Assessing and Diagnosing Patients with Major Depressive Disorder

Comprehensive Psychiatric Evaluation of Major Depressive Disorder-Nursing Paper Example

Patient Initials: N.D.

Gender: Female

SUBJECTIVE:

CC: “I have been feeling down lately.”

HPI: The patient is a 25-year-old Indian woman who presented at the clinic complaining of feeling down lately. The patient states she does not understand her mood lately. She feels off and has lost interest in most activities she was engaging in. The patient does not exercise regularly like before because she feels fatigued quickly. For the past month, she has been inactive most of the time. Her mood and lack of energy are affecting her functioning. She reported decreased effectiveness and speed in completing home chores and activities of daily living. The patient reports poor concentration, agitation, and easy irritability. She has problems sleeping, around 3-4 hours every day. Her appetite has changed, and she noticed gradual weight loss. The patient denies having depressive feelings, despite her mood being down, social withdrawal and decreased activity. She reports increased anxiety and stress before her wedding but was not diagnosed with any anxiety disorder. Her marriage has been enjoyable until her mood lately, which is the source of many arguments and disagreements with her husband. She does not understand what the problem is, and she fears for her marriage.(Comprehensive Psychiatric Evaluation of Major Depressive Disorder-Nursing Paper Example)

Social History: N.D. moved from India to America with her parents when she was 10. She is now 25 years and married. She has lived with her husband in Minnesota since their wedding six months ago.  

Education and Occupation History: N.D. is educated in college and works as a homemaker.

Substance Current Use and History: The patient denied any history of substance abuse.

Legal History: The patient denied any legal history.

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

Past Psychiatric History:

            Hospitalization: Denied previous hospitalization

Medication trials: No previous medical trails

Psychotherapy or Previous Psychiatric Diagnosis: No previous psychiatric diagnosis

Medical History: Denies medical history.   

• Current Medications: Xanax for her anxiety.
• Allergies: The patient is allergic to animal fur and grass pollen.
• Reproductive Hx: Sexually active. She is not under birth control. The patient reports irregular menses since a year ago and amenorrhea for the last two months.(Comprehensive Psychiatric Evaluation of Major Depressive Disorder-Nursing Paper Example)

ROS:  

General: Reports gradual weight loss and fever and occasional feelings of weakness and fatigue. Denies fever.

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.(Comprehensive Psychiatric Evaluation of Major Depressive Disorder-Nursing Paper Example)

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 Major Depressive Disorder-Nursing Paper Example)

Genitourinary: Denies burning on urination, urgency, hesitancy, odor, 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 Major Depressive Disorder-Nursing Paper Example)

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.

OBJECTIVE:

Vital signs: Stable

Temp: 98.8F

            B.P.: 100/60

            P: 83

             R.R.: 17

             O2: Room air

             Pain: 4/10

             Ht: 5’5 feet

             Wt: 110 lbs

             BMI: 18.3

             BMI Range: Underweight

LABS:

Lab findings WNL

Tox screen: Negative

Alcohol: Negative

Physical Exam:

General appearance: The patient appears lean, malnourished, and dehydrated, with the BMI indicating she is underweight. The patient converses appropriately and regularly with the interviewer but appeared irritated with some questions. In addition, the patient has impaired concentration and did not answer some questions appropriately.(Comprehensive Psychiatric Evaluation of Major Depressive Disorder-Nursing Paper Example)

HEENT: Normocephalic and atraumatic. Sclera anicteric, No conjunctival erythema, PERRLA, oropharynx red, moist mucous membranes.(Comprehensive Psychiatric Evaluation of Major Depressive Disorder-Nursing Paper Example)

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 within normal range, and capillaries refill within two seconds.

Musculoskeletal: Normal range of motion. Low muscle mass for age. No signs of swelling or joint deformities. Muscle and back pain is rated 4/10 on the pain scale.(Comprehensive Psychiatric Evaluation of Major Depressive Disorder-Nursing Paper Example)

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. However, the patient has frequent headaches.(Comprehensive Psychiatric Evaluation of Major Depressive Disorder-Nursing Paper Example)

Psychiatric: The patient has a depressed mood, irritability, insomnia, and impaired concentration and attention.  (Comprehensive Psychiatric Evaluation of Major Depressive Disorder-Nursing Paper Example)

Neuropsychological testing: Social-emotional functioning is impaired.

Behavior/motor activity: Patient behavior was appropriate and constant throughout the assessment

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

Orientation: Oriented to self, place, situation, and general timeframe.(Comprehensive Psychiatric Evaluation of Major Depressive Disorder-Nursing Paper Example)

Attention/concentration: Impaired

Insight: Good

Judgment: Good.

