spaced further apart as she stabilizes.

Referrals: At this time, no additional referrals are necessary. Continue collaborative care between mental health professionals and closely monitor her response to treatment.

References

Dwivedi, Y. (2022). The emerging role of microRNAs in major depressive disorder: diagnosis and therapeutic implications. Dialogues in clinical neuroscience. https://doi.org/10.31887/DCNS.2014.16.1/ydwivedi

Kennedy, S. H. (2022). Core symptoms of major depressive disorder: relevance to diagnosis and treatment. Dialogues in clinical neuroscience. https://doi.org/10.31887/DCNS.2008.10.3/shkennedy

Morey-Nase, C., Phillips, L. J., Bryce, S., Hetrick, S., Wright, A. L., Caruana, E., & Allott, K. (2019). Subjective experiences of neurocognitive functioning in young people with major depression. BMC Psychiatry, 19, 1-9.

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The patient is a 15‐year‐old Puerto Rican adolescent female living with both her parents and a younger sibling. Her parents presented with significant marital problems, had been separated several times, and were discussing divorce. Her mother reported having a history of psychiatric treatment for depression and anxiety and indicated that the patient’s father suffered from bipolar disorder and had been receiving psychiatric treatment. He was hospitalized on multiple occasions during previous years for serious psychiatric symptoms.

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