History Of Presenting Complaint

The presenting case is of Nancy, a 27 year married woman living with her husband and their two sons.  Nancy does not work and her husband does casual work. Nancy was admitted in mental health acute inpatient ward after her husband was concerned about her deterioration in her mental state. Husband reported 2 weeks of insomnia, withdrawn behaviour, flattened mood and suicidal ideation. Every day she has been burdening her husband with worries and excessive care.  She has been crying and feeling sad.  She has lost interest in the day to day activities.  Nothing seems to excite her not even the joy of her children.  All social activities she used to attend are now a thing of the past and looks forward to nothing important in life. Physically she has not been able to lose her weight and she weighs about 20 more than her recommended⁵.  She is a heavy eater and most are fast food and a fatty diet.  She has become fatigued and loses energy after short errands.  She has been nervous and felt worthless and guilty. She has become indecisive and has been unable to make sound decisions. On admission she reported suicidal thoughts with not plan to act on them.

Neurologically the patient reports no significant history of the problems during her growth.  Nancy was born in a family of 4, younger brother, younger sister, a father who is 57 years and a mother who is 52 years. Her childhood history is characterised by instability and stressful episodes.  Her parents engaged in domestic violence frequently due to her mother binge drinking.  The family separated when she was 11 years and the mother vanished for several years. Nancy’s mother used to communicate with them over the phone but she did not seek time to visit them. She returned when Nancy was 18 years. Being the eldest sibling took responsibility of raising her younger siblings and other house chores.  Nancy reported a period of desperation when her mother was away. She started feeling neglected and overworked. Her father took the full obligation of taking care of the children financially.  He used to work for prolonged hours and seemed frustrated. Nancy always feared to communicate her frustrations and feelings before the father and since she felt he was not strong enough to take more stress.  By the age of 19 years, she was involved with the boyfriend and married. The had their first child when she was 22.

Patient History / Family And Social History

Nancy experienced a minor accident in the house that hurt her back. As a result, she has not been going to the work and her employment contract has been terminated. She is not expressing concerns of increased family burdens due to lack of enough finances.  Presentation Of Major Depressive Disorder In Nancy Case Study

Nancy reported beginning treatment of post-partum depression 7 months ago after the birth of her second son.  Depression started when the patient realized she was pregnant and that continued after the child was born.  The first three months of her pregnancy, Nancy felt like crying all the time, reduced energy, sad, and tired.  She had lost control of her life.  She sought medical help after suffering from the same feelings post the birth of her son. Her GP prescribed six months dose of Paxil at 20mgs and Zoloft 50mg daily. Nancy ended up discontinuing the medication upon realising that her situation was not getting better. According to her, she experienced no significant difference before and after the medication and she experienced dry mount from both medication. But she admits that she slept better.  Nancy complained of persistent menstrual flows that go for nine days.  In addition, Nancy complained to have been on birth control pills when she conceived her second son.  She, therefore, refers to herself as a statistic among which pills do not work.

People with depression, panic attacks and anxiety disorders tend to have an unbalanced chemical in the brain known as serotonin. The Paxil tablet rectifies this imbalance and thereby helps calm the patient. Paxil is therefore meant for treating depression, Post-traumatic stress disorder (PTSD), anxiety disorders and premenstrual syndrome ^9.

Zoloft belongs to the category of drugs called selective serotonin reuptake inhibitors (SSRIs). It is used to balance the serotonin substance in the brain. Zoloft treats depression, anxiety and obsessive compulsive disorders ^9.

Basing on the presented findings Nancy was diagnosed with a moderate single-episode major depressive disorder. Nancy was placed on inpatient treatment order level 1 (ITOL1) following medical assessment. She was initially refusing treatment stating that she wanted to go home.   Her conditions are showing features of major depressive disorder. Major depressive disorder is a mental health condition that is characterised by persistently depressed mood or loss of interest in activities affecting activities of daily living ¹³ . She has reported lack of pleasure and losing interest in the main events in her life.  She is also complaining of changed sleeping patterns. She is experiencing guilt and lack of self-worth.  In this regard, her decision-making process is impaired and she is not able to concentrate.  She has no suicidal attempts but expresses concerns of wanting to escape from her current situations. Nancy has been experiencing the depressions symptoms for more than two weeks in a row.  It has created a major deficit in her functioning, occupational and social life ⁵. She is hopeless and always sad. This positions her to cry often.  Therefore, depressions signs such as phobias, somatic complaints, anxiety and worrying are present. Her presenting signs and symptoms are for those patients suffering from Major Depressive Disorder.  However, she has not reported cases such as hypomanic or manic.  Her prevailing symptoms are not associated with the physiological impact of a medical condition or substance abuse.  Nancy has not suffered any bereavement and no death has been reported in her family or friends.  She does not show evidence of psychomotor retardation or psychotic symptoms.

