Psych eval 2-response

Discussion including at least one meaningful response to at least one of your peers’ Psych Evals should occur by Wednesday at 11:59 pm EST in weeks 4, 8, and 12. A meaningful response demonstrates critical thought. Refer to the Carlat and Kaplan & Kaplan texts for assistance. Posts that are perfunctory or only minimally meet all grading criteria do not necessarily qualify as “excellent” which would yield full points (100). This is true for both the initial post and the response post. One response post is considered to meet the criteria minimally.

STUDENT’S PSYCH EVALUATION

Psychiatric Evaluation

Demographic Data

Patient initials: CR. Age: 78. Gender: Female. Ethnicity: White. Setting: Skilled nursing facility, in-house psychiatric consultation. Primary source of information: The patient, supplemented by the hospital discharge records, including the inpatient psychiatry consult note, the facility medical record, and nursing staff. Reliability: Fair; the patient was alert, answered questions consistently, and her account matched the records. Reason for referral: CR was evaluated and cleared by inpatient psychiatry at the hospital after she stated she wanted to "die" during a hospitalization for a congestive heart failure (CHF) exacerbation and pneumonia. The skilled nursing facility also requested clearance from in-house psychiatry, and this evaluation was completed by our team. Patient understanding of referral: CR stated she was seen because she "said something she shouldn't have" and agreed to the evaluation.

Subjective Data

Chief complaint. "I just want to die. I'm tired of being sick."

History of present illness. CR is a 78-year-old woman and long-term resident of the facility with a history of major depressive disorder (MDD), treated with duloxetine 60 mg daily and mirtazapine 15 mg nightly. She was hospitalized with a CHF exacerbation complicated by community-acquired pneumonia and has since returned to the facility. During the hospitalization she told staff she wanted to "die," and inpatient psychiatry was consulted. Onset: The statement began on hospital day 2, following a decline in her respiratory status requiring increased oxygen. Duration: Present for approximately 4 days, occurring intermittently, worse at night. Character: Passive wish to be dead; she denied active thoughts of ending her life. Aggravating factors: Shortness of breath, repeated hospitalizations, loss of independence, and frustration with her illness. Relieving factors: Family visits, symptom control, and reassurance. Severity: Endorsed a "5 out of 10" level of distress; Columbia Suicide Severity Rating Scale (C-SSRS) endorsed passive suicidal ideation without intent, plan, or preparatory behavior. On the hospital evaluation her statement was judged to reflect frustration over her medical illness, with no plan and no intent, and inpatient psychiatry cleared her and found no need for inpatient psychiatric admission. One-to-one observation was placed as a precaution and remains in place at the facility, with a plan to step down monitoring as she remains free of suicidal thoughts. Because the facility required clearance from in-house psychiatry as well, we completed our own evaluation. She again described the statement as frustration with being sick and was clear that she had no plan and no intent to harm herself.

Depressive symptoms before this hospitalization: CR reported low mood, diminished interest in activities, poor sleep, decreased appetite, low energy, and poor concentration over the past 2 weeks, with gradual worsening since her recent illness. Longitudinal course: MDD diagnosed in 2015, with three prior episodes; stable on current regimen until the recent illness. Pertinent negatives: Denies a plan, intent, or preparatory behavior. Denies prior suicide attempts. Denies homicidal or violent ideation. Denies auditory or visual hallucinations and paranoia. Denies manic symptoms. Denies confusion or new memory problems. Current psychiatric medications and response: Duloxetine 60 mg daily (started 2020) and mirtazapine 15 mg nightly (started 2021), with good response and tolerability prior to the hospitalization; adherence confirmed via the medication administration record. The timing links the wish to die to the medical decline, but it sits on a background of recurrent depression, so both must be addressed.

Past Psychiatric History

Diagnoses: Major depressive disorder, recurrent, since 2015. Hospitalizations: Denies psychiatric admissions. Outpatient treatment: Follows with primary care prescriber; no current psychotherapy. Suicide attempts and self-harm: Denies. Medication trials: Duloxetine 60 mg daily for 6 years, good response, no significant side effects; mirtazapine 15 mg nightly for 5 years, improves sleep and appetite, no significant side effects. No other antidepressant trials. Pertinent negatives: No electroconvulsive therapy, no history of mania or psychosis, no history of violence.

Substance Use History

Denies alcohol, tobacco, cannabis, opioids, stimulants, sedatives, and other illicit substances. Denies prescription misuse. Caffeine: 1–2 cups of coffee daily. Denies gambling or compulsive spending. No withdrawal history.

Past Medical History and Review of Systems

Medical history: CHF with reduced ejection fraction (~35%), hypertension, atrial fibrillation (on apixaban), chronic kidney disease stage 3, and pneumonia during the recent hospitalization. Surgeries: Knee replacement (2012), cholecystectomy (1998). Allergies: Penicillin (rash). Medications: Duloxetine 60 mg, mirtazapine 15 mg, furosemide 40 mg, metoprolol succinate 50 mg, lisinopril 10 mg, apixaban 5 mg, and to complete 3 more days of antibiotics  per the hospital discharge orders. Review of systems: Reports mild dyspnea, fatigue, and poor sleep. Denies chest pain, fever, headache, new confusion, or falls. Reports appetite as poor. Reports no acute pain. Dyspnea, poor sleep, and low energy overlap with depression in heart failure, so the history separates cardiac symptoms from mood symptoms.

