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Diagnosis to Consider and Codes
Major Depressive Disorder, recurrent moderate F33.1
Generalized anxiety disorder 41.1
Rationale for Diagnosis
Major Depressive Disorder, recurrent moderate-The patient meets at least the required five criteria needed for a MDD diagnosis (American Psychiatric Association, 2013). He is in a low mood for a better part of the day (American Psychiatric Association, 2013), most days as he spends the day lying on the couch. He has stopped volunteering at a nursing home, which meets marker number two: a decrease of pleasure in activities (American Psychiatric Association, 2013). He also has both insomnia and hypersomnia because he cannot fall asleep and then spends the day on the couch (American Psychiatric Association, 2013). Next, he has a fatigue in which he believes himself to be moving in slow motion (American Psychiatric Association, 2013). Lastly, he has been having recurrent thoughts regarding death, as he has had a recent diagnosis of prostate cancer, and his father’s current health status (American Psychiatric Association, 2013).
GAD- He meets the criteria for this because he has had anxiety and worry for over six months, he has difficulty controlling the anxiety, and the anxiety is manifested by being fatigued easily, with sleep disturbances, and restlessness when he attempts to fall asleep (American Psychiatric Association, 2013).
Tests and Tools
For MDD, I would use the Hamilton Depression Rating scale or the Patient health Questionnaire. I would also check the T3, T4, CBC, CMP, and A1C of the patient to rule out any external factors. For GAD, I would use the Beck Anxiety Inventory (BAI) or the GAD-7 for measurement of the symptom’s severity.
Differential Diagnosis to Consider
For MDD I would consider Posttraumatic Stress disorder and adjustment disorder (American Psychiatric Association, 2013). I would also consider anxiety disorder due to another medical condition (American Psychiatric Association, 2013).
Treatment Strategy and Rationale
For this patient, I would recommend therapy, to include CBT, and possibly family therapy. Recommendation of these items addresses the depression head on, including the family may be beneficial to the patient’s treatment (Depression, 2020). I would like to trial bupropion with this patient and recommend an increase of activity with alternative approaches like seeking religious counseling (if he is religious). I would also recommend attending a support group for the loss of his wife and the impending death of his father.
With this patient, I would develop a safety plan to put in place in case the patient developed and SI. I would also identify a person close to the patient, who would be willing to listen to the patient in a crisis or would be able to hold possible weapons for the patient. I would also provide crisis line numbers to the patient in the event of a crisis occurring after hours.
Since this patient has trialed Effexor, Prozac, Zoloft, Lexapro and duloxetine, I would trial bupropion for this patient I would titrate up to 300mg per day to see if there has been any improvement in mood and adjust or switch from that point.
I would use the PHQ depression scale and the HAM and the GAD-7 tests to monitor and track the progression or the digression of the diagnosis.
I would begin with supportive listening and CBT. If after a few sessions, this did not provide any relief, I would adjust my approach to fit the patient’s needs.
This would be most advantageous to the patient because this would empower the patient to understand about depression, giving the patient an opportunity to talk about their experiences and to be a part of their treatment plan (Depression an Information Guide, 2020). If he includes his family, it would also be beneficial to them by learning about the signs and symptoms of depression and what they can do to assist them (Depression an Information Guide, 2020).
For MDD, I would establish a therapeutic alliance, complete a psychiatric assessment, evaluate the patient’s safety, establish an appropriate treatment setting, coordinate and collaborate with other providers (Practice Guideline for the Treatment of Patients with Major Depressive Disorder, 2020). I would continue to monitor and adjust treatments as necessary to his psychiatric status and integrate measurements such as the PHQ (Practice Guideline for the Treatment of Patients with Major Depressive Disorder, 2020). I would also provide education to both the patient and with approval, the patient’s family (Practice Guideline for the Treatment of Patients with Major Depressive Disorder, 2020).
Clinical Note: Is depression a normal part of aging?
Some would consider depression to be a normal part of aging. However, that is a common misconception because people become more susceptible to sadness and anxiety (CDC, 2020). This increased risk may be from chronic health conditions, misdiagnosis, and undertreatment of symptoms (CDC, 2020). Being able to accurately identify and treat depression in an aging person needs to be a fundamental part of a PMHNP’s repertoire. Knowing the signs and the symptoms in an aging patient is key to identifying and accurately diagnosing depression.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
Depression an Information Guide (2020). [Ebook]. Retrieved from http://www.camh.ca/- /media/files/guides-and-publications/depression-guide-en.pdf
Depression is Not a Normal Part of Growing Older | Healthy Aging | CDC. (2020). Retrieved 28 October 2020, from https://www.cdc.gov/aging/mentalhealth/depression.htm
Depression | NAMI: National Alliance on Mental Illness. (2020). Retrieved 28 October 2020, from https://www.nami.org/About-Mental-Illness/Mental-Health-Conditions/Depression
Gautam, S., Jain, A., Gautam, M., Vahia, V. N., & Grover, S. (2017). Clinical Practice Guidelines for the management of Depression. Indian journal of psychiatry, 59(Suppl 1), S34–S50. https://doi.org/10.4103/0019-5545.196973
Practice Guideline for the Treatment of Patients with Major Depressive Disorder. (2020). [Ebook]. Retrieved from https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/mdd.p df
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