MDD Comprehensive Psychiatric Evaluation

Comprehensive Psychiatric Evaluation of a Patient with Major Depressive Disorder

Patient Initials: D.T.

Gender: Female

SUBJECTIVE:

CC: “I do not enjoy my life as I used to.”

HPI: The patient, a 27-year-old Latina woman, arrived at the clinic complaining that she had been feeling down recently. The patient claims she has been confused by her current mood. She does not feel well and has lost interest in most things she previously enjoyed. Also, the client does not exercise as frequently as she used to cause she gets tired quickly. She has been largely inactive during the previous month. Her mood and fatigue are hampering her ability to function. She noted that she was no longer as successful or as quickly doing household tasks and daily activities. The patient complains of being unfocused, agitated, and easily irritated. She only sleeps about 3–4 hours daily due to her issues. She has noticed a change in her appetite as well as a progressive loss of weight. Despite having a low mood, withdrawing from social situations, and reduced activity, the patient denies experiencing depression symptoms. Although she admits feeling more stressed and anxious recently, she has not been diagnosed with anxiety disorder. Her current mood has caused many disputes and clashes with her husband and family. She worries about her relationship as she does not know the issue.(Comprehensive Psychiatric Evaluation of a Patient with Major Depressive Disorder)

Social History: When D.T. was eight years old, she and her parents relocated to America from the Caribbean Islands. She recently turned 27. She now resides in Texas with her husband.  

Education and Occupation History: D.T. has a college degree and is a landscape designer.

Substance Current Use and History: The client denies any history of substance abuse.   

Legal History: The client denies any legal history.

Family Psychiatric/Substance Use History: Denied family mental health or substance use issues.

Past Psychiatric History:

            Hospitalization: Hospitalized with Covid in March 2021.

Medication trials: Denies history of medical trials

Psychotherapy or Previous Psychiatric Diagnosis: Denies previous psychiatric evaluation

Medical History: Covid-19 in 2021.

• Current Medications: Over-the-counter Xanapril to treat anxiety.
• Allergies: Dust and paint allergies.
• Reproductive Hx: Sexually active and not on birth control.  

ROS:  

General: States progressive weight loss and fever and occasional feelings of weakness and fatigue. Denies fever.(Comprehensive Psychiatric Evaluation of a Patient with Major Depressive Disorder)

HEENT: Eyes: Patient denies visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.

Skin: No rash or itching.

Cardiovascular: Denies chest pain, chest pressure, or chest discomfort. No palpitations or edema.

Respiratory: Denies wheezes, shortness of breath, consistent coughs, and breathing difficulties while resting.

Gastrointestinal: The patient reports diet changes and feelings of nausea and vomiting. Denies diarrhea: no abdominal pain or blood. The patient reports experiencing constipation.  (Comprehensive Psychiatric Evaluation of a Patient with Major Depressive Disorder)

Genitourinary: Denies burning on urination, urgency, hesitancy, odor, and odd color.

Neurological: The patient reports frequent headaches and denies dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control. Reports concentration and attention problems.(Comprehensive Psychiatric Evaluation of a Patient with Major Depressive Disorder)

Musculoskeletal: The patient reports occasional muscle pain and weakness. Denies back pain and muscle or joint stiffness.

Hematologic: Denies anemia, bleeding, or bruising.

Lymphatics: Denies enlarged nodes. No history of splenectomy.

Endocrinologic: Denies sweating. No reports of cold or heat intolerance. No polyuria or polydipsia.(Comprehensive Psychiatric Evaluation of a Patient with Major Depressive Disorder)

OBJECTIVE:

Vital signs: Stable

Temp: 98.8F

            B.P.: 100/65

            P: 84

             R.R.: 18

             O2: Room air

             Pain: 3/10

             Ht: 5’8 feet

             Wt: 110 lbs

             BMI: 16.7

             BMI Range: Underweight

LABS:

Lab findings WNL

Tox screen: Negative

Alcohol: Negative

Physical Exam:

General appearance: The patient is underweight, thin, malnourished, and dehydrated. The patient addressed the interviewer politely and regularly. The questions about her marriage agitated her. The patient also struggles with concentration, impairing clinical assessment. (Comprehensive Psychiatric Evaluation of a Patient with Major Depressive Disorder)

HEENT: Normocephalic and atraumatic. Sclera anicteric, No conjunctival erythema, PERRLA, oropharynx red, moist mucous membranes.(Comprehensive Psychiatric Evaluation of a Patient with Major Depressive Disorder)

Neck: Supple. No JVD. Trachea midline. No pain, swelling, or palpable nodules.

