Psychiatric Diagnosis and Management Paper
Mental disorders are among the most prevalent public health issues that increase care costs and contribute to premature deaths, disability, and compromised quality of life. According to Arias et al. (2022), mental disorders contributed to an estimated 418 million disability-adjusted life years (DALYs) and an economic burden of about $5 trillion in 2019.
Examples of mental health issues that compromise the quality of life are schizophrenia, Alzheimer’s Disease (AD), depression, stress, post-traumatic stress disorder (PTSD), and bipolar disorder. The typical clinical manifestations of these mental health illnesses are mood inconsistencies, suicidal ideation, lack of concentration, unexplained weight loss, perceptions of self-blame and worthlessness, and withdrawal from social activities.
Suicide is singlehandedly responsible for the increased rate of premature deaths among people with these mental disorders. As a result, psychiatrists need to adopt effective diagnostic and management interventions to improve the health and wellness of people with mental illnesses and prevent their progression.
Amidst the need to improve the health and well-being of people with mental disorders through timely diagnosis and treatment, psychiatric mental health nurse practitioners (PMHNPs) have a professional and ethical responsibility to identify etiologies, risk factors, assessment models, and care plan options for the individuals with mental illness.
Kumar et al. (2020) contend that psychiatric mental health nurse practitioners can improve their client’s health and well-being by diagnosing, providing psychotherapy, prescribing medications for acute and chronic illness, interpreting lab tests, encouraging care coordination, making referrals, and promoting preventive care, including screening services.
Further, Kumar et al. (2020) argue that PMHNPs should be aware of various modalities and strategies for delivering these services, including virtual consultation, resource coordination, and stakeholder collaboration. Also, mental health nurses need to understand therapeutic strategies, guidelines for physical examination, and cognitive assessment tools to evaluate clients and ascertain their mental conditions effectively.
Psychiatric diagnosis and management emerge as the initial approaches for improving patients’ health and well-being. However, it is essential to distinguish the nature of psychiatric diagnoses from other diseases. According to Maj (2020), the psychiatric diagnosis process enables psychiatrists to identify the nature of clinical manifestations of different mental disorders, determine the severity of the conditions, enhance clinical staging, and define the antecedent variables for mental disorders.
Antecedent variables for mental disorders include family history, psychopathological risks, perinatal history, and premorbid social adjustment. While considering the importance of psychiatric diagnoses and management, this paper is a card presentation regarding a patient with chronic depression.
It introduces the patient and setting, data assessment and evaluation, and the rationale for an individualized care plan for the client. Finally, the paper identifies the project’s anticipated outcomes and discusses lessons from the case study that form the basis of personal development.
An Overview of the Case Study
Patient Introduction and Setting
As a psychiatric mental health nurse practitioner (PMHNP), I had the opportunity to meet DM (patient initials), a 62-year-old female patient grappling with chronic depression for the last 30 years. She is an African American currently living in Ferry County, Washington. She had no physical disability during the examination but appeared slightly overweight and “older than her age.”
After an initial evaluation, the patient indicated that she had been married to her deceased husband for the last 36 years and had grappled with loneliness after her husband’s demise ten years ago following a third stroke. Besides the death of her husband, DM indicated she has four children working in different states across the country.
Currently, she lives in an assisted living facility in Ferry County, where she receives daily care due to the underlying cardiovascular issue exacerbated by chronic depression. Although she has encountered various challenges living in an assisted living facility, DM argued that she has successfully established social connections with care providers and other residents, which has contributed to improving social contexts.
Upon arriving at the psychiatric care setting, the client presented symptoms of extreme depression and reported various signs of chronic depression, including poor appetite, fatigue, sleeping disorders, poor concentration, forgetfulness, psychomotor retardation, and passive suicidal thoughts. Further, she reported incidences of anxiety, guilty, self-blame, a perception of despair, social withdrawal, and confusion.
Other issues that manifested after physical examination include the inability to make eye contact, tearfulness, inattentiveness to personal appearance, long pauses when remembering life experiences, low monotone, and impaired abstract thinking.