Remote memory: considered good

Short-term memory: considered good

Intellectual /cognitive function: considered good

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

Fund of knowledge: Good.

Suicidal ideation: The patient reports suicidal ideation but is negative for active plans.

Homicide ideation: Negative.

ASSESSMENT:

Mental Status Examination:

The patient is a 25-year-old female presenting with complaints of feeling down lately. The patient reports easy irritability. During the psychiatric interview, the patient was sometimes uncooperative, and her concentration was impaired, making it difficult to establish a rapport. She expressed a low mood, persistent probing, decreased attention and concentration, apathy, and easy fatigability. The patient appeared bleak and expressed pessimistic ideas about her life, marriage, and future, fearing her husband would leave her. She reports suicidal ideation but negative active plans. She denies homicidal ideation. (Comprehensive Psychiatric Evaluation of Major Depressive Disorder-Nursing Paper Example)

Differential Diagnosis:

1. F32.9 Major Depressive Disorder

Depression is a mood disorder leading to constant sorrow and disinterest. All depressive disorders share the symptoms of melancholy, emptiness, or irritation, along with physical and mental changes that significantly impair the patient’s capacity to operate (Chand et al., 2021). Patients who are depressed have a noticeably lower interest in or enthusiasm for nearly all activities for the majority of the day, practically every day. According to the DMS-5 criteria, a diagnosis must include 5 of the following symptoms: trouble sleeping, decreased interest or enjoyment, feelings of guilt and worthlessness, fatigue and energy swings, difficulty focusing or paying attention, changes in appetite and weight, psychomotor problems, suicidal thoughts, and depressed mood (Agostino et al., 2021). N.D. reports sleeping disturbances, low interest in previously enjoyable activities like working out, impaired attention and concentration, appetite and weight changes, suicidal thoughts, and depressed moods, qualifying for at least five symptoms described in the DSM-5 criteria and confirming MDD.(Comprehensive Psychiatric Evaluation of Major Depressive Disorder-Nursing Paper Example)

• F40. 10 Social Anxiety Disorder

Individuals with MDD commonly experience anxiety in social situations and are often concerned about how people perceive them. Therefore, during the assessment, patients tend to indicate symptoms of social anxiety. Research shows that 44% to 74% of people with social anxiety disorder are also diagnosed with major depressive disorder during their lifetime (Langer et al., 2019). Per the DSM-5 criteria, a person must exhibit pronounced fear or anxiety in one or more social situations where they may come under others’ potential scrutiny. The individual worries that they will behave in a way that might be perceived adversely. Most of the time, social situations cause anxiety or fear, which is excessive compared to the threat they truly present. As a result, people either avoid them entirely or tolerate them with worry or fear. Usually lasting at least six months, the avoidance, fear, or worry significantly impairs or distresses one of the fundamental areas of functioning. The symptoms of another mental disorder or the consequences of a substance should not be linked to this fear. If a different medical issue is present, the anxiety, avoidance, or fear is also excessive or unconnected (Rose & Tadi, 2021). This diagnosis was refuted because, although the patient admits to anxiety and fear, she does not indicate intense fear and anxiety relative to the requirements to diagnose SAD.(Comprehensive Psychiatric Evaluation of Major Depressive Disorder-Nursing Paper Example)

• F50. 0 Anorexia Nervosa:

Major depressive disorders commonly co-occur with eating disorders, particularly Bulimia Nervosa and Anorexia Nervosa. In this case, Anorexia Nervosa is more likely. It is characterized by a restriction of nutrient intake comparable to requirements, resulting in substantially low body weight (Van Eeden et al., 2021). Patients suffering from this eating disorder will experience a fear of weight gain, a distorted perception of themselves, and difficulty comprehending the gravity of their condition. Menstrual irregularities, cold intolerance, bowel problems, extremity edema, exhaustion, and irritability are among the symptoms reported by patients (Gibson & Mehler, 2019). Patients describe food-related restrictive behaviors such as calorie restriction or portion control and purging methods, including self-induced vomiting or the using diuretics or laxatives (Moore & Bokor, 2022). In addition, many people exercise obsessively for long periods. Numerous complications result from anorexia nervosa patients’ extended fasting and purgation. DMS-5 criteria for Anorexia Nervosa requires a patient to indicate energy intake restriction relative to requirements, causing significant weight loss relative to age, sex, developmental trajectory, and physical health, less than minimally expected. To establish the diagnosis, the patient should report excessive fear of gaining weight, fattening, or persistent behavior interfering with weight gain (Moore & Bokor, 2022). N.D. indicates dietary management to maintain her lean body and frequent exercises before she began feeling off mood. The diagnosis was refuted because the patient did not admit to fear of gaining weight or intense nutritional restrictions.(Comprehensive Psychiatric Evaluation of Major Depressive Disorder-Nursing Paper Example)

PLAN:

The patient would benefit from a combination of pharmacotherapy and psychotherapy.

