MDD - Case Study

by Samuel John, KCC SN

Assessment Data
Identifiers:
Female, 15 yrs
Adm: 01/12/2016
Insur: Tricare

Legal:

MH5 - Voluntary
Admission

DSM Dx:
I: MDD, Recurrent, Mod-toSevere w/ Psychotic
Features; GAD
II: Deferred

Adv Dir: None

III: POTS
Ht: 68.2 in
Wt: 134.2 lbs (61 kg)
BMI: 20.3

IV: Probs w/ Primary

support, Social, Educational
V: GAF at Adm - 40

Reason for Admission

Pt was a transfer from Queens on 1/12/16. She arrived on the Acute unit, and was
subsequently transferred to Residential. LOS will have been approx 6 weeks on 2/24/16.
Estimated discharge date is unknown at this time.
Pt abruptly D/Cd her meds in Oct 2015 without informing parents/caregivers. Her condition
worsened as she began having suicidal ideations and thoughts of hurting others. Both client and
parents voluntarily sought help for these issues.

Financial data, Insurance, Implications

Father is Retired Military. Mother is Teacher. Patient is financially dependent on parents.
Insurance is Tricare (Military health insurance provider).
(From Mental Health FS 2015 pdf) Psychiatric Residential Treatment Center Care
RTC care always requires a referral and prior authorization, because RTC placement is never a psychiatric emergency. Psychiatric inpatient hospitalization should be sought in a
psychiatric emergency. RTC placement sometimes occurs after an inpatient psychiatric hospitalization as a step-down level of care. RTC placement can also be a step-up level of care
when a beneficiary can no longer function at home and in the community. The following rules apply:
Facilities must be TRICARE-authorized.
Unless therapeutically contraindicated, the family and/or guardian should actively participate in the continuing care of the patient through either direct involvement at the facility or
geographically distant family therapy.
Prior authorization from your regional contractor is required.
RTC care is considered elective and is not considered an emergency.
Admission primarily for substance use rehabilitation is not authorized for psychiatric RTC care.
In an emergency, psychiatric inpatient hospitalization must be sought first.
Care must be recommended and directed by a psychiatrist or clinical psychologist.
Limitations:
Care is limited to 150 days per FY or for a single admission.
RTC care is only covered for patients until reaching age 21.
RTC care does not count toward the 30- or 45-day limit for acute inpatient psychiatric care.
Day limitations may be waived if determined to be medically or psychologically necessary.

Pts description of problem

I had general anxiety and severe performance anxiety at school. Ive gotten angrier and thought about
hurting people.

Ethnicity/religious/spiritual concerns &

implications
Ethnic: Caucasian; Pt states - Im white on white on white.
Religion: Episcopalian, Christian
Spiritual: Kind of, questioning things. Parents are Episcopalian
Implications: Pt is in developmental stage of Identity vs. Role Confusion according to Erikson. At
this time she identifies as being very white, a military brat and claims no real home AEB her
statement I grew up pretty much all over. This can be a contributing factor exasperating her
condition, however, can also be a normal aspect of appropriate G&D.

Pts Strength & Limitations

Strengths:
-Creative, artistic
-Enjoys making origami and reading
-Close with family and supported by them
-Goal-oriented
-Aspirations of being preschool teacher
Limitations:
-POTS diagnosis (chronic condition), unwilling to face certain challenges of illness
-Managing physical illness
-Peer relationships
-Psychosocial stressors (highly anxious in school, unable to attend physically)

Medications
-Melatonin 3 mg tabs - 2 tabs PO qHS for Insomnia
(Sedative/hypnotic; Side fx = hypotension, drowsiness, GI; usual dose = 0.3 - 10 mg daily
-Propanolol (Inderal) 40 mg tabs - 1 tab PO BID for POTS *Hold if SBP <100 or DBP <60
(Beta blocker; Side fx = fatigue, weakness, arrhythmias, ortho hypo; usual dose = 40 mg BID initially, up to 120-240
mg/day, max is 1 g/day)
-Buproprion XL (Wellbutrin XL) 150 mg - 1 tab PO qAM for Depression
(Aminoketones/Antidepressant; Side fx = seizures, suicidal T/B, tremor, N/V, agitation, HA; usual dose = 150 mg once qAM,
up to 300 mg/day after 4 days, max 450 mg/day)
-Fluoxetine (Prozac) 10 mg caps - 1 cap PO qAM for Depression
(SSRI/Antidepressant; Side fx = NMS, seizures, suicidal T, Serotonin Syn, diarrhea, HA, itching; usual dose = 10 mg/day,
may be up to 20 mg/day after 2 wk, up to range of 20-60 mg/day after several more wks)
-Multi vitamin - 1 tab PO qAM for Food Supplement
-Sunscreen to exposed skin BID & before pool and/or outing

