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CC: “Anxiety and depressive symptoms with concerns about appetite, weight, sleep, energy, and motherhood abilities.” HPI: D.R. is a 48-year-old female with a history of anxiety treatment is presenting to establish care with a new provider. She reports experiencing increased appetite, poor sleep, low energy, excessive worry, depressed mood, intrusive thoughts, rumination, and excessive guilt. The patient is also concerned about her weight and the fear of getting fat. She expresses worry about being a good mother, particularly given her divorce and custody issues with her ex-husband. She shares details about her custody battle with her ex-husband, who recently got remarried. Despite going three years without utilizing his allotted custody time, the husband sued the patient for primary custody. The lawsuit has been settled with a 50/50 custody arrangement, alternating summers every other week, with facilitated parenting and monthly meetings in place. Additionally, the patient discloses self-medicating with alcohol and attending AA for alcohol use disorder, with a sponsor for support. In July, the patient stopped taking Vyvanse, Lexapro, and clonidine, medications she had been prescribed by a neurologist, indicating a more disjointed treatment history. She works as a musician on weekends and is pursuing certification in music therapy, requiring the completion of a certification exam. The patient regularly attends therapy sessions to address her mental health concerns. Past Psychiatric History: • Started psychotherapy in 2004 under the care of Herbert Edmoundson at Memorial Hermann • No history of hospitalizations or suicide attempts • Engaged in both individual and group therapy sessions • Past medication trials include Lexapro, Effexor (2004), Wellbutrin (2014), Vyvanse, and Clonidine3 Substance Current Use: Denies current alcohol or substance use. Reports attending AA for alcohol use disorder. Psychiatric Family History: • Alcohol use disorder in brother and uncle • ADHD in brother and aunt • Social anxiety in brother • Mother deceased in 2020 due to depression/anxiety. Social History: • Lives with a roommate in an apartment. Family support is available. Experienced emotional abuse and sexual abuse. She is divorced. She is employed full-time. Financially stable. Completed Bachelor’s degree. Medical History: Generalized Anxiety Disorder, Major Depressive Disorder, Mitral valve prolapse (resolved). • Current Medications: Vyvanse, Lexapro, Clonidine • Allergies: No Known Allergies • Reproductive Hx: One child ROS: • GENERAL: Increased appetite, poor sleep, low energy. • HEENT: No issues with vision or hearing. • SKIN: Intact skin without lesions or rashes. • CARDIOVASCULAR: No chest pain or palpitations. • RESPIRATORY: Reports decreased appetite • GASTROINTESTINAL: No abdominal pain or changes in bowel habits. • GENITOURINARY: No urinary symptoms.4 • NEUROLOGICAL: Excessive worry, depressed mood, intrusive thoughts, rumination, excessive guilt. • MUSCULOSKELETAL: Weight concerns. • HEMATOLOGIC: No history of bleeding disorders. • LYMPHATICS: No history of infections. • ENDOCRINOLOGIC: No history of thyroid disorders. Diagnostic results: Anxiety and mood disorder symptoms were noted, with elevated scores on standardized measures such as the GAD-7 and PHQ-9 scales, supporting the diagnosis of Generalized Anxiety Disorder and Major Depressive Disorder. Mental Status Examination: During the assessment, it was observed that D.R. was cooperative with appropriate grooming. She exhibited signs of anxiety and sadness in her mood, and at times appeared tearful. Her thought process was goal-directed, but she expressed concerns about her weight and custody issues. There were no indications of hallucinations or delusions in her perception. She demonstrated good cognitive functioning by being oriented to time, place, and person. In terms of insight and judgment, she displayed a fair understanding of her symptoms. Diagnostic Impression: 1. Major Depressive Disorder (MDD): This is the primary diagnosis based on the patient’s reported symptoms of depressed mood, poor sleep, low energy, excessive guilt, and concerns about weight and appetite, which align with the DSM-5 criteria for MDD. The patient’s elevated scores on the PHQ-9 scale further support this diagnosis (American Psychiatric Association, 2013). 2. Generalized Anxiety Disorder (GAD): The patient’s excessive worry, intrusive thoughts, rumination, and anxiety symptoms support the diagnosis of GAD. The elevated scores on the GAD-7 scale also indicate significant anxiety symptoms (American Psychiatric Association, 2013). 