Module 4: Lecture Materials & Resources, discuss the following:
Ms. Z is a 28-year-old assistant store manager who arrives at your outpatient clinic complaining of sadness after her boyfriend of 6 months ended their relationship 1 month ago. She describes a history of failed romantic relationships, and says, “I don’t do well with breakups.’ Ms. Z reports that, although she has no prior psychiatric treatment, she was urged by her employer to seek therapy. Ms. Z has arrived late to work on several occasions because of oversleeping. She also has difficulty in getting out of bed stating. “It’s difficult to walk; it’s like my legs weigh a ton.” She feels fatigued during the day despite spending over 12 hours in bed and is concerned that she might be suffering from a serious medical condition. She denies any significant changes in appetite or weight since these symptoms began.
Ms. Z reports that, although she has not missed workdays, she has difficulty concentrating and has become tearful in front of clients while worrying about not finding a significant other. She feels tremendous guilt over “not being good enough to get married, and says that her close friends are concerned because she has been spending her weekends in bed and not answering their calls. Although during your evaluation Ms. Z appeared tearful, she brightened up when talking about her newborn nephew and her plans of visiting a college friend next
summer. Ms. Z denied suicidal ideation.
Remember to answer these questions from your textbooks and clinical guidelines to create your evidence-based treatment plan. At all times, explain your answers.
1. Summarize the clinical case including the significant subjective and objective data.
2. Generate a primary and two differential diagnoses. Use the DSM5 to support the assessment. Include the DSM5 and ICD 10
codes.
3. Discuss a pharmacological treatment would you prescribe? Use the clinical guidelines to support the rationale for this treatment.
4. Discuss non-pharmacological treatment would you prescribe? Use the clinical guidelines to support the rationale for this
treatment
5. Describe a health promotion intervention that would be appropriate for this patient.
1. Summary of the Clinical Case
Subjective Data:
- Patient: Ms. Z, 28-year-old assistant store manager.
- Chief Complaint: Sadness following a breakup one month ago.
- History: History of failed romantic relationships, difficulty with breakups, urged by employer to seek therapy, no prior psychiatric treatment.
- Symptoms: Oversleeping, difficulty getting out of bed, feeling of legs being heavy, fatigue despite prolonged sleep, no significant appetite or weight changes, difficulty concentrating, tearfulness in front of clients, guilt over not being good enough to get married, withdrawal from friends, and spending weekends in bed.
- Positive Indicators: Brightened up when talking about newborn nephew and future plans to visit a friend.
- Negative Indicators: Denied suicidal ideation.
Objective Data:
- Appearance: Tearful during evaluation.
- Behavior: Sadness, difficulty concentrating, tearfulness, withdrawal from social activities.
2. Primary and Differential Diagnoses
Primary Diagnosis:
- Major Depressive Disorder (MDD)
- DSM-5 Criteria: At least five of the following symptoms present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.
- Depressed mood most of the day, nearly every day.
- Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day.
- Significant weight loss when not dieting or weight gain, or decrease or increase in appetite nearly every day.
- Insomnia or hypersomnia nearly every day.
- Psychomotor agitation or retardation nearly every day.
- Fatigue or loss of energy nearly every day.
- Feelings of worthlessness or excessive or inappropriate guilt.
- Diminished ability to think or concentrate, or indecisiveness, nearly every day.
- ICD-10 Code: F32.1 (Moderate depressive episode)
- DSM-5 Criteria: At least five of the following symptoms present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.
Differential Diagnoses:
- Persistent Depressive Disorder (Dysthymia)
- DSM-5 Criteria: Depressed mood for most of the day, for more days than not, for at least 2 years.
- Poor appetite or overeating.
- Insomnia or hypersomnia.
- Low energy or fatigue.
- Low self-esteem.
- Poor concentration or difficulty making decisions.
- Feelings of hopelessness.
- ICD-10 Code: F34.1 (Dysthymia)
- DSM-5 Criteria: Depressed mood for most of the day, for more days than not, for at least 2 years.
- Adjustment Disorder with Depressed Mood
- DSM-5 Criteria: The development of emotional or behavioral symptoms in response to an identifiable stressor(s) occurring within 3 months of the onset of the stressor(s).
- Marked distress that is out of proportion to the severity or intensity of the stressor.
- Significant impairment in social, occupational, or other important areas of functioning.
- ICD-10 Code: F43.21 (Adjustment disorder with depressed mood)
- DSM-5 Criteria: The development of emotional or behavioral symptoms in response to an identifiable stressor(s) occurring within 3 months of the onset of the stressor(s).
3. Pharmacological Treatment
Antidepressants
- Selective Serotonin Reuptake Inhibitors (SSRIs)
- Medication: Sertraline (Zoloft)
- Dosage: Starting dose 50 mg/day, can be increased to a maximum of 200 mg/day based on patient response.
- Rationale: SSRIs are first-line treatments for MDD due to their efficacy and tolerability. Sertraline is effective in treating symptoms of depression, including mood changes, sleep disturbances, and concentration difficulties.
- Clinical Guidelines: According to the American Psychiatric Association (APA) guidelines, SSRIs are recommended as initial treatment for moderate to severe MDD.
4. Non-Pharmacological Treatment
Cognitive Behavioral Therapy (CBT)
- Rationale: CBT is effective in treating MDD by addressing negative thought patterns and behaviors that contribute to depression. It helps patients develop coping strategies and problem-solving skills.
- Clinical Guidelines: The APA guidelines recommend CBT as a first-line psychotherapeutic treatment for MDD, either alone or in combination with pharmacotherapy.
Interpersonal Therapy (IPT)
- Rationale: IPT focuses on improving interpersonal relationships and social functioning, which can help alleviate symptoms of depression. It is particularly useful for patients with relationship difficulties.
- Clinical Guidelines: IPT is recommended as an evidence-based treatment for depression, helping patients navigate and improve their interpersonal relationships.
5. Health Promotion Intervention
Physical Activity
- Intervention: Encourage Ms. Z to engage in regular physical activity, such as brisk walking, yoga, or other forms of exercise that she enjoys.
- Rationale: Regular physical activity has been shown to improve mood, reduce symptoms of depression, and enhance overall well-being. It can also help with fatigue and improve sleep quality.
- Clinical Guidelines: The Centers for Disease Control and Prevention (CDC) recommend at least 150 minutes of moderate-intensity aerobic activity per week for adults, which can help reduce depressive symptoms and improve mental health.
By following this evidence-based treatment plan, Ms. Z can receive comprehensive care addressing both her psychological and physical health needs.