Heart/Peripheral Vascular: Regular rate and rhythm noted. No murmurs. No palpitation. No peripheral edema to palpation bilaterally.

Cardiovascular: The patient’s heartbeat and rhythm are normal. The patient’s heart rate is normal, and capillaries refill within two seconds.(Comprehensive Psychiatric Evaluation of a Patient with Major Depressive Disorder)

Musculoskeletal: Normal range of motion. Low muscle mass for age. No signs of swelling or joint deformities. Muscle and back pain rated 3/10.

Respiratory: No wheezes, and respirations are easy and regular.

Neurological: Balance is stable, gait is normal, posture is erect, the tone is good, and speech is clear. The patient has frequent headaches.(Comprehensive Psychiatric Evaluation of a Patient with Major Depressive Disorder)

Psychiatric: The patient has a depressed mood, irritability, insomnia, and impaired concentration and attention.  

Neuropsychological testing: Social-emotional functioning is impaired.

Behavior/motor activity: Patient behavior was appropriate and constant throughout the assessment(Comprehensive Psychiatric Evaluation of a Patient with Major Depressive Disorder)

Gait/station: Stable.

Mood: Depressed mood.

Affect: The patient’s mood was depressed.

Thought process/associations: comparatively linear and goal-directed.

Thought content: Thought content was appropriate.

Attitude: the patient was uncooperative at times(Comprehensive Psychiatric Evaluation of a Patient with Major Depressive Disorder)

Orientation: Oriented to self, place, situation, and general timeframe.

Attention/concentration: Impaired

Insight: Good

Judgment: Good.

Remote memory: Good

Short-term memory: Good

Intellectual /cognitive function: Good

Language: clear speech, with a tone assessed to be normal

Fund of knowledge: Good.

Suicidal ideation: Negative.

Homicide ideation: Negative.

ASSESSMENT:

Mental Status Examination:

The 27-year-old female patient complained of feeling down recently when she first came in. The patient claims to get angry quickly. The patient was occasionally uncooperative and had trouble focusing during the psychiatric examination, which made it challenging to build rapport. She displayed a depressed demeanor, was frequently prodded, paid less attention and was less focused, was apathetic, and was easily irritated. The patient had a depressing appearance and stated negative beliefs about her life, marriage, and future because she feared her husband would leave her. She denies any thoughts of suicide or homicide. (Comprehensive Psychiatric Evaluation of a Patient with Major Depressive Disorder)

Differential Diagnosis:

1. F32.9 Major Depressive Disorder

Depression is a mood disorder characterized by persistent melancholy and apathy. Melancholy, emptiness, or annoyance are common symptoms of all depressive disorders, and physical and mental changes severely limit the patient’s ability to function (Chand et al., 2021). For the bulk of the day, practically every day, patients who are depressed have noticeably diminished interest in or excitement for almost all undertakings. The DMS-5 criteria state that a diagnosis requires five of the following symptoms: trouble sleeping, loss of intrigue or pleasure, feelings of inadequacy or helplessness, fatigue or erratic energy, problems concentrating or listening attentively, fluctuations in appetite or weight, psychomotor issues, suicidality, and depressed mood (Agostino et al., 2021). D.T. shows sleeping problems, loss of interest in once-enjoyable pursuits like exercise, trouble paying attention and concentrating, fluctuations in appetite and weight, suicidality, and depressed moods, which confirm MDD and meet the requirements for at least five symptoms listed in the DSM-5 criteria.(Comprehensive Psychiatric Evaluation of a Patient with Major Depressive Disorder)

