Respond 3

Week 7: Complex Case Study Presentation

Walden University

PRAC 6675: PMHNP Across the Lifespan II

July 16, 2023

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WEEK 7: COMPLEX CASE STUDY PRESENTATION 8

Week 7: Complex Case Study Presentation

Subjective:

CC: “I just don’t know. It’s hard to explain.”

HPI:

N.M. is a 17-year-old African American male admitted with worsening depression and anxiety. The patient reports that over the past year, his anxiety and depression have gradually declined. However, within the past two weeks, his anxiety has interfered with his ability to work and function at home. He states that he became more anxious as it got closer for him to go to work on Friday, and as a result, he called in and missed his last scheduled shift. He initially sought help from his primary care provider. He was prescribed Lexapro for two weeks but received no resolution of symptoms due to the lack of an adequate trial and, as a result, presented to the emergency department. The patient states that his increased anxiety and worsening mood have been related to stressors related to work, finances, and increased demands of helping his mother care for his siblings. He reports feeling overwhelmed and often worries about job-related issues and whether he can help his mom as much as he desires. He also verbalized feelings of depression. He states that he struggles with low self-esteem and admits to feeling hopeless at times with some passive suicidal ideation in the recent past. He reports the following associated symptoms: sadness, anhedonia, decreased focus/concentration, sleep disturbances, fatigue, excessive worry, and a reduced appetite that has contributed to a 10lb weight loss over the past few months. He reports that, on average, he gets four to five hours of sleep a night. He denies any suicidal or homicidal ideation. He also denies any auditory or visual hallucinations. He does not report any history of mania.

Substance Current Use: none

Current Medications: Lexapro 10mg PO daily

Allergies: NKA

Reproductive Hx: No congenital disabilities reported.

ROS:

GENERAL: Sleep difficulties and a ten-pound weight loss over the past few months.

CARDIOVASCULAR: No cardiovascular-related problems were reported.

GASTROINTESTINAL: No gastrointestinal symptoms were reported.

NEUROLOGICAL: No neurological symptoms were reported.

Objective:

Diagnostic results:

Although no diagnostic tools, other than criteria set by the Diagnostic and Statistical Manual (DSM), were used in this case, rating scales such as the Generalized Anxiety Disorder Questionnaire– 7 (GAD-7) and the Patient Health Questionnaire—9 (PHQ-9) could have been utilized. These scales are used to detect symptoms of depression and anxiety (Pranckeviciene et al., 2022). They are reliable and best when used as initial screening tools (Pranckeviciene et al., 2022).

Assessment:

Mental Status Examination:

N.M. is a 17-year-old male who looks his stated age and is appropriately dressed. He is cooperative but appears anxious with a guarded attitude. He has a depressed and anxious mood with a congruent affect. His speech is of average rate, volume, and prosody. His thoughts are pertinent for depressive preoccupation. He denies any suicidal ideation, intent, or plan. He does admit to passive suicidal ideation in the past. There is no evidence of auditory, visual, or tactile hallucinations, paranoia, or delusions. He is alert and oriented to person, place, time, and situation. His fund of Knowledge is average. Memory is intact, with fair insight and judgment.

Diagnostic Impression:

(F33.2) Major Depressive Disorder, Recurrent Episodes, Severe

Given N.M.s clinical presentation, it was evident that major depressive disorder (MDD) was an appropriate diagnosis. According to recommendations for diagnosing MDD, there must be at least five related symptoms for at least two weeks that cause significant distress or impairment in functioning (American Psychiatric Association, 2022). At least one of the symptoms must be a depressed mood or anhedonia and not better explained by another mood or schizophrenia spectrum disorder (American Psychiatric Association, 2022). In addition, N.M. denied any episodes of mania, which is another qualifying factor. N.M. reported a depressed mood and other related symptoms such as sadness, anhedonia, decreased focus/concentration, sleep disturbances, fatigue, hopelessness, and a reduced appetite with unintentional weight loss. He also stated that he struggles with low self-esteem and passive suicidal ideation at times. His depression may have led to his anxiety.

(F41.1) Generalized Anxiety Disorder (GAD)

Generalized anxiety disorder and major depressive disorder can be a dual diagnosis for this patient. Given his presenting timeline, related symptoms, and impaired occupational functioning, the patient met DSM criteria for GAD. To make an accurate diagnosis, there must be at least three associated symptoms, a six-month time frame of frequent anxiety or excessive worry, and significant distress or impaired functioning (American Psychiatric Association, 2022). N.M. presented with the following symptoms of GAD: decreased focus/concentration, sleep disturbances, fatigue, and excessive worry. His symptoms have also persisted for at least six months and have caused impairment in his ability to work, which further supports GAD as a diagnosis.

(F31.81) Bipolar II Disorder

Bipolar two disorder was considered, given N.M.s signs of major depressive disorder and denial of a manic episode. Although he met partial criteria for bipolar disorder, it can be ruled out because he never had a hypomanic episode. He also failed to meet the three symptom requirements from criterion B. Hence, MDD and GAD would be a more appropriate diagnosis.

