A young woman with Depression Assignment.

Decision 1: Differential Diagnosis

The most probable differential diagnosis in this case is a Major Depressive disorder.

Reason for this Decision

As stated by Remick (2012), the DSM-5 criteria for diagnosing a major depressive disorder should include: a patient presenting with 5 or more symptoms that meet the diagnostic criterion. They include: a depressed mood for most part of the day daily, displeasure on nearly all activities of the day, weight loss or weight gain, a slowdown of thoughts, loss of energy/fatigue, feelings of worthlessness, indecisiveness and a diminished ability to concentrate (Remick, 2012). A young woman with Depression Assignment. Similarly, Stefanie presented with symptoms that match criterion 1, 5, 6 and 8, although they do not amount to five or more than 5 as expected.

Expected Outcome

It is expected that Stefanie will be diagnosed with a major depressive disorder.

Difference between the Expected Outcome and the Actual Outcome

Stefanie presented with symptoms of both depression and hypomanic disorder. Stefanie presented with the following symptoms of depression. Criteria #1 where she had a depressed mood during most times of the day daily as indicated in the subjective data where she reportedly had feelings of sadness, hopelessness and emptiness. She also demonstrated criteria 6 of fatigue and loss of energy and criteria 8 of diminished ability to concentrate, think and to remain decisive.

At the same time, Stefanie had symptoms of increased goal-directed distractibility and activity but her levels of increased energy only lasted for 3 consecutive days rather than 4 days which do not meet the criteria for a hypomanic disorder. Therefore, basing on the fact that Stefanie presented with symptoms of both depression and hypomania but does not meet the DSM-5 criterion for either a hypomanic or major depressive disorder, and that the occurrence of these behaviors were neither influenced by an underlying illness or drug abuse (Perugia, Hantouchec & Vannucchia, (2017). She will therefore be diagnosed with a cyclothymic disorder whose criteria she fits best.

Decision 2: Treatment Plan for Psychotherapy

The client will be scheduled for follow-up and psychotherapy every twelve weeks. More specifically, Stefanie will be started on Cognitive Behavioral therapy.

Reason for this decision

Psychotherapy will help to establish Stefanie’s symptoms on an ongoing basis progressively to determine whether they follow the same patterns as before when she initially presented to the clinic or they are gradually subsiding (Tomba, et al., 2016). Cognitive Behavioral therapy has proven to be the most efficient form of therapy sin the management of cyclothymic disorders as they help to decrease the frequency of depressive moods which result to descent behaviors such as social withdrawal.

Expected Outcome

With CBT, Stefanie can learn how to manage, change and challenge negative thoughts and to rectify behavioral patterns that are troublesome (Tomba, et al., 2016).

Difference between Expected Outcome and Actual Outcome

While assessing the general impact of the symptoms experienced by Stefanie to her overall physical and physiological and their impact on the life of Stefanie, CBT alone was not able to realize effective health outcomes. This called for the decision to include pharmacologic agents to the plan of treatment.

Decision 3: Treatment Plan for Psychopharmacology

Therefore, I would start Stefanie on Depakote250mg orally thrice daily and Abilify 10mg orally daily for the first four weeks. Most mental health practitioners manage cyclothymic disorders with drugs used in the management of bipolar disorders since most clients who present with cyclothymic disorders are at very high risk of progressing to bipolar disorders (Perugia, Hantouchec & Vannucchia, 2017).

Expected Outcome

It is expected that the client will return to the clinic after four weeks for follow-up. With the combination of an antipsychotic and a mood stabilizer, it is also expected that she will have a mood that is more stable as compared to before (Perugia, Hantouchec & Vannucchia, 2017). She will be happier than before and with a significant reduction in the hypomanic episodes.

Difference between Expected Outcome and Actual Outcome

Stefanie returned to the psychiatric clinic with information that she stopped taking the medications after one week due to general fatigue and weight gain. Besides, she also complained about feelings of lightheadedness when moving from a sitting to a standing position which has actually subsided. The symptoms of lightheadedness that Stefanie might have experienced are similar to that of orthostatic hypotension which is common during the initiation of Abilify (Perugia, Hantouchec & Vannucchia, 2017). However, she will need encouragement with continuous monitoring where the current dose of 10mg orally daily will be maintained rather than increasing or discontinuing it.