• F40. 10 Social Anxiety Disorder

Individuals with MDD frequently feel anxious in social settings and worry about how others will judge them. As a result, patients often mention their social anxiety symptoms throughout the assessment. According to research, major depressive disorder is diagnosed in 44%-74% of patients with a social anxiety disorder during their lifespan (Langer et al., 2019). A person must display extreme fear or anxiety in one or more social situations in which they could be subject to others’ prospective scrutiny, according to the DSM-5 criteria. The person is concerned that their actions might be interpreted negatively. Social events frequently result in disproportionate anxiety or panic compared to the threat they pose.(Comprehensive Psychiatric Evaluation of a Patient with Major Depressive Disorder)

Consequently, people either completely avoid them or put up with them out of worry or fear. The avoidance, anxiety, or worry significantly impairs or distresses one of the fundamental areas of functioning, normally lasting no less than six months. It is not pertinent to associate this fear with the signs of another mental illness or the effects of a drug. The anxiety, avoidance, or fear is exorbitant or unrelated if a different medical condition is present (Rose & Tadi, 2021). Although the patient acknowledges her concern and fear, she does not exhibit intense fear and anxiety per the criteria for diagnosing SAD; hence this diagnosis was rejected.(Comprehensive Psychiatric Evaluation of a Patient with Major Depressive Disorder)

• F50. 0 Anorexia Nervosa:

Bulimia and Anorexia Nervosa are two eating disorders that frequently co-occur with major depression. Anorexia Nervosa is more common in this situation, characterized by food intake restrictions comparable to needs, leading to noticeably low body weight (Van Eeden et al., 2021). Individuals with this eating disorder will have a distorted self-perception, a fear of gaining weight, and trouble understanding the seriousness of their illness. Patients have described symptoms such as irregular menstruation, cold intolerance, gastrointestinal issues, extremities edema, tiredness, and irritability (Gibson & Mehler, 2019). Patients discuss restrictive eating habits such as calorie counting, portion control, self-inflicted vomiting, and using laxatives or diuretics for purging (Moore & Bokor, 2022). In addition, many people engage in prolonged, compulsive exercise. Patients with anorexia nervosa experience numerous difficulties due to prolonged fasting and purging. According to the DMS-5 criteria for anorexia nervosa, a patient must demonstrate an energy intake limitation compared to needs, resulting in significant weight loss that is less than minimally expected given the patient’s age, sex, developmental trajectory, and physical health. To confirm the diagnosis, the patient must disclose an excessive fear of gaining weight, conduct that prevents weight growth, or fattening (Moore & Bokor, 2022). D.T. says she frequently exercised before she started feeling moody and managed her food to keep a slim body. The patient’s refusal to acknowledge a fear of gaining weight or severe dietary restrictions led to the diagnosis being ruled out.(Comprehensive Psychiatric Evaluation of a Patient with Major Depressive Disorder)

PLAN:

Combining pharmacotherapy and psychotherapy would generate optimal outcomes.

Safety Risk/Plan:

The patient says she has no desire to harm herself and no current plans. The patient exhibits no malice toward other people. The patient has no suicidal or homicidal thoughts. Admission is not required.  (Comprehensive Psychiatric Evaluation of a Patient with Major Depressive Disorder)

Pharmacological Interventions:

Major depressive disorder and its symptoms can be effectively treated with antidepressants. As the first line of treatment, the patient should be given fluoxetine and citalopram, which are selective serotonin reuptake inhibitors. Antipsychotics and mood stabilizers will assist antidepressants to work more effectively to produce the expected results of an improved mood and high energy.(Comprehensive Psychiatric Evaluation of a Patient with Major Depressive Disorder)

Psychotherapy:

The patient will receive rigorous therapy for a couple of hours every three days for the first three weeks. Family-based psychotherapy will assist in examining, comprehending, and restructuring the fundamental basis of the family environment. Cognitive behavioral therapy will boost positive behavior by addressing the negative ideas and sensations that make the patient feel caught in a negative cycle. It will assist the practitioner and patient in recognizing difficult situations, being conscious of thoughts, feelings, emotions, and associated beliefs, and reshape unhelpful and harmful behavioral patterns.(Comprehensive Psychiatric Evaluation of a Patient with Major Depressive Disorder)

