MR is a 67-year old white female with a bachelor’s degree and a retired social worker after a successful career that spanned over three decades. She is a mother of three children, and she mentions that she has established a great relationship with all of them. She feels so proud of the years she spent serving communities as a social worker, and she finds a sense of pride in spending time with her grandchildren. However, she regrets that she did not go for that master’s and doctorate to become a professor, as she has always loved teaching. She stays alone since all her kids are away from home for work and family. She mentions that the most momentous times in her life are the moment her children were born and her wedding day. The loss that MR has successfully navigated in the past is the death of her husband. MR’s strengths are assertiveness and being organized.
Unhealthy vs. healthy coping mechanisms
Coping mechanisms are activities that people either take unconsciously or consciously to deal with problems, stress, or tough emotions. While unhealthy coping strategies may feel great instantly, they have negative consequences in the end. On the other hand, healthy coping mechanisms do not offer instant gratification but result in positive effects in the end. The unhealthy coping mechanisms function by numbing the senses and avoiding the problems instead of helping understand and process the problem.
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Some of the unhealthy coping strategies include aggression, self-harm, social withdrawal, sleeping too little or too much, procrastination, overeating, and alcohol or drug abuse (Kamimura et al., 2015). On the other hand, healthy coping skills include problem-solving techniques, using social support, relaxation techniques (such as deep breathing), seeking professional help, healthy eating, talking about your problem, reading, going out into nature, doing art, going out with friends, and exercising. One gets to express self-care through healthy coping skills.
MR mentions that she has seen a therapist for professional help and has incorporated meditation and relaxation techniques in her lifestyle. She also says that if she talked to her younger self, she would tell her not to worry about everything because they fall into place eventually and not to be afraid to ask for help and advice, as it does not compromise your fierce independence. (3) Live in the moment, enjoy your experiences, and create memories because good memories take you through the toughest moments in life.
MR scores eight on the Geriatric Depression Case, three on the Fulmer SPICES Assessment, 15 on the Patient Stress Questionnaire, and 19 on the Mini-Mental State Exam.
Integrity vs. Despair
According to Erik Erikson, as human beings age, they pass through developmental stages, which assist them in creating and transforming their personalities (Goodcase & Love, 2017). If a person’s needs are fulfilled and their ego is satisfied, they can move on to the next challenge. For adults at 65 years and above, they tend to look back at their lives in terms of disappointment and merit. Elders must look back and analyze the mistakes that they made as well as the good times they had and the wise decisions that they reached (Goodcase & Love, 2017). They reflect upon the bad and good memories created for many decades. If the elder is satisfied with the life that he or she lived, that is an accomplishment in itself.
MR looks back at her life and identifies the events that she is most proud of as well as those that she regrets. MR scores a five on the ego integrity vs. despair test because while she feels proud of how she juggled family life, raising children and her career, she feels like she got so comfortable as a social worker and failed at becoming a professor as she initially wanted to become one. She has a balance between despair and integrity, and she is willing to work towards a sense of completeness and closure.
Diagnosis
Depression
Based on the scores from the screening tools, MR has depression. Depression can result in significant suffering as well as impaired functioning in day-to-day life. It is important to note that MR has retired recently, and retirement can lead to feelings of depression and not necessarily relaxing and enjoying life with so much pride in the accomplishments. For most individuals, work provides a sense of purpose and usefulness. People desire always to be great providers to their families and stay useful to society (Grossberg, Beck, & Zaidi, 2017). After one retires, they experience a sense of loss of self, especially when they cannot define who they are beyond their work.
There is also the changing dynamics at home. Since the loss of her husband, work has been cushioning MR. She explains how she was diagnosed with depression when her husband died, and that is when she started therapy to help her cope with the trauma. Retirement has been a major cause of stress for her since she has enough time on her hands with so little to do. It is important to note the interconnection between a sense of purpose, a steady routine, and social connections.
MR is slowly learning how to replace these factors with new ones and finding things to keep her socially, physically, and mentally occupied. The process of integrating back into the community has been quite stressful for her. She mentions that whenever her grandchildren are not around, she sometimes feels empty and sad (Grossberg, Beck, & Zaidi, 2017). She also mentions that she is finding it difficult to sleep well at night, loss of appetite, she also feeling alone as she has been thinking about her late husband a lot lately. She feels excessively guilty about some of her life choices.
Anxiety Disorders
While depression is predominant, MR also has a generalized anxiety disorder (GAD). Anxiety is reported when one feels nervous, worried, or afraid about something happening. It is associated with repetitively imagining the worst-case scenarios of situations. Anxiety disorders are reported in three to fourteen percent if older adults above 65 years old (Bower, Wetherell, Mon, & Lenze, 2015). Anxiety affects day-to-day life since it can lead to a decline of physical and mental health as well as a loss of enjoyment in life.