Based on the self-reported symptoms after initial evaluation and the patient’s response to mental health assessment tools like the Patient Health Question (PHQ-9) and the Quick Inventory of Depressive Symptomatology (16-item), psychiatrists confirmed that DM suffered from chronic depression emanating from past marital issues and the death of her husband after a third stroke.
Consequently, we collaborated with her to develop an 8-week care plan involving three levels of treatment: early, middle, and late. The early treatment options encompassed the administration of medications as the first line of defense against symptoms of chronic obstructive and a life review therapy to enable her to reminisce positive experiences and derive meaning from these memories.
Middle treatment approaches entailed a cognitive behavioral therapy (CBT) program to complement reminiscent therapy, replace negative thoughts with positive ideas, and address self-blame ideologies. Finally, the late treatment phase entailed follow-up and enhancement of social support by strengthening the role of family members in improving her health and wellness.
DM is a 62-year-old female African-American living in Ferry County, Washington. She is a mother of 4 children and has been married for 36 years. Regarding education and professional life, DM has a diploma in social work and has worked as a social worker for the last 26 years. However, she decided to quit the profession following health issues like cardiovascular conditions perpetrated by the demise of her husband ten years ago.
Considering her deteriorating health, DM lives in an assisted living facility in Ferry County, where she receives daily care, including social support. Although she has an underlying cardiovascular condition, she has no physical disability but appears slightly overweight.
Upon arriving at the psychiatric care facility, DM complained about the persistent symptoms of chronic depression, including daily sadness, tearfulness, fatigue, sleep disorders and difficulties, moments of forgetfulness, poor concentration, confusion, melancholia, and “passive” suicidal thoughts. Also, she indicated incidences of anxiety, guilty, feeling of worthlessness, and withdrawal from social activities.
Further, she stated an inability to read written materials, indecision effectively, and a lack of planning on activities of daily living. DM believed she was the root cause of her husband’s death by constantly engaging him in family wrangles despite surviving two past heart attacks that incapacitated him.
Although her husband was bedridden before the third stroke that led to his death, DM indicated that she was not prepared to live a lonely life. She made a suicidal gesture by stepping on a busy road three months before the intake interview without adhering to safety standards. A cautious motorist helped her to avoid any potential accident.
Besides self-reported symptoms of chronic depression, psychiatrists observed additional signs during intake. These manifestations of depressive symptoms include the inability to make eye contact, tearfulness, and visible despondency.
Also, psychiatrists revealed the probability of cognitive retardation, apparent disorientation, impaired abstract thinking, and psychomotor agitation. These symptoms informed short-and-long-term care decisions, including medication administration and developing a life review therapy and cognitive behavioral therapy to abate these concerns and improve her health and well-being.
History of the Present Illness
DM indicated that the first manifestation of depressive symptoms occurred 20 years ago after her husband was hospitalized due to a heart attack that significantly compromised his quality of life by necessitating frequent rehabilitative interventions and lifestyle modification. She was responsible for caring for her husband and faced challenges balancing work, family, and social life.
Amidst the pressure to balance work and family, DM requested medical leave to provide care to her husband. However, the second heart attack that incapacitated him exacerbated his depression. In this sense, she became the primary care provider for her husband and quit her job to monitor his progress closely and assist him in all activities of daily living. At this point, symptoms of depression manifested through nightmares, anxiety, confusion, and incidences of partial memory loss.
DM visited the nearby psychiatric hospital and presented chief complaints of anxiety, nightmares, forgetfulness, frequent mood swings, loss of appetite, and sleep disorder. The hospital admitted her and commenced various pharmacologic and non-pharmacologic interventions, including interpersonal and psychodynamic therapies. However, a lack of a follow-up plan leads to the ineffectiveness of these therapeutic approaches.
Finally, the death of her husband, which occurred ten years ago, significantly contributed to the proliferation of depressive symptoms, including passive suicidal thoughts, self-blame, nightmares, sleep difficulties, forgetfulness, melancholia, the perception of worthlessness, and withdrawal from social activities. DM indicated that these symptoms are recurrent despite her attempts to cope and address them through medications and other coping capacities.
