Diagnosis
The patient presents with symptoms of depression and anxiety. First, the patient has difficulty falling asleep. Secondly, he has lost interest in routine activities, as evidenced by his lack of interest in family affairs and quitting his volunteer job. Thirdly, the patient reports a feeling of hopelessness as indicated by his feeling like he is moving in slow motion and spending most of his day time lying on the couch. When questioned, the patient revealed that his depression and anxiety were triggered by the imminent death of his father, whom he considers as his primary support. Earlier in the year, he also received psychotherapy for his living in denial upon learning that he is living with prostate cancer. However, the patient reports that he has no history of psychiatric disorders and that he has never had suicidal tendencies. Based on the facts stated above, it is evident that the patient has situational depression (Pietrangelo, 2018). This type of depression is triggered by, among other issues, the death of a loved one, having a serious illness, and facing a life-threatening event (Pietrangelo, 2018).
DSM-V Coding
According to the DSM-V codes, situational depression can be classified as a trauma- and stress-related disorder and further as an adjustment disorder for the following reasons. First, the patient reported emotional and behavioral symptoms as a result of his father’s imminent death and on learning that he has prostate cancer. Secondly, the two stressful events have led to extremely high levels of depression that the patient can no longer take part in routine activities. Lastly, his symptoms are not part of a pre-existing mental disorder or normal grief. Based on the results of the mental examination, the DSM-V coding for the diagnosis is 309.4(F43.25) since he portrays a mixed disturbance of emotions and conduct (Substance Abuse and Mental Health Services Administration (SAMHSA), 2016). For instance, his affect and mood show him as being depressed and anxious while his thought processes show that he is goal-directed but guilty at the same time. Though he concentrated during the entire diagnosis process, he reports having difficulty with concentration and paying attention when reading.
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Tests/Tools for Correct Diagnosis
Since there are no standard laboratory tests for diagnosing depression, the best tools for diagnosis are symptom-based rating scales. In this case, either the Zung Self-Rating Depression Scale (SDS) and Zung Self-Rating Anxiety Scale (SAS) or the Depression Anxiety Stress Scale (DASS) can be used (Dunstan et al., 2017). Similarly, the Geriatric Depression Scale (GDS) can be used to determine a differential diagnosis (Ng et al., 2016). The GDS, in this case, would help to determine whether the self-reported symptoms are as a result of aging and age-related illnesses such as Alzheimer’s disease.
Treatment Strategy
People with a history of depression, those with chronic conditions, and those who have witnessed a recent stressful event are at risk of developing a major depressive disorder. Therefore, the treatment strategy employed in this case should be one that prevents the patient from developing a major depressive disorder. Through the support of his son and other family members, the patient should be encouraged to engage in extracurricular activities such as taking a dance lesson. The family should also introduce routine activities such as praying together to minimize the patient’s solitude. The family members should always monitor the patient closely to prevent him from self-harm.
Psychopharmacology
The drug that the patient is currently using, Lorazepam, has some adverse cognitive effects that last for up to five hours after the oral administration (Pomara et al., 2015). Therefore, I would recommend the discontinuation of the current medication and prescribe Nervoheel N 1 mg BID for an initial four weeks. According to evidence-based research, Nervoheel N is a better alternative for Lorazepam, especially for patients with mild depression, insomnia, and fatigue (van den Meerschaut & Sünder, 2007; Hubner et al., 2009).
Psychotherapy and Psychoeducation
In addition to pharmacotherapy, cognitive behavioral therapy (CBT) will be introduced to help the patient cope with his condition. CBT helps the patient understand and identify negative behaviors that might cause sadness and anxiety (Health Quality Ontario, 2017). In the end, it helps them change their behavior and be able to cope with their difficult situations. Regarding psychoeducation, the patient will be provided will relevant booklets and videos to help them learn how to cope with their condition. They will also be advised to talk virtually with their caregiver every week.
Standard Guidelines to Treat or Assess this Patient
Gautam and others (2017) recommend the following standard procedures. First, obtain the patient’s full history with information from all possible sources, conduct a physical examination to check for any underlying conditions, and conduct a mental health examination. The next step involves obtaining correct diagnosis using DSM-IV and DSM-V and conducting a differential diagnosis to rule out secondary diseases such as bipolar disorder. Thirdly, the symptoms should be evaluated according to their severity. Afterward, the caregivers are assessed to determine their knowledge on the impacts, and their attitudes and beliefs towards the condition. The patient should also be assessed to determine whether they are under any medications if they are adhering to medications, the presence of side effects, and other health care needs. Lastly, standardized self-rating scales are used to rate the disease.
Clinical Note
Depression is a normal part of aging, particularly for patients with chronic conditions such as cancer.
References
Dunstan, D.A., Scott, N., & Todd, A.K. (2017). Screening for anxiety and depression: reassessing the utility of the Zung scales. BMC Psychiatry, 17 (1), 329-337. https://doi.org/10.1186/s12888-017-1489-6
Gautam, S., Jain, A., Gautam, M., Vahia, V. N., & Grover, S. (2017). Clinical practice guidelines for the management of depression. Indian Journal of Psychiatry, 59 (Suppl 1): S34–S50. https://doi.org/10.4103/0019-5545.196973
Health Quality Ontario. (2017). Psychotherapy for major depressive disorder and generalized anxiety disorder: A health technology assessment. Ontario Health Technology Assessment Series, 17 (15), 1–167.
Hubner, R., van Haselen, R., & Klein, P. (2009). Effectiveness of the homeopathic preparation Neurexan (R) compared with that of commonly used Valerian-based preparations for the treatment of nervousness/restlessness - An observational study. The Scientific World Journal 9 , 733-45. https://doi.org/10.1100/tsw.2009.95
Ng, C. M., Med, How, C. H., & Ng, Y. P. (2016). Major depression in primary care: making the diagnosis. Singapore Medical Journal, 57 (11), 591–597. https://doi.org/10.11622/smedj.2016174
Pietrangelo, A. (2018, September 25). 9 types of depression and how to recognize them. Healthline. https://www.healthline.com/health/types-of-depression#major-depression
Pomara, N., Lee, S. H., Bruno, D., Silber, T., Greenblatt, D. J., Petkova, E., & Sidtis, J. J. (2015). Adverse performance effects of acute lorazepam administration in elderly long-term users: pharmacokinetic and clinical predictors. Progress in Neuro-Psychopharmacology & Biological Psychiatry , 129–135. https://doi.org/10.1016/j.pnpbp.2014.08.014
Substance Abuse and Mental Health Services Administration (SAMHSA). (2016). Impact of the DSM-IV to DSM-5 changes on the national survey on drug use and health . SAMHSA.
Van den Meerschaut, L., & Sünder, A. (2007). The homeopathic preparation Nervoheel N can offer an alternative to Lorazepam therapy for mild nervous disorders. Evidence-based Complementary and Alternative Medicine, 6 (4), 507-15. https://doi.org/10.1093/ecam/nem144