Reflections:

If this interview could be done again, gathering more subjective data from the family would be helpful (Carlat, 2017). Adolescents usually minimize or deny specific details that could be instrumental in diagnosing and creating a treatment plan (Carlat, 2017). Although the mom was present for discussions regarding treatment, she was not there during the initial evaluation. She could have verified and ultimately contributed more information, including a past family psychiatric history.

One health promotion activity would be developing good sleep hygiene. Developing good habits before bed could assist in receiving a better night of sleep. The patient could also be educated regarding potential side effects (including the black box warning), risks of abrupt discontinuation, and psychotherapy. One form of psychotherapy found effective in treating anxiety and depression is cognitive behavioral therapy (CBT). This treatment can alter dysfunctional thinking and behavior patterns (Carpenter et al., 2018). CBT can also reduce relapse rates, diminish negative distortions, and address psychosocial factors related to stress from work (Gautam et al., 2020). One social determinant impacting this patient’s mental health status is his finances. Given his lack of finances, he may be unable to afford psychotherapy. Therefore, suggesting resources such as websites where the patient can find a local therapist based on coverage would be helpful. One website found to be a good resource is psychologytoday.com.

If a follow-up appointment could be conducted, it would be essential to inquire about his current mood and any experienced side effects. Although a better side effect profile is associated with selective serotonin reuptake inhibitors (SSRIs), there is still a potential for increased suicidal ideation, given the black box warning and a lack of response. It is essential to determine if the medication is effective and whether or not the patient is tolerating it well. Inquiring about these factors can determine the next course of action, such as whether a new medication should be prescribed or used in adjunct after an adequate trial period. If the drug had been effective and the patient was satisfied with the improvements, no adjustments would be necessary.

Case Formulation and Treatment Plan:

1. The patient is admitted to the behavioral health unit for further evaluation and treatment of worsening mood and anxiety.

2. Discussed treatment options and alternatives with the patient and family. The patient was started on Lexapro 20 mg PO daily and Vistaril 25mg PO BID for mood and anxiety. Lexapro is FDA-approved for treating MDD in adults and adolescents and is also used for treating GAD (Landy et al., 2023). Lexapro is within the SSRI class of antidepressants, which is a first-line treatment option for anxiety and depression and has demonstrated safety and efficacy (Patel et al., 2018). Vistaril is an antihistamine with anxiolytic properties (Patel et al., 2018). Prescribing Vistaril may help alleviate anxiety symptoms before Lexapro can become effective.

3. The patient will be engaged in therapeutic groups, including individual, group, milieu, and activity therapy.

4. The prognosis for this patient is fair at this time

5. Anticipated discharge plan would be home with appropriate follow-up care.

PRECEPTOR VERFICIATION: I confirm the patient used for this assignment is a patient that was seen and managed by the student at their Meditrek approved clinical site during this quarter course of learning.

Preceptor signature: ________________________________________________________ Date: ________________________

References

American Psychiatric Association. (2022). Section I: DSM-5 basics. In Diagnostic and statistical manual of mental disorders (5th ed., text rev.).

Carlat, D. J. (2017). The psychiatric interview (4th ed.). Wolters Kluwer.

Carpenter, J. K., Andrews, L. A., Witcraft, S. M., Powers, M. B., Smits, J. J., & Hofmann, S. G. (2018). Cognitive behavioral therapy for anxiety and related disorders: A meta‐analysis of randomized placebo‐controlled trials. Depression and Anxiety, 35(6), 502–514. https://doi.org/10.1002/da.22728

Gautam, M., Tripathi, A., Deshmukh, D., & Gaur, M. (2020). Cognitive behavioral therapy for depression. Indian Journal of Psychiatry, 62(8), 223. https://doi.org/10.4103/psychiatry.indianjpsychiatry_772_19

Landy, K., Rosani, A., & Estevez., R. (2023, January 1). Escitalopram. StatPearls. Retrieved July 11, 2023, from https://www.ncbi.nlm.nih.gov/books/NBK557734/

Patel, D. R., Feucht, C., Brown, K., & Ramsay, J. (2018). Pharmacological treatment of anxiety disorders in children and adolescents: A review for practitioners. Translational Pediatrics, 7(1), 23–55. https://doi.org/10.21037/tp.2017.08.05

Pranckeviciene, A., Saudargiene, A., Gecaite-Stonciene, J., Liaugaudaite, V., Griskova-Bulanova, I., Simkute, D., Naginiene, R., Dainauskas, L., Ceidaite, G., & Burkauskas, J. (2022). Validation of the patient health questionnaire-9 and the generalized anxiety disorder-7 in lithuanian student sample. PLOS ONE, 17(1), e0263027. https://doi.org/10.1371/journal.pone.0263027