Medical issues, labs

-UA
-Endocrinology (T4, TSH)
1/14/16 -

Sed Rate = 19 (0-20)

C-reactive Protein = 0.5 (<0.8)

1/13/16 -

UA = Yellow, clear
Spec Grav = 1.019
pH = 6.0
Blood = 1+H
WBC = 0
RBC = 10-50

1/13/16 -

Free T4 = 1.0 (0.9-1.8)

TSH = 2.95 (0.55-4.78)

Leuk Ester = 0
Nitrite = 0
Protein = 0
Bacteria = 0
Casts = 0

Gluc = 0
Ketone = 0
Urobil = Normal
Bile = Neg
Culture = - (a)

Mental Status Assessment

Clients appearance is appropriate to age, environment and situation. Clients hygiene is good. Client
maintains fair eye contact. Clients speech is clear and spontaneous. Client is cooperative, interactive
and engaged in both group and 1-on-1 discussions and activities. Client displays wide range of affect,
congruent to situation and mood. Clients mood is euthymic. Clients thought process is linear, logical and
coherent. Client presently denies any suicidal or homicidal ideations, hallucinations and delusions. Client
is A&O x4, good attention span, memory intact, able to express self and stay on task. Client verbalizes
awareness of own situation. Client identifies psychosocial stressors. Client seeks help, claims she
understands components of treatment.

Hospital Tx Plan
Initial Problems:
-Monitor for Safety
-Clarify Dx
-Obtain collateral info
-Baseline labs
Planned Tx:
-Increase Propanolol from 20 mg to 30 mg. Restart Buproprion XL 150 mg. Continue Fluoxetine 10 mg.
-Outside hours for calls & visits OK but Pt to attend ALL groups & school.
-CBT
Precautions:
-Suicide
-Assault
-Elopement

Discharge plan/community resources

-Return to home
-Continue to work on managing somatic Sx while also participating in program.
-Tx team decided to create Behavioral plan to encourage Pt to participate.
-Family has been consistent in Therapy & working on managing familial conflict.
-Discharge criteria per Pt = Taking control of her anxiety.

Standardized assessment tool(s)/implications

Coppersmith Self-Esteem Inventory (CSEI)
Score: 9
Implication: Very low self-esteem

Coppersmith Self-Esteem Inventory

Pts Sxs vs. DSM criteria

DSM-5 criteria for major depressive disorder
Major depressive disorder (in children and adolescents, mood can be irritable)
5 or more of 9 symptoms (including at least 1 of depressed mood and loss of interest or pleasure) in the
same 2-week period; each of these symptoms represents a change from previous functioning
-Depressed mood (subjective or observed)
-Loss of interest or pleasure
-Change in weight or appetite
-Insomnia or hypersomnia
-Psychomotor retardation or agitation (observed)
-Loss of energy or fatigue
-Worthlessness or guilt
-Impaired concentration or indecisiveness
-Thoughts of death or suicidal ideation or suicide attempt

Nursing process
3 Highest Priorities
1.
2.
3.

Safety
Compliance (Meds, Txs)
Coping

Prioritization r/t Selected Problems

1.

Safety (rationale: priority need based on Maslows hierarchy)

P: Pt is at-risk for self-harm, suicide
E: Pt has verbalized having had thoughts & feelings of SI
S: Assess Pt for SIs, encourage Pt to verbalize if/when feeling or thinking SIs

2.
Compliance (rationale: sudden med discontinuation associated with high risk of condition
worsening, leading to stronger depression, SIs, HIs, etc.)
P: Pt is at-risk for noncompliance with meds/Tx
E: Pts admission precipitated by past history of abruptly D/Cing Meds
S: Teach Pt benefits and risks of medication compliance/noncompliance. Assess and
explore Pts rationale/potential barriers for noncompliance with Meds, along with Side Fxs,
etc.
3.
Coping (rationale: inability to cope associated with negative feelings, behaviors & outcomes, which
can lead to/exacerbate compliance issues leading to safety issues)
P: Pt is having issues with self-esteem
E: Pts own subjective statements, I have low self-esteem.
S: Assist Pt to identify and explore positive strengths and aspects of life to bolster selfesteem

Nursing Diagnoses 1.

Reference: Gulanick, M., & Myers, J. L. (2014). Nursing care plans: Diagnoses,
interventions and outcomes (8th ed.). Philadelphia, PA: Mosby.

Risk for Suicide (p. 185)

P: Pt at risk for self-inflicted, life-threatening injury
E: Verbal cues, severe depression, SI, lack of social resources
S: Pt discloses suicidal thoughts & feelings. Pt agrees to Tx plan to reduce risk for suicidal
behaviors. Pt discloses all impulses to harm self and talks to staff immediately.