Safety Risk/Plan:

The patient indicates minimal intent to cause self-harm and is negative on active plans. The patient shows no intent to harm others. The patient has minimal suicidal and negative homicidal ideation. No admissions are necessary.  (Comprehensive Psychiatric Evaluation of Major Depressive Disorder-Nursing Paper Example)

Pharmacological Interventions:

Antidepressants are effective in treating major depressive disorder and its associated symptoms. Therefore, the patient should be prescribed selective serotonin reuptake inhibitors (SSRIs) like fluoxetine and citalopram as first-line treatment. In addition, mood stabilizers and antipsychotics will help enhance the effects of antidepressants to achieve the desired outcomes of an elevated mood and increased energy levels.

Psychotherapy:

The patient will undergo intensive therapy for 2-3 hours every three days for the first three weeks. Family-based psychotherapy will help investigate and understand the underlying nature of the home environment and restructure it. Cognitive behavioral therapy will help reinforce positive behavior by addressing negative thoughts and feelings that make the patient feel trapped in a negative cycle. It will help the practitioner and patient identify troubling circumstances, become aware of thoughts, feelings, emotions, and beliefs attached to these circumstances, and reshape the negative and problematic thoughts and behavioral patterns.  (Comprehensive Psychiatric Evaluation of Major Depressive Disorder-Nursing Paper Example)

Education:

1. Educate the patient about side effects, potential complications, and the need for medication adherence.
2. Educate the patient on the need to follow up with therapy to manage complications and address body image.(Comprehensive Psychiatric Evaluation of Major Depressive Disorder-Nursing Paper Example)
3. Monitor vital signs.
4. Monitor withdrawal symptoms to determine the risk of relapse.
5. Educate the patient regarding making healthy lifestyle choices.
6. Encourage the patient to work with the healthcare team and seek help anytime.  
7. Advise the patient to join a support group or group therapy to help enhance social skills.

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

Referral: The patient needs to see a gynecologist to address menstruation irregularities.

Reflection

Major depressive disorder is often unrecognized and underdiagnosed, increasing the risk of remaining untreated or treated inappropriately. Dealing with MDD patients is a problem because most have leached motivation, and low energy levels, are uncooperative and easily agitated or irritated. Treating this disorder requires commitment from the patient and a reliable support system because the risk of relapse is high. Ethical treatment of MDD is complicated because most patients deny experiencing depressive episodes despite reporting low mood, energy changes, irritable mood, decreased activity, and disinterest. Treating MDD has distinct ethical principles, including respect for persons, autonomy, veracity, nonmaleficence, privacy, duty to protect, and beneficence. However, these principles are weighed and applied differently depending on the situation and severity of MDD. For instance, in severe depression, the need to protect the patient from harm might override the need to promote patient autonomy. Treatment refusal is an issue in treating MDD because of the leached motivation and low energy levels, always conflicting with the principle of autonomy. This case offers insights into the impact of MDD on a patient’s life and is associated with social anxiety and eating disorders. Given another chance with the patient, I would go deeper into her mental health history to discover underlying circumstances and factors. I would also ask the husband to be present to explore his attitude towards her wife’s mood and behavior and how the home environment contributes to the situation. (Comprehensive Psychiatric Evaluation of Major Depressive Disorder-Nursing Paper Example)

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 Major Depressive Disorder-Nursing Paper Example)

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

Gibson, D., & Mehler, P. S. (2019). Anorexia nervosa and the immune system—a narrative review. Journal of clinical medicine, 8(11), 1915.(Comprehensive Psychiatric Evaluation of Major Depressive Disorder-Nursing Paper Example)

Moore, C.A., & Bokor, B.R. (2022). Anorexia Nervosa. In StatPearls [Internet]. StatPearls Publishing.(Comprehensive Psychiatric Evaluation of Major Depressive Disorder-Nursing Paper Example)

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 Major Depressive Disorder-Nursing Paper Example)

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 Major Depressive Disorder-Nursing Paper Example)

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