Case Study: Kel

Full Answer Section

• • Neglect of personal hygiene and appearance (unkempt, disheveled, drab and unironed clothes, not attending to makeup).
  • Impaired functioning at work (overwhelmed by normal tasks, feeling disorganized, spotty attendance).
  • Changes in eating habits (eating mostly crackers and canned soup due to lack of energy to shop and prepare meals).
  • Weight loss (15 pounds over the last 2 months) not due to intentional dieting.
  • Increased sleep without feeling rested ("Although I sleep for many hours, I am still tired all the time.").
  • Disorganized living environment (unclean and in disarray apartment).

2. Generate a Primary and Differential Diagnosis using the DSM-5 and ICD-10 Codes:

Based on the presenting problems, the most likely primary diagnosis is Major Depressive Disorder (MDD).

• DSM-5 Criteria for Major Depressive Disorder (at least five of the following 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):  

  1. Depressed mood most of the day, nearly every day: Reported by Kel as "sad and hopeless" and observed as flat affect.  
  2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day: Loss of enjoyment in work and even the anticipation of her annual cruise.
  3. Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day: Reported 15-pound weight loss in 2 months and lack of hunger.  
  4. Insomnia or hypersomnia nearly every day: Reports sleeping many hours but still feeling tired (hypersomnia).
  5. Fatigue or loss of energy nearly every day: A prominent complaint, impacting her ability to perform daily tasks.
  6. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick): Expresses feelings of being a "bad person."  
  7. Diminished ability to think or concentrate, or indecisiveness, nearly every day: Feels overwhelmed and disorganized with her work.
  8. (A) Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down): While not explicitly stated, her lack of energy and slowed engagement could indicate psychomotor retardation.  
  9. (Not explicitly mentioned in the provided text, but important to assess): Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide. This needs to be specifically screened for.  

• DSM-5 Code for Major Depressive Disorder, Single Episode, Moderate Severity (assuming the symptoms significantly impact her functioning): F32.1

• ICD-10 Code for Major Depressive Disorder, Single Episode, Moderate: F32.1

Differential Diagnoses:

Other conditions that could present with some overlapping symptoms and need to be considered include:

• Adjustment Disorder with Depressed Mood (F43.21 / 309.0): This involves a maladaptive reaction to an identifiable stressor within three months of its onset, with symptoms remitting within six months after the stressor has ceased. While Tax Day could be a stressor, Kel's symptoms seem pervasive and ongoing beyond a typical adjustment period.
• Persistent Depressive Disorder (Dysthymia) (F34.1 / 300.4): This involves a chronically depressed mood for at least two years (one year in children and adolescents), with at least two other symptoms of depression. While some symptoms overlap, the reported significant functional impairment and recent marked changes suggest MDD might be more accurate. However, further history is needed to rule out a longer-standing low-grade depression that has worsened.
• Generalized Anxiety Disorder (GAD) (F41.1 / 300.02): While anxiety can sometimes present with fatigue and difficulty concentrating, the prominent sadness, loss of interest, feelings of worthlessness, and significant weight loss are more indicative of a depressive disorder.
• Hypothyroidism (E03.9 / 244.9): This medical condition can cause fatigue, weight gain (though weight loss is possible), depression-like symptoms, and cognitive difficulties. Medical workup, including thyroid function tests, is essential to rule this out.
• Anemia (D50-D64 / 280-285): Various types of anemia can lead to fatigue, weakness, and sometimes mood changes. A complete blood count (CBC) can help rule this out.
• Bipolar Disorder (F31.x / 296.xx): While the current presentation points towards depression, it's crucial to inquire about any past episodes of elevated mood, energy, or impulsivity (mania or hypomania) to rule out bipolar disorder. A diagnosis of bipolar disorder requires a history of manic or hypomanic episodes.

3. Formulate and Prioritize a Treatment Plan:

The treatment plan for Kel should be multimodal and individualized. The initial priorities are to ensure her safety and address the acute depressive symptoms.

Prioritized Treatment Plan:

1. Safety Assessment:

   • Immediate and direct assessment for suicidal ideation, intent, and plan. This is the highest priority due to her expressed hopelessness and sadness. If suicidal ideation with a plan is present, immediate safety measures are required (e.g., hospitalization, safety contract, involving emergency services).
   • Assess for any immediate self-neglect issues (e.g., inability to care for basic needs like eating and hygiene) that require immediate intervention.

2. Comprehensive Diagnostic Evaluation:

   • Thorough psychiatric evaluation: This includes a detailed history of her current symptoms, past psychiatric history, family psychiatric history, substance use history, medical history, social history, and a mental status examination.
   • Physical examination: To rule out any underlying medical conditions contributing to her symptoms (e.g., thyroid issues, anemia).
   • Laboratory tests: Including a complete blood count (CBC), thyroid function tests (TSH, T4), and potentially other tests as indicated by the physical exam and history.