Besides, it is necessary that Stefanie is educated that sedation and weight gain are transient side effects that are associated with Depakote which are likely to continue for the entire duration when she will be on treatment (Perugia, Hantouchec & Vannucchia, 2017). By decreasing the dosage, the side effects will be reduced and this is the best choice for this case. On the other hand, doubling the dosage will likely increase the side effects of weight gain and sedation. Therefore, the dosage of Depakote will be decreased to 125mg orally twice daily.

How Ethical Decisions Might Impact the Treatment Plan and Communication with Clients and Their Family

The ethics of confidentiality and privacy requires that a mental health nurse protects a patient’s right to privacy by ensuring that, client medical information is not shared with other family members or friends without an informed consent. In cases where family support is necessary for decisions in treatment and follow-up, patient onset before disclosure of information must always prevail.  Observing this ethical concern tends to encourage respect, communication and a therapeutic relation (Perugia, Hantouchec & Vannucchia, 2017). A young woman with Depression Assignment.Besides, based on the ethics of autonomy, mental health nurses need to ensure that decisions on treatment meet the needs and will of a patient. There are instances where a patient may be mentally challenged to make informed choices which may require the intervention of a family member or healthcare provider (Perugia, Hantouchec & Vannucchia, 2017). However, mental health nurses are required to fully educate a patient when mentally stable and let them make their own decisions.

 

References

Perugia, G., Hantouchec, E., & Vannucchia, G. (2017). Diagnosis and treatment of cyclothymia: the “primacy” of temperament. Current neuropharmacology, 15(3), 372-379.

Remick A. R., (2012). Diagnosis and management of depression in primary care: a clinical update and review. Canadian Medical Association Journal, 167(11). 1253-1260.

Tomba, E., Tecuta, L., Guidi, J., Grandi, S., & Rafanelli, C. (2016). Demoralization and response to psychotherapy: A pilot study comparing the sequential combination of cognitive-behavioral therapy and well-being therapy with clinical management in cyclothymic disorder. Psychotherapy and psychosomatics, 85(1), 56-57.

 

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. A young woman with Depression Assignment.
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.

 

SUBJECTIVE Stefanie is a 32-year-old female from Puerto Rico who presents to your office today with complaints of difficulty sleeping. You learn that Stefanie can go for a few days with minimal sleep (about 3 hours/night), but does not seem to be fatigued the next day. Stefanie explains that after 3 days with minimal sleep, she “crashes” and has a good night’s sleep. She states that sleep will be “alright” for a few days, even a few weeks, and then she will have a similar issue with sleep. You learn throughout the assessment process that Stefanie has had this problem for years. She noticed that it began in college and thought it was just because of the workload and academic demands. However, she found that it persisted after college. She also notices that she has periods where she will engage in increased amounts of goal-directed activity. She states that things will just “pile up” at work and she gets this burst of energy to “make everything right.” She states that these bursts will last most of the day. She states that these periods show up probably every 2 to 3 weeks. Stefanie also confesses to problems with being “down in the dumps.” She states that when she has her episodes in which she endeavors to “make everything right,” she feels fantastic and on top of the world. However, when these periods of energy end, she reports that she feels “depressed”—but then states: “well, maybe not depressed, but I definitely feel sad and empty.” She also endorses feelings of fatigue and a decreased ability to concentrate when she is feeling sad. She finally tells you: “I have lived with this for so long, I have to admit that it is finally a relief to tell someone how I feel!” OBJECTIVE Stefanie is dressed appropriately to the weather. She has no gait abnormalities. Physical assessment is unremarkable. Gross neurological assessment is within normal limits. MENTAL STATUS EXAM Stefanie is alert and oriented × 4 spheres. Her speech is clear, coherent, goal directed, and spontaneous. Self-reported mood is “sad.” Affect does appear consistent with dysphoria. Eye contact is normal. Speech is clear, coherent, and goal directed. She denies visual or auditory hallucinations. No overt evidence of paranoid or delusional thought processes noted. She denies suicidal or homicidal ideation and is future oriented. At this point, please discuss any additional diagnostic tests you would perform on Stefanie. 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. A young woman with Depression Assignment.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. Stefanie’s symptoms are most consistent with orthostatic hypotension, which is not uncommon when initiating Abilify. At this point, it sounds as if the side effects have subsided. There is nothing to tell us that we should increase the dose. Similarly, there is nothing in the case to tell us that we should discontinue the Abilify. Instead, routine monitoring should occur. A young woman with Depression Assignment.