Family History, Psychosocial, and Developmental History

Family psychiatric history: Mother had depression treated with medication; no known family history of suicide. Family of origin and development: Born in Puerto Rico, eldest of three siblings, denies abuse or early losses. Education: High school graduate. Employment: Retired school secretary. Relationships: Widowed 8 years; two adult children who visit regularly. Living situation: Resides in a skilled nursing facility since a fall 6 months ago. Spirituality: Catholic; reports faith is protective. Legal/Military: None. Access to firearms: No. Protective factors: Family support, faith, engagement in care, no prior attempts.

Objective Data

Vital signs on the day of evaluation: BP 118/72, HR 78, RR 20, Temp 98.6°F, SpO2 94% on 2 L nasal cannula, weight 142 lb. Pertinent labs (hospital discharge records): Sodium 134 mEq/L, potassium 4.1 mEq/L, creatinine 1.4 mg/dL, BUN 28 mg/dL, WBC 11.2 × 10³/µL, TSH 2.1 mIU/L, B12 410 pg/mL, BNP 1,850 pg/mL. ECG (hospital): QTc 438 ms. Chest imaging (hospital): Right lower lobe infiltrate consistent with pneumonia. Physical exam: Alert, mild respiratory effort, bilateral lower extremity edema, no tremor, no focal neurologic deficits.

Mental status exam. Appearance: CR is a 78-year-old woman who looks her stated age, average build, gray hair, adequate grooming and hygiene, dressed appropriately for the setting, on nasal cannula, no visible scars. Behavior: Cooperative, fair eye contact. Motor activity: No psychomotor agitation or retardation, no tremor. Speech: Normal fluency, low volume, normal rate and tone, spontaneous. Affect: Congruent with mood, constricted, tearful at times. Mood: "Tired and frustrated." Thought process: Linear and goal-directed. Thought content: Passive death wish as described. No plan, intent, or preparation. No homicidal ideation, delusions, hallucinations, obsessions, or paranoia. Themes of frustration, burden, and loss of independence. Cognition: Alert; oriented to person, place, date, and situation; spelled WORLD backward correctly; recalled 3 of 3 words at 5 minutes; serial 7s correct to 72; named current and prior president; interpreted 2 of 3 proverbs correctly. Insight: Fair; recognizes mood is tied to illness. Judgment: Fair; accepts treatment and asks for help. Delirium screen: Confusion Assessment Method (CAM) negative; attention intact.

Assessment

CR is a 78-year-old woman with recurrent MDD on a serotonin norepinephrine reuptake inhibitor (SNRI) and mirtazapine who voiced a passive wish to die during a hospitalization for a CHF exacerbation with pneumonia. Inpatient psychiatry cleared her at the hospital, and the facility asked for in-house confirmation. Her statement came with no plan, intent, or preparation, and she is future-oriented and engaged in care. Even so, older adults with serious medical illness carry real suicide risk, and a death wish in this setting should be treated as a symptom to be understood. Risk factors include advanced age, chronic cardiopulmonary illness, recurrent MDD, loss of function, and a recent hospitalization with return to the facility. Protective factors include family support, no prior attempts, no access to firearms, engagement in treatment, and help-seeking. Overall acute risk is low to moderate given the absence of plan or intent, and chronic risk is elevated. I agree with the inpatient psychiatry impression. She does not meet criteria for inpatient psychiatric admission and can remain at the facility with the monitoring and follow-up below.

Sbolli et al. (2020) report that up to 30% of patients with heart failure have depression, and that the diagnosis rests on DSM-5 criteria rather than cardiac symptoms alone. Fatigue, poor sleep, and low appetite can stem from heart failure, so cognitive and emotional symptoms, such as hopelessness, guilt, and loss of interest, were weighted more heavily.

Diagnosis. Major depressive disorder, recurrent, moderate, without psychotic features, current episode active (American Psychiatric Association, 2022). Criteria met: depressed mood, diminished interest, poor sleep, decreased appetite, low energy, poor concentration, and feelings of worthlessness for more than 2 weeks. The mental status exam supports this with constricted affect, a mood described as "tired and frustrated," and themes of hopelessness.

Differential diagnosis. (a) Delirium: Pneumonia, hypoxia, and heart failure increase vulnerability, and a death wish can accompany hypoactive delirium (Wilson et al., 2020). Her intact attention, orientation, and negative CAM argue against it, but nursing will continue screening each shift. (b) Depressive disorder due to another medical condition or medication effect, including hypoxia, hyponatremia, thyroid disease, B12 deficiency, or beta-blocker exposure; labs will help clarify. (c) Adjustment disorder with depressed mood: Frustration over illness fits, but her history of recurrent MDD makes a full episode more likely. (d) Major or mild neurocognitive disorder: No reported memory complaints; Montreal Cognitive Assessment (MoCA) to be completed after acute illness resolves. (e) Demoralization or an understandable response to serious illness not meeting MDD criteria.