Some of the symptoms that MR has reported include hot flushes, sweating, having trouble sleeping, feeling detached from her physical self and even her surroundings, and increased heart rate. She also mentions that she is feeling overwhelmingly panicky. She is always nervous and afraid that some unlikely events would occur, and she gets afraid when facing certain situations, especially social gatherings (Bower et al., 2015). She also mentions that she is getting startled easily, finding it difficult making decisions; she is not as assertive as she has always been, and she is always avoiding situations, which can cause anxiety-like social gatherings.
Treatment Plan for MR
Pharmacological
Remeron (mirtazapine) 7.5-45mg will be prescribed for MR since she is experiencing poor sleep and appetite. Mirtazapine improves an individual’s mood and feelings of well-being. This antidepressant is tolerable for individuals at 65 years and above, especially those with appetite and sleep difficulties.
Non-pharmacological
Psychotherapy
Co-administering psychotherapy and pharmacotherapy are very effective when treating depression and anxiety disorders among older adults. I would recommend problem-solving or cognitive therapy for MR. These therapies assist people in establishing how the past and present aspects may have influenced their anxieties or depression and edify them on the most effective way of dealing with them (Holvast et al., 2017). The interventions can assist people in establishing the negative and distorted patterns that influence the feelings of hopelessness and helplessness that are linked to anxiety disorders and depression.
Lifestyle modifications
Some of the lifestyle changes that I will recommend for MR include healthy eating and exercise. During exercise, the body is triggered to produce serotonin and endorphins, which are neurotransmitters that ease depression symptoms (Hua et al., 2015). Physical activity also establishes a sense of empowerment, boosts self-confidence, increases self-esteem, and develops social relations and connectedness, all of which have a positive influence on depression.
With a healthy diet, MR is supplied with the nutrients necessary for the neurotransmitter production and reduction of anxiety and depression symptoms. She should also stop drinking alcohol; establish a regular bedtime routine to enhance the quality and amount of sleep she acquires. She needs to incorporate some mental training techniques such as positive and meditation for her to be more resilient, happier, and calmer. Getting a social support system will assist her to minimize the feelings of loneliness and social isolation (Hua et al., 2015). A solid spiritual bearing may also assist her in getting a sense of meaning even in the toughest situations.
Patient Education
I will teach her about depression, its treatment, ongoing symptoms monitoring, and the importance of adhering to the treatment plan (Sadock et al., 2017). I will remind her about the medications, how to take them, and the side effects that she needs to watch out for.
Follow-up
I will recommend the patient to come back for a follow-up visit after two weeks to evaluate treatment adherence, any medication side effects, and prognosis of the anxiety disorder and depression. During the visit, suicide risk will also be evaluated. MR will then come for monthly follow-ups until remission.
Referral
In the event the symptoms persist, I will refer the patient to other mental health disorders, including (psychiatrists, psychologists, psychiatric nurses, and social workers) for further assessment.
References
Bower, E. S., Wetherell, J. L., Mon, T., & Lenze, E. J. (2015). Treating anxiety disorders in older adults: current treatments and future directions. Harvard Review of Psychiatry , 23 (5), 329-342.
Goodcase, E. T., & Love, H. A. (2017). From despair to integrity: Using narrative therapy for older individuals in Erikson’s last stage of identity development. Clinical Social Work Journal , 45 (4), 354-363.
Grossberg, G. T., Beck, D., & Zaidi, S. N. Y. (2017). Rapid depression assessment in geriatric patients. Clinics in Geriatric Medicine , 33 (3), 383-391.
Holvast, F., Massoudi, B., Voshaar, R. C. O., & Verhaak, P. F. (2017). Non-pharmacological treatment for depressed older patients in primary care: A systematic review and meta-analysis. PloS one , 12 (9), e0184666.
Hua, Y., Wang, B., Wallen, G. R., Shao, P., Ni, C., & Hua, Q. (2015). Health-promoting lifestyles and depression in urban elderly Chinese. PloS one , 10 (3), e0117998.
Kamimura, A., Ashby, J., Jess, A., Chernenko, A., Tabler, J., Trinh, H. N., & Reel, J. J. (2015). Stress, coping strategies, and depression–uninsured primary care patients. American Journal of Health Behavior , 39 (6), 742-750.
Sadock, E., Perrin, P. B., Grinnell, R. M., Rybarczyk, B., & Auerbach, S. M. (2017). Initial and follow‐up evaluations of integrated psychological services for anxiety and depression in a safety net primary care clinic. Journal of Clinical Psychology , 73 (10), 1462-1481.