2.

Noncompliance (p. 132)

P: Pt behavior is fully or partially nonadherent with health-promoting/therapeutic plan, leading
to clinically/partially ineffective outcomes.
E: Behavior indicative of failure to adhere to a therapeutic recommendation, evidence of
development of complications, evidence of exacerbation of Sxs
S: Pt reports compliance with therapeutic plan. Pt complies with therapeutic plan AEB
evidence of therapeutic effect, appropriate amount of meds taken, and/or fewer hospital
admissions.

3.

Ineffective coping (p. 53)

P: Pt is unable to effectively cope with current stressors, inability to use available resources
E: Verbalization of inability to cope, fatigue, sleep disturbances
S: Pt uses available resources & support systems. Pt describes & initiates effective coping
strategies. Pt describes positive results from new behaviors.

Long-term Goals
Suicide Ideation
Be free of all suicide thoughts/feelings and gestures prior to D/C.
Compliance
Adhere to medication Tx regimen as prescribed and confirm compliance at next follow-up appointment
with PCP in 3-6 months post-D/C.

Short-term Goals
Suicide Ideation
Verbalize at least 2 strengths & positive aspects of life that will assist in working through thoughts of selfharm by 2/27/16.
Compliance
Verbalize control of symptoms r/t POTS by 2/27/16.

Interventions -

Reference: Gulanick, M., & Myers, J. L. (2014). Nursing care plans:

Diagnoses, interventions and outcomes (8th ed.). Philadelphia, PA:
Mosby.

Risk for Suicide

1. Assess all support resources available to Pt
2. Assist Pt with problem-solving in a constructive manner
3. Teach the Pt cognitive-behavioral self-management responses to suicidal thoughts
Noncompliance
1. Assess the Pts individual perceptions of health problems and interest in following the Tx plan
2. Include the Pt in planning the treatment regimen
3. Provide social support through the Pts family and self-help groups
Ineffective coping
1. Assess for specific stressors
2. Encourage the Pt to identify her own strengths and abilities
3. Provide opportunities to express concerns, fears, feelings, and expectations

Rationales (in BOLD) - 1 of 3

Reference: Gulanick, M., & Myers, J. L. (2014).

Nursing care plans: Diagnoses, interventions
and outcomes (8th ed.). Philadelphia, PA:
Mosby.

Risk for Suicide

1.
[Assess all support resources available to Pt]
Pts who are depressed and whose lives are pervaded with a sense of hopelessness may isolate themselves or be
unable to access available resources. The patient contemplating suicide often has few contacts with a meaningful
support system.
2.
[Assist Pt with problem-solving in a constructive manner]
Pts learn to recognize situational, interpersonal, or emotional triggers and learn to assess a problem and
implement problem-solving measures before reacting.
3.
[Teach the Pt cognitive-behavioral self-management responses to suicidal thoughts]
Pts are better able to recognize and respond to early thoughts of suicide. The Pt can be taught to identify negative
self-talk or automatic thoughts that lead to suicidal ideas. Then the Pt learns how to develop positive approaches
and positive self-talk to those negative ideas.

Rationales - 2 of 3
Noncompliance
1.
[Assess the Pts individual perceptions of health problems and interest in following the Tx plan]
According to the Health Belief Model, a patients perceived susceptibility to and perceived seriousness and threat
of disease, along with perceived benefits from adhering to treatment plan, affect compliance. Some Pts may not
understand the chronicity of their disease or their ability to manage some of the ongoing Sxs.
2.
[Include the Pt in planning the treatment regimen]
Pts who become co-managers of their care have a greater stake in achieving a positive outcome. They know best
their personal and environmental barriers to success.
3.
[Provide social support through the Pts family and self-help groups]
Such groups may assist the Pt in gaining greater understanding of the benefits of treatment.

Rationales - 3 of 3
Ineffective coping
1.
[Assess for specific stressors]
Accurate appraisal can facilitate development of appropriate coping strategies. Because a Pt has an altered health
status does not mean the coping difficulties he or she exhibits are only (if at all) related to that. Persistent
stressors may exhaust the Pts ability to maintain effective coping.
2.
[Encourage the Pt to identify her own strengths and abilities]
During crises, Pts may not be able to recognize their strengths. Fostering awareness can expedite use of these
strengths.
3.
[Provide opportunities to express concerns, fears, feelings, and expectations]
Verbalization of actual or perceived threats can help reduce anxiety and open doors for ongoing communication.