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Psychiatric / Medical History

Basing on the above findings, therefore, the case of dysthymic disorder is not applicable since the depression is not yet over two years ⁸.   It is also wise to rule out the incidence of Bipolar since the patients have not shown signs of manic episodes. Medically; no condition seems present to be contributing to the depression. In addition, she does not abuse any substance that could lead to a mood disorder.

It is also wise that we rule out Adjustment Disorder. Adjustment Disorder is associated with somatic complaints, substance abuse, and suicide attempts ¹² . These conditions are not present in Nancy’s case.  Conclusively the patient does not suffer from Adjustment Disorder. Nancy argues that there are some cases of mental illness in the family. Nancy state that her aunt suffered from depression and believes that her mother could be suffering from undiagnosed depression/bipolar.

Nancy requires antidepressant medications especially in the group of Selective Serotonin Reuptake Inhibitors (SSRIs) ⁴. The medication needs to be taken regularly for about six months.  Serotonin is a chemical that is found in the brain and mainly influences a person mood ⁴  .The drug functions by improving sleep and mood.  Individuals like Nancy are exhibiting the low amount of serotonin.  Therefore, the use of SSRI stimulates the production of serotonin in the brain. Citalopram 20mg daily was prescribed. The drug has little side effect and according to the diagnostic history of Nancy, she is supposed to tolerate the effects.  In case the drugs will not be effective after two weeks in the third-week review it will be recommended for Nancy to try Tricyclic antidepressants. Tricyclic antidepressants are usually considered for those whos depression is resistant to other drugs ¹¹. However, the medication comes with side effects that mainly cause sleeplessness and weight gain.  Nancy is not nursing her child after episodes of depression she opted out. Therefore, the medication is safe for her consumption

Oral medication will be preceded by psychotherapy which means talk therapy with the psychologist ¹⁴.  It is expected to make the oral medication more effective for Nancy.  The psychotherapies are scheduled after every two weeks but the procedure will change depending on the recovering process.  The therapeutic sessions are expected to help Nancy adjust to the stressful side of her life. It is expected that she will become more positive about life as opposed to negative. The therapies are expected to help Nancy improve in her communication skills and instead of expressing sadness and anger she can channel her views effectively. It is expected that she will increase self-esteem and regain control and satisfaction in her life.

Diagnosis

Nancy will be needed to apply lifestyle changes in addition to the psychotherapy and medications ². It will be effective in improving the symptoms of MDD.  The initial process will be eating foods which are advisable for her to consume diet more of Omega -3 fatty acids salmon.  In addition, is expected that she takes a lot of Vitamin B diets including whole grain and beans which has shown major improvements for others suffering from the major depressive disorder.  A diet full of magnesium found in yoghurt, seeds and nuts is also recommended.  Nancy will be advised not to consume some processed and dried food. It works closely by not consuming alcohol. It will be efficient if Nancy engages in routine exercises in areas that can make her moods better.  Sleep is very important and it will be recommended for her to sleep about 6 to 8 hours on the daily basis. Fish oil 1000mg daily and Thiamine100mg mane was prescribed for Nancy.

Thiamine is essentially vitamin B1. Thiamine can be found in a number of foods such as cereals, beans, nuts, yeast and meat. Its main role in the body is breaking down carbohydrates from foods into products that are needed in the body. Thiamine tablets are used to treat vitamin B deficiency as well as its prevention. Thiamine can be taken orally or through injection¹.

Fish oil belongs to omega -3 polyunsaturated fatty acids. There are several forms of omega -3 acids. Fish is one example whose omega -3 acids is known as DHA and EPA. Other sources, in the form ALA, include vegetable oils and spinach ⁹.

Fish oil lowers the level of blood fat called triglycerides which in huge amounts can lead to coronary artery disease and stroke. Fish oil helps in fighting heart diseases by preventing inflammation and slowing down plaque build-up in your blood vessels ⁹.