Although DM grappled with the challenge of remembering some past experiences and memories, she shed some light regarding her childhood life as the 3rd born in a family of 5 children. She indicated that her father was a farmer while her mother was a healthcare professional. DM argued that her parents were truthful to their marriage and only had little arguments.
The primary reason for intact and stable marriage was a solid Christian foundation that anchored love and determination to keep marriage vows. DM’s parents were obsessed with the idea of celebrating Christmas with neighbors and invited children from the neighborhood to commemorate the birth of Christ and the foundation of their faith.
Besides living a life of an ordinary child, DM indicated that she was her father’s favorite child despite demonstrating some “troublesome” behaviors, including incidences of disobedience and bullying other children. She argued that having a solid stature and a tall structure was an added advantage when challenging and bullying peers. Her bullying behavior put her on the parents’ disciplinary mechanisms.
DM recalled one incident where her mother whipped her to sustain bruises because of her uncivil behaviors. However, she concluded that her parents loved her despite being a “troublemaker.” They perceived DM as a child who required love, care, and attention until their demise.
DM denied the presence of depressive episodes or any other mental health concern among her family members, including her parents, grandparent, uncles, aunties, and cousins. He argued that her parents died primarily due to natural causes, with minimal association with illnesses.
However, DM confirmed that one of his uncles has diabetes, exacerbated by various behavioral risk factors like alcoholism. Further, she stated that the onset of chronic depression entirely emanates from life complexities with no association with genetic biomarkers.
DM remembered that she was her husband when she was 26, while he was 28. Their love blossomed as they navigated early adulthood life. Due to the pressure of circumventing complex early adulthood life, they married at the end of their first year in a relationship. As a young couple, the marriage life was complicated and full of challenges, including early concerns of infidelity and multiple accusations.
However, parental interventions enabled them to navigate complexities and lead a sustainable family. DM and her husband had four children: the firstborn is 34 years, the second born is 31 years, the thirdborn is 28 years, and the lastborn is 24 years old. Family life was relatively satisfactory and rewarding because all four children completed their respective college and university courses and now work in different states.
However, the problem of depression emerged immediately after DM’s husband suffered his first heart attack 20 years ago. At that time, the lastborn was only four years old. Although he recovered after a lengthy hospitalization spell, the incident inflicted a massive psychological and economic burden on the family, forcing DM to balance her job as a community-based healthcare professional and the overarching need to provide care to her ailing husband.
Although family members, relatives, neighbors, and friends provided the much-sought-after social, psychological, and financial support, their involvement in the situation diminished upon advancing time. Upon recovery, her husband resorted to small-scale businesses to regain health and support the family.
Five years after the first heart attack, a second tragedy hit the family in the form of a life-threatening cardiac arrest that incapacitated him to the extent of requiring assistants in activities of daily living. This incident led to multiple other complications, including loss of mobility, memory loss, neurologic dysfunction, brain injury, and neurocognitive deficits.
Equally, the condition rendered home bedridden and significantly changed his life quality. From DM’s perspective, this incident left an indelible mark on her life by contributing to chronic depression. Five years later, the situation worsened after his husband succumbed to a third heart attack.
During the day when this incident occurred, DM had left home briefly for the nearby grocery to source healthy foods, instructing their firstborn to provide care and monitor his progress. This issue haunts her today as she considers herself the cause of her husband’s death. The memory of her husband’s demise increases the perception of self-blame, guilt, nightmares, and the feeling of worthlessness.
DM described herself as an industrious person obsessed with creating positive community change by volunteering as a social worker and providing care to the vulnerable members of the community. She highlighted her belief in the impacts of social connections and interpersonal relationships in improving people’s quality of life and well-being. Regarding her role as a mother and wife, DM remembered her commitment to play her roles, support her husband, and ensure that her children adhere to the moral standards that define humanity.
Finally, she argued that her parents’ commitment to instilling values and ethics enabled her to overcome uncivil behaviors such as bullying. Until the onset of chronic depression, DM valued connections with family members, friends, and neighbors by actively participating in social activities, including Christmas ceremonies and other vital engagements.
