A young woman with Depression: Case Study

Learning Objectives

Students will:

Evaluate clients for treatment of mental health disorders
Analyze decisions made throughout diagnosis and treatment of clients with mental health disorders

https://mym.cdn.laureate-media.com/2dett4d/Walden/NURS/6670/05/mm/decision_tree/index.html

Examine Case 2: You will be asked to make three decisions concerning the diagnosis and treatment for this client. Be sure to consider co-morbid physical, as well as mental factors that might impact the client’s diagnosis and treatment.

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At each Decision Point stop to complete the following:

Decision #1: Differential Diagnosis
- Which Decision did you select?
- Why did you select this Decision? Support your response with evidence and references to the Learning Resources.
- What were you hoping to achieve by making this Decision? Support your response with evidence and references to the Learning Resources.
- Explain any difference between what you expected to achieve with Decision #1 and the results of the Decision. Why were they different?
Decision #2: Treatment Plan for Psychotherapy
- Why did you select this Decision? Support your response with evidence and references to the Learning Resources.
- What were you hoping to achieve by making this Decision? Support your response with evidence and references to the Learning Resources.
- Explain any difference between what you expected to achieve with Decision #2 and the results of the Decision. Why were they different?
Decision #3: Treatment Plan for Psychopharmacology
- Why did you select this Decision? Support your response with evidence and references to the Learning Resources.
- What were you hoping to achieve by making this Decision? Support your response with evidence and references to the Learning Resources.
- Explain any difference between what you expected to achieve with Decision #3 and the results of the decision. Why were they different?

Also include how ethical considerations might impact your treatment plan and communication with clients and their family.

Use above link to access case.

Decision Point One

BASED ON THE INFORMATION PROVIDED IN THE SCENARIO ABOVE, WHICH OF THE FOLLOWING DIAGNOSES WOULD THE PSYCHIATRIC/MENTAL HEALTH NURSE PRACTITIONER (PMHNP) GIVE TO STEFANIE?

In your write-up of this case, be certain to link specific symptoms presented in the case to DSM–5 criteria to support your diagnosis. 

– Cyclothymic disorder

Decision Point Two

BASED ON THIS DIAGNOSIS, SELECT YOUR CHOICE OF ACTIONS:

– Begin Depakote 250 mg orally three times daily

RESULTS OF DECISION POINT TWO

 Client returns to clinic in four weeks

 Stefanie returns to your office and informs you that she had to stop taking the medication last week. “I have been too tired to do anything,” she explains, “plus, I have gained about 2 pounds since I started this medicine… I can’t keep gaining weight like this.”

Decision Point Three

BASED ON THE ABOVE INFORMATION, SELECT YOUR NEXT ACTION. BE CERTAIN TO DISCUSS THE RATIONALE FOR YOUR DECISION.

-Decrease the dose to 125 mg orally twice a day Guidance to Student

Guidance to Student

In order to meet the criteria for a major depressive episode, the client needs to have five or more symptoms (refer to DSM–5 major depressive episode criteria). She only demonstrates criteria # 1: depressed mood most of the day, nearly every day, as indicated by either subjective reports (e.g., feels sad, empty, or hopeless) or observation made by others (e.g., appears tearful); criteria # 6: “fatigue or loss of energy nearly every day”; and criteria # 8: “diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others).” Thus, Stefanie does not meet the criteria for a major depressive episode as she only has three out of the needed five criteria for the diagnosis of a major depressive episode.

In order to meet criteria for a hypomanic episode, the client needs to have a period of abnormally and persistently elevated, expansive, or irritable mood, and abnormally and persistently increased activity or energy, lasting at least 4 consecutive days and present most of the day, nearly every day. Stefanie’s symptoms last 3 days. Additionally, during the period of mood disturbance, the person must have three or more of the qualifying symptoms. Stefanie only has an increase in goal-directed activity and distractibility. Thus, Stefanie does not meet criteria for a hypomanic episode as she only has a decreased need for sleep and an increase in goal-directed activity.

Since Stefanie has symptoms of both hypomania and depression (but does not meet the criteria for a major depressive or hypomanic episode), and since these behaviors do not occur in the context of a drug/substance or medical condition, Stefanie meets the diagnostic criteria for cyclothymic disorder.

Some providers will treat cyclothymic disorder with pharmacologic agents used to treat bipolar disorder because individuals with cyclothymic disorder have a higher risk of progression to bipolar disorder. However, there is no consensus in the literature as to the optimal treatment, or if prophylactic psychopharmacologic treatment is beneficial in consideration of the side effects associated with antipsychotics and mood stabilizers.

Whereas the side effects of many medications may be transient, weight gain associated with Depakote can continue for the duration of treatment. Decreasing the dose may serve only to slow the rate of weight gain; but of the available choices, this would be the most correct choice (although not the “correct” answer, it will minimize the side effects of this medication). Doubling the dose will of course increase sedation and most likely weight gain.

Bipolar I, current phase, depressed