Most of the therapy sessions concentrated on the cognitive behaviour which was selected because it has successfully worked to other patients who presented the similar conditions before.  Nancy goals to treatment were splinted down into five sessions.  The first session was the ability to share with the family and enjoy time together.  The second goals were recovering from the sadness and being capable of reducing significantly her dry spells. The third goal was the ability to sleep for longer periods and the ability to be firm while providing a negative response to her friends and families.  The goals were very efficient in offsetting therapeutic sessions.  She was explained about the effectiveness of the cognitive behavioural treatment procedure for depression.  It was accompanied by an activity schedule which she completed to find out whether she achieved the set goals and objectives.   The sheet was helpful for her to evaluate whether the treatment was effective. She was very excited to tick the goal met but developed sadness whenever her goals were not met. It was also an important moment for the nurse to be able to identify her behavioural thoughts and symptoms.  The association of her feelings and thoughts were identified and important issues were discussed with her. The sheet was very impactful in leading her to a period of self-discovery.

Medication / Therapies

Lorazepam belongs to a class of drugs known as benzodiazepines which act on the brain and nerves (central nervous system) to create a calming effect that relieve symptoms of anxiety. Presentation Of Major Depressive Disorder In Nancy Case Study  The drug works by enhancing the effects of a certain natural chemical in the body (GABA). This medication may also be used as a treatment for short-term insomnia ⁷.

Nursing care management will be very important or Nancy.  The nurse shall be applying both the subjective cues and the objective cues. The subjective cues include checking or symptoms like lack of appetite, emotional tensions, drug and substance abuse, fatigue, sleep disturbance, and inability to cope.  The objective cues include the inability to resolve the problem or goal –redirected behaving, engaging in destructive behaviour, and inadequacy in solving problems. After the identification of the problems, the nurse will consider the following management strategies.  Consider whether Nancy is at risk of self-destruction. It means that whether the condition can lead to sexual, emotional, and physical harm.  It can be prevented by encouraging Nancy to seek for assistance whenever she feels the urge to be sad, angry or engage in substance abuse.  In case Nancy is not at risk then the nurse on duty can make an arrangement with the family and learn how to control the crisis.  In this regard, she will be required to network as much as possible to keep her away from excessive thinking.

The nurse must ensure the patient has full education regarding issues of personal hygiene and the self-care ¹³ .  It is advisable to ensure the patient is consuming the right diet. The Nancy must engage in activities that encourage her energy levels.  In addition, she should be encouraged to communicate by sharing her feelings and the response of the medication.  The nurse should also ensure that Nancy has a full education regarding depression and the importance of engaging in pleasurable activities and expressing feelings.  In addition, encourage her to seek effective methods of responding to the on setting symptoms.  The patients require to always signalling the importance of the patient need extra assessment and consultation.

The nurse should check whether the Nancy is responding to the current situations positively.   The patients should have knowledge of understanding the dangers of ineffective coping behaviours and responding to them.  It is also advisable to create awareness of the coping feelings and abilities. It comes hand in hand in being alert in meeting the physiological needs such as the use of resources, identification of options and expression of feelings ³.

Nancy complained of insomnia, low mood, feeling of self-condemnation. Nancy responded well to the cognitive behavioural therapy for the Major Depressive Disorder.  After a few sessions, she showed remarkably improved as shown by the Beck Depression Inventory scores ¹⁰. She is reporting improved physical signs such as feeling happier when making decisions, sleeping better, having more energy, being more active, and feeling better.  She is very optimistic about the recovering process and it is a positive sign that she will eventually recover.

Nancy was a bit negative to the antidepressants before of her previous experience.  She reported a mild dry mouth that showered a more resistant to the medication in the future.  She is very involved in the process of identifying and confronting her cognitive distortions that are a position sign to better manage her depression.  Nancy feels more control of the situation and she is recovering positively to the negative thoughts. She has been able to confront the reality and feels to positively handle her life.  Nevertheless, she has episodes of anger that is expected to reduce significantly as she undergoes more therapies and treatments.

Conclusion

In conclusion, Nancy was suffering from Major Depressive Disorder. She was always crying and complained of sadness. She was not capable of containing her negative feelings that drove her away from the family and friends. Nancy upbringing was unstable and stressful.  Their mother was an alcoholic and engages in verbal fights with the father. She left home when she was a teenager that led her to assume household chores. It is a practice that degraded her position before that of her friends and positioned her to a feel of socially deprived and depressed. She was diagnosed with depression in the early stages of pregnancy that prolonged after pregnancy and hence was termed as postpartum depression. The analysis of her symptoms and the use of the Beck Depression Inventory her depression rate was very high but decreased significantly upon the onset of the treatment. She was administered medical and psychotherapy treatment. The medical treatment contained the antidepressants and the psychotherapy treatment contained the sessions that improved the cognitive behaviours. Finally, it was observed that Nancy was recovering from her depressive symptoms. She became more positive about life and engages with friends and family about her condition. The improvement after several sessions showed her readiness to recover and go back to self.

References

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