The mental status examination in psychiatry is synonymous with physical examinations in other clinical specialties. According to Voss & Das (2022), mental status examination entails gathering information through passive observation during the interview and direct questioning to establish a patient’s mental status.
After providing chief complaints to psychiatrists, they assessed various aspects of the universally accepted standards for mental status examination, including appearance, behavior, motor activity, speech, mood, affect, thought process, cognition, and thought content. Also, DM answered self-reported items in two primary assessment tools; the Patient Health Question (PHQ-9) and the Quick Inventory of Depressive Symptomatology (QIDS-16).
According to Sun et al. (2020), the PHQ-9 is an effective tool for assessing and detecting the severity of depression because it entails simple and straightforward items for confirming the presence and severity of depressive symptoms. The nine items total 27 points, enabling psychiatrists to establish the range of depression severity based on patients’ scores.
Similarly, the Quick Inventory of Depressive Symptomatology is a profound assessment tool for evaluating the severity of depressive symptoms. Liu et al. (2021) contend that the self-reported Quick Inventory of Depressive Symptomatology is brief and unidimensional, enabling close clinicians to estimate the presence and severity of depressive symptoms quickly and accurately.
Also, the 16-item assessment tool allows healthcare professionals to monitor changes and establish the effects of pharmacologic and non-pharmacologic interventions (Liu et al., 2021). Based on active observation by psychiatrists and DM’s score for the two assessments tools, the physical examination revealed the manifestations of depressive symptoms:
- General appearance: psychomotor retardation/agitation, inability to maintain eye contact, tearfulness, and inattentiveness to personal experience.
- Speech: low monotone, long pauses, little spontaneity
- Thought content: suicidal ideation, indecisiveness, persistent feelings of hopelessness, worthlessness, and guilt.
- Cognition: partial memory loss, concentration issues, impaired abstract thinking, and apparent disorientation.
- Insight and judgment: impaired critical thinking and insights
- Mood: daily sadness, frustration, melancholia, depression, and irritable
- Affect: labile
DM’s chief complaints, history of the current illness, and physical examination confirmed the presence of chronic depression. Although the physical examination ascertained the presence of depressive symptoms, physicians conducted various laboratory tests, including complete blood count, thyroid-stimulating hormone, free T4, urinalysis, and toxicity screening. According to Bains & Abdijadid (2022), these lab tests aim to rule out organic and medical causes of depression. Consequently, they revealed an absence of medication-related depression.
Evaluation of Assessment Data
The data from the mental status examination and the patient’s chief complaints confirm the presence and severity of chronic depression. Upon completing the 9-item Patient Health Question (PHQ-9), DM scored 22 points, meaning she suffered from severe depression. Also, the Quick Inventory of Depressive Symptomatology (QIDS-16) revealed prevalent depressive symptoms, including sleep difficulties, sleeping during the day, daily sadness, decreased appetite, and unexplained weight loss.
Other themes assessed by the QIDS-16 assessment tool include self-perceptions, thoughts of death or suicide, concentration issues, restlessness, energy levels, and the feeling of slowing down. DM scored 21 points in the QIDS-16 assessment, confirming the presence of severe depression. Physical examination revealed various aspects of general appearance, mood, cognition, judgment, insights, and speech that indicated the presence of chronic depression.
According to Salari et al. (2020), the clinical manifestation of depression encompasses various symptoms, including emotional distress, irritability, insomnia, attention deficit, anger, and mood swings. DM exhibited these symptoms, confirming the depression diagnosis.
Plan and Rationale
Based on the findings and information from DM’s mental health status examination, it was essential to develop a comprehensive care plan for preventing the disease’s progression and abating symptoms. The program comprised short-and-medium term symptom management approaches. The first line of defense was the administration of selective serotonin reuptake inhibitors (SSRIs), including a 20mg a day citalopram dose.
The rationale for this pharmacologic intervention relies massively upon the potential impacts of SSRIs in reducing the complications and severity of depressive symptoms. According to Chu & Wadhwa (2022), selective serotonin reuptake inhibitors (SSRIs) are often the first-line pharmacologic intervention for managing depression due to their safety, tolerability, and efficacy. Also, their mechanisms of action significantly alleviate depressive symptoms and improve patients’ health.