Education:

1. Inform the client of medication side effects, potential complications, and the need for medication adherence.
2. Inform the client of the need to follow up with therapy sessions.
3. Regularly assess withdrawal symptoms to avoid relapse.
4. Inform the client regarding healthy lifestyle choices.(Comprehensive Psychiatric Evaluation of a Patient with Major Depressive Disorder)
5. Motivate the client to work with the healthcare team and seek help anytime.  
6. Advise the client to participate in a support group or group therapy to improve social skills.

Consultation/follow-up: Follow-up is in one week for further assessment.  

Reflection

Because major depressive disorder is frequently misdiagnosed and underrecognized, there is a greater chance that it may go untreated or receive the wrong care. Most MDD patients lack motivation, have poor energy, are uncooperative, and are often agitated or angered, making them difficult to treat. Because there is a high possibility of relapse, treating this disease demands dedication from the patient and a solid support network. Most individuals with MDD deny having depressive episodes while expressing low mood, energy fluctuations, irritability, decreased activity, and indifference. This makes ethical treatment of MDD challenging. Respect for people, autonomy, truthfulness, nonmaleficence, nondisclosure, privacy, the obligation to protect, and beneficence are some of the specific ethical concepts that apply to treating MDD.(Comprehensive Psychiatric Evaluation of a Patient with Major Depressive Disorder)

Nevertheless, depending on the circumstance and severity of MDD, these concepts are weighed and used differently. For instance, in cases of severe depression, it may be more important to protect the patient from pain than to support patient autonomy. Because of the depleted motivation and poor energy levels, which constantly collide with the notion of autonomy, treatment rejection is a problem when treating MDD. This example sheds light on how MDD affects a patient’s life and is linked to eating disorders and social anxiety. If I had a second chance to work with the patient, I would go further into her mental health history to find the root causes. I would also like the spouse to be there to talk about how he feels about her mood and conduct and how the home environment affects the situation.    (Comprehensive Psychiatric Evaluation of a Patient with Major Depressive Disorder)  

References

Agostino, H., Burstein, B., Moubayed, D., Taddeo, D., Grady, R., Vyver, E., … & Coelho, J. S. (2021). Trends in the incidence of new-onset anorexia nervosa and atypical anorexia nervosa among youth during the COVID-19 pandemic in Canada. JAMA network open, 4(12), e2137395-e2137395.(Comprehensive Psychiatric Evaluation of a Patient with Major Depressive Disorder)

Chand, S. P., Arif, H., & Kutlenios, R. M. (2021). Depression (Nursing). In: StatPearls [Internet]. StatPearls Publishing.(Comprehensive Psychiatric Evaluation of a Patient with Major Depressive Disorder)

Gibson, D., & Mehler, P. S. (2019). Anorexia nervosa and the immune system—a narrative review. Journal of clinical medicine, 8(11), 1915.

Moore, C.A., & Bokor, B.R. (2022). Anorexia Nervosa. In StatPearls [Internet]. StatPearls Publishing.

Rose, G. M., & Tadi, P. (2021). Social anxiety disorder. In StatPearls [Internet]. StatPearls Publishing.

Van Eeden, A. E., van Hoeken, D., & Hoek, H. W. (2021). Incidence, prevalence and mortality of anorexia nervosa and bulimia nervosa. Current opinion in psychiatry, 34(6), 515.(Comprehensive Psychiatric Evaluation of a Patient with Major Depressive Disorder)

Langer, J. K., Tonge, N. A., Piccirillo, M., Rodebaugh, T. L., Thompson, R. J., & Gotlib, I. H. (2019). Symptoms of social anxiety disorder and major depressive disorder: A network perspective. Journal of affective disorders, 243, 531–538. https://doi.org/10.1016/j.jad.2018.09.078(Comprehensive Psychiatric Evaluation of a Patient with Major Depressive Disorder)

https://www.ncbi.nlm.nih.gov/