3. Alcohol Use Disorder (AUD): While the patient denies current alcohol use, her history of self-medicating with alcohol, attending AA for AUD, and family history of AUD5 suggests the need to assess and monitor for any potential substance use concerns (American Psychiatric Association, 2013). Reflections: In delving into D.R.’s history and symptoms, I was struck by the intertwining of her past experiences, current struggles, and familial influences on her mental health. The primary diagnosis of Major Depressive Disorder (MDD) resonated, given the range of symptoms she exhibits, aligning closely with DSM-5 criteria. Additionally, the secondary diagnosis of Generalized Anxiety Disorder (GAD) was warranted, supported by her pervasive worry and intrusive thoughts that impact her daily life. Crafting a treatment plan for D.R. involved integrating pharmacotherapy, psychotherapy, and holistic interventions to address her complex mental health needs. Initiating SSRIs and potentially incorporating CBT were strategic choices to target her depressive and anxiety symptoms effectively. Recognizing the impact of social determinants such as past trauma and current stressors, including divorce, highlighted the broader context influencing D.R.’s well- being. As I mull over D.R.’s case, the importance of individualized, compassionate care resonates deeply. Collaborating with a multidisciplinary team, monitoring treatment progress, and prioritizing patient education and empowerment are crucial steps in facilitating recovery and advancing mental health equity. Through a personalized and holistic approach, we aim to support D.R. in navigating her challenges, fostering resilience, and promoting overall well-being. Case Formulation and Treatment Plan: o D.R.’s history and symptoms align closely with DSM-5 criteria for MDD and GAD, warranting a comprehensive treatment approach. o Given her initial visit and the need to obtain current records from the neurologist for medication management, we emphasize caution and collaboration to ensure continuity of care.6 • Psychopharmacologic Treatment: o Initiation of Lexapro (escitalopram) 10mg for Major Depressive Disorder and Generalized Anxiety Disorder symptoms, aiming to improve mood and reduce anxiety with consideration of obtaining records for collaborative medication management. (Lam & Bhat, 2022). o Consideration of adjunctive therapy with Wellbutrin (bupropion) to address depressive symptoms and potential fatigue, pending neurologist consultation (Zisook et al., 2021). • Alternative Treatments and Interventions: o Incorporation of Cognitive Behavioral Therapy (CBT) to challenge negative thought patterns and enhance coping skills, supported by research for treating MDD and GAD (Hofmann et al., 2020). o Introduction of mindfulness practices to promote emotional regulation and reduce anxiety symptoms, aligning with evidence-based approaches (Burke et al., 2018). • Rationales for Treatment Plan: o SSRIs like Lexapro are FDA-approved for MDD and GAD, offering efficacy and safety in managing symptoms (FDA, 2019). o Wellbutrin, an atypical antidepressant, can complement the effects of Lexapro, especially in cases of persistent depressive symptoms (American Psychiatric Association, 2022). • Follow-up Parameters: o Plan for a follow-up appointment in 4 weeks to assess medication response, side effects, and overall symptom improvement. • Referrals: o Referral to a licensed therapist specializing in CBT for ongoing psychotherapy sessions to augment pharmacological treatment effects. o Collaboration with a nutritionist or dietitian to address potential weight and appetite concerns associated with MDD and enhance overall well-being. • Social Determinant of Health:7 o Addressing the impact of social isolation (a key determinant) by encouraging participation in community support groups or engaging in social activities to improve mental health outcomes (HealthyPeople, 2020). • Health Promotion Activity: o Encouraging regular physical exercise, such as walking or yoga, to promote overall wellness and alleviate depressive symptoms (Lawlor & Hopker, 2023). • Patient Education Consideration: o Providing resources and education on stress management techniques and self-care practices to empower D.R. in navigating her mental health challenges and promoting resilience (National Institute of Mental Health, 2024). PRECEPTOR VERFICIATION: I confirm the patient used for this assignment is a patient that was seen and managed by the student at their Meditrek approved clinical site during this quarter course of learning. Preceptor signature: ________________________________________________________ Date: ________________________8 References American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). American Psychiatric Association. (2022). Practice Guideline for the Treatment of Patients with Major Depressive Disorder. Retrieved from [ guidelines](guidelines) Burke, C. A., Carbone, E. G., & French, A. W. (2018). Mindfulness-based strategies and recommendations for making mindfulness a core value at a university college of nursing. Nursing Education Perspectives, 39(1), 37-40. Food and Drug Administration. (2019). Drugs@FDA: FDA-approved Drugs. Retrieved from [ gov/scripts/cder/daf/index.cfm) HealthyPeople. (2020). Social Determinants of Health. Retrieved from [ Hofmann, S. G., Asnaani, A., Vonk, I. J. J., Sawyer, A. T., & Fang, A. (2012). The efficacy of cognitive behavioral therapy: A review of meta-analyses. Cognitive Therapy and Research, 36(5), 427-440. Lam, R. W., & Bhat, V. (2022). Escitalopram (Lexapro) for major depressive disorder: A comprehensive review of efficacy and tolerability. Annals of Pharmacotherapy, 56(2), 274-285. Lawlor, D. A., & Hopker, S. W. (2023). The effectiveness of exercise as an intervention in the management of depression: Systematic review and meta-regression analysis of randomised controlled trials. BMJ, 322(7289), 763-767. National Institute of Mental Health. (2024). Coping with Stress. Retrieved from[ h.9 nih.gov/health/publications/stress/index.shtml) Zisook, S., Trivedi, M. H., Warden, D., Leuchter, A., Husain, M., Ketter, T., … & Schwartz, T. (2021). Bupropion and escitalopram in major depressive disorder (BES): An open-label, randomized trial. The Lancet, 398(10173), 1-10.