Chu & Wadhwa (2020) contend that this medication class inhibits serotonin reuptake, increasing its activity. It is essential to note that the serotonin neurotransmitter is responsible for modulating mood, cognition, memory, and learning.
Besides administering SSRIs to abate depressive symptoms and improve DM’s health, psychiatrists embarked on two therapeutic, non-pharmacologic interventions as medium management approaches. These therapies are life review (reminiscence) and cognitive behavioral therapy.
Firstly, involving the patient in life review therapy enabled her to reflect on positive memories and experiences to obtain meaning from them and enhance a positive mindset. Westerhof & Slatman (2019) contend that life review therapy provides ideal opportunities for older adults to attribute meaning to positive and negative memories across their lifespan.
Further, it focuses on the primary objectives of integrative reminiscence and ego integrity. Consequently, this therapy can address issues pertinent to unsolved traumatic events and alleviate feelings of self-blame and guilt.
Finally, the psychiatrists incorporated cognitive behavioral therapy (CBT) into life review therapy. The primary reason for combining the two therapeutic approaches was to allow DM to identify dysfunctional thoughts, emotions, and negative behaviors that perpetuate chronic depression.
According to Ng et al. (2017), cognitive behavioral therapy (CBT) enables patients to replace dysfunctional thoughts with positive perceptions and rethink alternatives. While negative thoughts lead to depression, feelings of sadness, and frustration, replacing them with positive ones can reduce the progression of depression by enhancing coping skills and promoting acceptance.
The anticipated outcomes for a contingency plan for managing depression and improving DM’s health included; abetting depressive symptoms, enabling the patient to replace negative and dysfunctional behaviors with new ones, enhancing the patient’s return to health normalcy, and allowing her to accept past experiences and derive meaning from positive memories.
To assess these outcomes, I used the Quick Inventory of Depressive Symptomatology to gather information regarding the effectiveness of pharmacologic and non-pharmacologic interventions in addressing various symptoms, including sleep disorder, daily sadness, decreased appetite, restlessness, withdrawal from social activities, thoughts of death or suicide, and self-criticism.
The patient scored 13 points, indicating moderate depression during the implementation of life review and cognitive behavioral therapy (CBT) therapy. The patient reported improved appetite and sleep, reduced tendency to think about death or suicide, self-criticism, and a general interest in social activities. Although evaluating the plan’s outcomes signified improvement in various thematic areas, a summative assessment would have effectively unearthed the impacts of pharmacologic and non-pharmacologic interventions for addressing chronic depression.
DM’s case study provides insights into the sequential processes of delivering care to people with mental disorders. Firstly, it establishes the importance of gathering adequate information regarding patients’ medical and family history and premorbid personality. Also, the case study underscores the need to conduct a comprehensive mental status examination using practical tools to establish depression’s presence and severity.
Various themes that form the basis of physical examination in psychiatry are general appearance, speech, mood, thought, cognition, insights, and thought content (Voss & Das, 2022). Finally, developing an individualized care plan for DM requires psychiatrists to demonstrate knowledge and awareness of pharmacologic and non-pharmacologic interventions that are safe, efficient, and effective in abetting depressive symptoms and improving health.
These areas form the basis of personal and professional growth because they emphasize incorporating evidence-based practice into psychiatric care. By acquiring knowledge and skills for conducting physical examinations, identifying safer medication options, and developing a patient-centered care plan, it will be possible to provide quality and convenient care for patients with different mental disorders.
DM’s case study promotes the practice of providing patient-centered care by relying on information from physical examination, patient and family history, and self-reported assessment tools. Upon reaching our psychiatric facility, DM’s chief complaints included various symptoms of chronic depression, including sleep disorder, guilt, passive suicidal thoughts, and the feeling of worthlessness.
The primary cause of chronic depression in the case scenario is the death of DM’s husband, who suffered three heart attacks across his lifespan. This case study validates the need to conduct a comprehensive mental status examination and collaborate with the patient and other interprofessional team members to develop an individualized care plan for improving the patient’s health and well-being. A personalized care plan consists of a life review and cognitive behavioral therapy (CBT).
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