3. Pharmacological Intervention:

   • Initiation of antidepressant medication: Based on the diagnostic evaluation and considering factors like side effect profile, past response (if any), and patient preference. Selective Serotonin Reuptake Inhibitors (SSRIs) or Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) are often first-line treatments for MDD. The nurse practitioner (NP) will need to consider the appropriate starting dose and monitor for therapeutic effects and side effects. It's crucial to educate Kel about the delayed onset of action (typically 4-6 weeks for significant improvement) and potential side effects.

4. Psychotherapeutic Intervention:

   • Referral for psychotherapy: Cognitive Behavioral Therapy (CBT) and Interpersonal Therapy (IPT) are evidence-based psychotherapies for depression. Therapy can help Kel identify and modify negative thought patterns, develop coping skills, improve interpersonal relationships, and address underlying emotional issues.  

5. Psychoeducation:

   • Educate Kel and her sister about Major Depressive Disorder: Explain the symptoms, causes, treatment options, and the importance of adherence to the treatment plan. Address stigma and encourage open communication.

6. Support System Involvement:

   • Encourage Sue's involvement (with Kel's consent): Family support can be crucial in recovery. Educate Sue on how to provide support and recognize warning signs.

7. Monitoring and Follow-up:

   • Regular follow-up appointments: To monitor Kel's response to medication and therapy, adjust treatment as needed, assess for side effects, and provide ongoing support. The frequency of follow-up will depend on the severity of her symptoms and the stage of treatment.

8. Lifestyle Modifications:

   • Encourage healthy habits: As Kel's energy improves, encourage regular sleep patterns, balanced nutrition, and gentle physical activity.

4. Identify and Discuss Appropriate Screening Instruments for a Patient Who Has Suicidal Ideation:

When a patient presents with or is suspected of having suicidal ideation, thorough screening is crucial to assess the risk level and guide intervention. Appropriate screening instruments and assessment techniques include:

• Direct Verbal Inquiry: The most fundamental step is to directly ask the patient about suicidal thoughts. Avoid euphemisms and be direct and clear:

  • "Have you been having thoughts of wanting to hurt yourself or end your life?"
  • "Have you been thinking about suicide?"
  • "How often do these thoughts occur?"
  • "Do you have a plan for how you would attempt suicide?"
  • "Do you have access to the means to carry out your plan?"
  • "Have you taken any steps to prepare for suicide?"
  • "What are your reasons for living?"
  • "Do you have any hope for the future?"

• Standardized Suicide Risk Assessment Scales: These tools can help quantify the level of risk and provide a more structured assessment. Examples include:

  • Columbia-Suicide Severity Rating Scale (C-SSRS): A widely used scale that assesses the severity of suicidal ideation and behavior. It has different versions for various settings and age groups. It explores the intensity and frequency of suicidal thoughts, presence of a plan, and any past suicidal behavior.
  • Beck Scale for Suicide Ideation (BSI): A 21-item self-report questionnaire that assesses the intensity of suicidal ideation.
  • Suicide Ideation Questionnaire (SIQ): A self-report measure designed to assess the frequency of suicidal thoughts in adolescents and adults.
  • Patient Health Questionnaire-9 (PHQ-9): While primarily a depression screening tool, item 9 specifically asks about thoughts of being better off dead or hurting oneself. A positive response necessitates further, more detailed suicide risk assessment.

• Clinical Interview and Observation: Beyond standardized scales, the NP should conduct a thorough clinical interview to gather contextual information and observe the patient's demeanor:

  • History of suicidal ideation or attempts: Past history is a significant risk factor.
  • Mental status examination: Assess mood, affect, thought content (including suicidal thoughts), thought process, judgment, and insight.
  • Presence of psychiatric disorders: Depression, bipolar disorder, anxiety disorders, substance use disorders, and personality disorders are associated with increased suicide risk.

Sample Answer

Describe the Presenting Problems:

Kel presents with a constellation of significant changes across several domains of her life, indicating a potential mental health issue. The key presenting problems include:

• Emotional/Mood Changes:
  • Persistent sadness and hopelessness ("sad and hopeless. Nothing is ever going to change.").
  • Flat affect and monotone voice, as observed by her sister.
  • Loss of interest and pleasure in previously enjoyed activities (dreaming of a cruise, enjoying her work).
  • Feelings of worthlessness and self-blame ("I am a bad person and I can’t even do my work right.").
• Behavioral Changes:
  • Significant decrease in energy levels, making even basic tasks "too labor intensive."
  • Withdrawal from social interactions (ignoring calls and emails from friends, not talking to co-workers, not initiating client contact).