Plan

Safety. Continue one-to-one observation with a written step-down plan. Reduce to q15-minute checks after 24–48 hours with no suicidal statements, a negative C-SSRS screen each shift, and a stable medical picture. Remove or secure potential means in the room. Reassess daily while on enhanced observation and return to routine monitoring once step-down criteria are met. Nursing will document any statement about dying and notify the on-call provider and in-house psychiatry right away.

Workup. Review the hospital discharge labs and ECG. Check a basic metabolic panel with attention to sodium through the facility lab, plus CBC, magnesium, TSH, B12, and folate if not already done, and repeat an ECG for QTc if a recent one is not available. Continue CAM screening each shift. Complete a baseline Geriatric Depression Scale and a MoCA once she has recovered from the acute illness, and share the results with the interdisciplinary care team.

Medications. Continue duloxetine 60 mg and mirtazapine 15 mg. Stopping an antidepressant mid-crisis adds risk, and a poor response is hard to judge while she is this sick. Two concerns require monitoring. First, hyponatremia: Gheysens et al. (2024) found the highest hyponatremia rates with SNRIs (7.44%) and the lowest with mirtazapine (1.02%), advising caution with SNRIs in patients prone to low sodium. CR is on an SNRI and a diuretic for CHF, so sodium will be followed closely; if it falls, duloxetine would be reconsidered before mirtazapine. Second, blood pressure and heart rate, as duloxetine can raise both. Ishtiak-Ahmed et al. (2024) found that clinical outcomes vary among commonly used antidepressants in older adults, supporting deliberate prescribing. If she remains depressed after the acute illness resolves, optimizing the mirtazapine dose, which also helps sleep and appetite, would be considered before adding another agent. Benzodiazepines and antipsychotics will be avoided unless clearly indicated (Wilson et al., 2020).

Neurobiology and rationale. Depression involves reduced monoaminergic signaling in circuits regulating mood, motivation, and stress response (Stahl, 2021). Duloxetine blocks reuptake of serotonin and norepinephrine, raising synaptic levels of both. Mirtazapine blocks presynaptic alpha-2 receptors, increasing release of norepinephrine and serotonin, and also blocks 5-HT2A, 5-HT2C, 5-HT3, and histamine H1 receptors, accounting for its benefit on sleep, appetite, and nausea (Stahl, 2021). The combination is rational for a patient sleeping and eating poorly from both depression and illness.

Therapy and psychosocial care. Provide brief supportive therapy at the facility, focusing on her frustration, sense of losing control, and what matters most to her. Consider problem-solving therapy or cognitive behavioral therapy through facility social services or outpatient psychotherapy once she is stable. Involve family with her consent. Request a palliative care consult to help with dyspnea, symptom burden, and goals of care. This is not a hospice referral but adds support for a patient living with advanced heart failure. Facility social services will review family involvement and supports, the room will be checked for potential means, and pastoral care will be offered since she reports her faith is protective.

Disposition and follow-up. In-house psychiatry will follow within 48 to 72 hours and then weekly until she is stable, and sooner for any change in mood or any statement about dying. She does not require transfer for inpatient psychiatric care at this time. Provide CR and her family with a safety plan and crisis resources (988 Suicide and Crisis Lifeline), and communicate the plan to the attending provider, nursing leadership, and cardiology. Educate CR and her family that worsening mood, hopelessness, or statements about dying should be reported promptly.

References

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). https://doi.org/10.1176/appi.books.9780890425787

Gheysens, T., Van Den Eede, F., & De Picker, L. (2024). The risk of antidepressant-induced hyponatremia: A meta-analysis of antidepressant classes and compounds. European Psychiatry, 67(1), Article e20. https://doi.org/10.1192/j.eurpsy.2024.11

Ishtiak-Ahmed, K., Musliner, K. L., Christensen, K. S., Mortensen, E. L., Nierenberg, A. A., & Gasse, C. (2024). Real-world evidence on clinical outcomes of commonly used antidepressants in older adults initiating antidepressants for depression: A nationwide cohort study in Denmark. American Journal of Psychiatry, 181(1), 47–56. https://doi.org/10.1176/appi.ajp.20230356

Sbolli, M., Fiuzat, M., Cani, D., & O'Connor, C. M. (2020). Depression and heart failure: The lonely comorbidity. European Journal of Heart Failure, 22(11), 2007–2017. https://doi.org/10.1002/ejhf.1865

Stahl, S. M. (2021). Stahl's essential psychopharmacology: Neuroscientific basis and practical applications (5th ed.). Cambridge University Press.

Wilson, J. E., Mart, M. F., Cunningham, C., Shehabi, Y., Girard, T. D., MacLullich, A. M. J., Slooter, A. J. C., & Ely, E. W. (2020). Delirium. Nature Reviews Disease Primers, 6(1), Article 90. https://doi.org/10.1038/s41572-020-00223-4