Evaluations - (in BOLD)

1. Pt will verbalize intensity & strength of suicide feelings
Pt continues to work on.
2. Pt will adhere to psychotropic medications as prescribed
Pt able to take as prescribed.
3. Pt will identify parts of their life that may be adding to desire to kill self
Pt continues to work on.
4. Pt will identify at least 1 alternative to suicide
Pt is able to.
5. Pt will verbalize strengths & positive aspects of life
Pt continues to work on.
6. Pt will verbalize control of her symptoms r/t to POTS
Pt continues to work on verbalizing and controlling somatic symptoms.

Evidence-based Journal article

Cognitive Behavioural Therapy for Anxiety Disorders in Children and Adolescents.
Article published in 2013.
This review alongside those in adults (Otte 2011) and older adults (Gould 2012) suggests that CBT is effective across the age
range, and CBT can, therefore, be recommended more generally for the treatment of anxiety disorders.
With regard to medication, the evidence is limited: CBT appears to be as effective as SSRI antidepressants, and the combination
therapy appears to be more effective than either treatment alone.
CBT appears equally effective in various formatsfamily, individual and groupwhich poses the question whether group CBT is
possibly more cost-effective.

James, A. C., James, G., Cowdrey, F. A., Soler, A., & Choke, A. (2013). Cognitive behavioural therapy for anxiety disorders in
children and adolescents. Cochrane Database Syst Rev, 6.

The BIG Picture

So my client is a teenager (likely dealing with Identity vs. Role Confusion - Erikson; values Peer
inclusion, Acceptance; could be adversely impacting her being different from the group, unable to
fit-in or participate, increasing isolative feelings), part of Gen-Z (born post-2000, digital natives
constantly plugged-in, less economic security; could impact her feelings of self-worth, self-image,
self-esteem) with a chronic illness POTS (could adversely affect her biological well-being, means
her situation is different from peers, that could negatively affect psychological & psychosocial wellbeing e.g. feelings of major depression, anxiety). She was the baby growing up in a big family of 8
(could affect amount of attention, nurturing she felt she received growing up). She also grew up on
military bases around the globe (could impact her sense of belonging, instability in living situation
could have been disruptive for her G&D) since her dad was in the air force (could be there was a lot
of pressure to perform or high-expectations per military culture or parents-being-parents). She selfidentifies her culture/ethnicity as not really having one, just being like white-white (could negatively
impact her sense of self, feeling as though shes lacking or missing, possibly adding to
depression/anxiety). Her thoughts (Im screwed up, not lucking out with genetics, Ive gotten
angrier and thought about hurting people) give way to feelings of inadequacy, worthlessness,
hopelessness, anger, frustration, anxiety and depression. Her behavior (not taking meds,
withdrawing, isolating, HIs and SIs) might signal a cry for help, rebellion, a desire to throw in the
towel.

Analysis & Suggestions

I believe patients plan of care to be relevant, reasonable, attainable and measurable.
With continued CBT & family therapy I think she will achieve a positive outcome.
I think it will benefit the client to get involved in a social support/therapeutic group, with peers. This can
help develop social ties and help her feel less isolated/alone.
It might help to stay rooted in one place for an extended period to help her develop a sense of
belonging.
I would recommend focusing on her strengths & hobbies/likes (artistic/creative, origami, reading) highlighting, encouraging and nurturing those traits and desires, to promote positive development of her
self-esteem.

Patient Needs
-

Cognitive behavioral therapy to assist in developing and promoting healthy behaviors, responses
A strong, supportive, understanding and encouraging social support system.
Understanding of and involvement in treatment (groups, Meds, etc.)
Stable living environment (avoiding frequent relocations)
Nurturing of likes, talents, skills
Development of healthy interpersonal relationships

My wish is that my client finds happiness, peace and joy in life. That she comes to appreciate, love and
value herself more and more each day. I hope to see her grow in a positive and healthy direction, and
achieve her desires (like being a preschool teacher). I want for her to view herself as those around her do
- a bright and enjoyable person to be around. And my wish is for her to figure out positive ways to deal
with and overcome the struggles that come with having a chronic illness.

References
Gulanick, M., & Myers, J. L. (2014). Nursing care plans: Diagnoses, interventions and outcomes (8th
ed.). Philadelphia, PA: Mosby.
Department of Defense, Defense Health Agency. (2015). Mental health factsheet. Tricare mental health
care services. Retrieved from http://www.tricare.mil/CoveredServices/Mental.aspx
James, A. C., James, G., Cowdrey, F. A., Soler, A., & Choke, A. (2013). Cognitive behavioural therapy
for anxiety disorders in children and adolescents. Cochrane Database Syst Rev, 6.
Uher, R. (2014). Persistent depressive disorder, dysthymia, and chronic depression: Update on
diagnosis, treatment. Psychiatric Times. Retrieved from http://www.psychiatrictimes.com/specialreports/persistent-depressive-disorder-dysthymia-and-chronic-depression