Ms. Z is a 28-year-old assistant store manager who arrives at your outpatient clinic complaining of sadness after her boyfriend of 6 months ended their relationship 1 month ago.

Ms. Z is a 28-year-old assistant store manager who arrives at your outpatient clinic complaining of sadness after her boyfriend of 6 months ended their relationship 1 month ago. She describes a history of failed romantic relationships, and says, “I don’t do well with breakups.” Ms. Z reports that, although she has no prior psychiatric treatment, she was urged by her employer to seek therapy. Ms. Z has arrived late to work on several occasions because of oversleeping. She also has difficulty in getting out of bed stating, “It’s difficult to walk; it’s like my legs weigh a ton.” She feels fatigued during the day despite spending over 12 hours in bed and is concerned that she might be suffering from a serious medical condition. She denies any significant changes in appetite or weight since these symptoms began.

Ms. Z reports that, although she has not missed workdays, she has difficulty concentrating and has become tearful in front of clients while worrying about not finding a significant other. She feels tremendous guilt over “not being good enough to get married,” and says that her close friends are concerned because she has been spending her weekends in bed and not answering their calls. Although during your evaluation Ms. Z appeared tearful, she brightened up when talking about her newborn nephew and her plans of visiting a college friend next summer. Ms. Z denied suicidal ideation.

Remember to answer these questions from your textbooks and clinical guidelines to create your evidence-based treatment plan. At all times, explain your answers.

1. Summarize the clinical case including the significant subjective and objective data.
2. Generate a primary and two differential diagnoses.  Use the DSM5 to support the assessment.  Include the DSM5 and ICD 10 codes.
3. Discuss a pharmacological treatment would you prescribe? Use the clinical guidelines to support the rationale for this treatment.
4. Discuss non-pharmacological treatment would you prescribe?  Use the clinical guidelines to support the rationale for this treatment.
5. Describe a health promotion intervention that would be appropriate for this patient.

ANSWER

Comprehensive Treatment Plan for Major Depressive Disorder: A Case Study Analysis

Clinical Case Summary

Ms. Z, a 28-year-old assistant store manager, presents to the outpatient clinic with complaints of sadness following a recent breakup with her boyfriend. She describes a history of failed romantic relationships and states that she doesn’t handle breakups well. Her employer encouraged her to seek therapy due to her late arrivals at work and difficulty getting out of bed. Ms. Z reports oversleeping, experiencing heavy legs, fatigue, difficulty concentrating, and tearfulness. She expresses guilt over not being good enough to get married and has withdrawn from social activities. Despite these symptoms, she brightens up when discussing positive events in her life and denies suicidal ideation.

Primary Diagnosis

Based on the information provided, the primary diagnosis for Ms. Z is Major Depressive Disorder (MDD), Single Episode, Moderate Severity (DSM-5 code: 296.22, ICD-10 code: F32.1). Ms. Z meets the criteria for MDD, as she has experienced depressed mood, loss of interest or pleasure, fatigue, sleep disturbance, psychomotor retardation, difficulty concentrating, feelings of worthlessness or excessive guilt, and social withdrawal (British Psychological Society (UK), 2010). These symptoms have persisted for at least two weeks and are causing impairment in her daily functioning.

Differential Diagnoses

Adjustment Disorder with Depressed Mood (DSM-5 code: 309.0, ICD-10 code: F43.21): This diagnosis would be considered if the symptoms were a direct response to the recent breakup, and the intensity and duration of the depressive symptoms were not as severe as in MDD.

Dysthymic Disorder (DSM-5 code: 300.4, ICD-10 code: F34.1): This diagnosis would be considered if the depressive symptoms had been present for at least two years, with milder severity but persistent duration.

Pharmacological Treatment

Considering the moderate severity of Ms. Z’s depressive symptoms and their impact on her functioning, pharmacological treatment with an antidepressant is recommended. Selective Serotonin Reuptake Inhibitors (SSRIs) are the first-line treatment for MDD. SSRIs, such as sertraline or escitalopram, have been shown to be effective and well-tolerated in treating depression (Karrouri et al., 2021). The choice of the specific antidepressant should be made based on the patient’s preferences, potential side effects, and previous response to treatment. Regular monitoring for symptom improvement and side effects is essential during the early stages of treatment.

Non-Pharmacological Treatment

Psychotherapy, particularly Cognitive-Behavioral Therapy (CBT), is a recommended non-pharmacological treatment for MDD. CBT helps individuals identify and challenge negative thought patterns and behaviors associated with depression. It can provide Ms. Z with coping strategies for managing her emotions, improving self-esteem, and enhancing problem-solving skills. Additionally, interpersonal therapy (IPT) may be beneficial for Ms. Z, as it focuses on interpersonal relationships and social functioning.

Health Promotion Intervention

In addition to the treatment options mentioned above, promoting self-care practices and healthy lifestyle habits can be beneficial for Ms. Z’s overall well-being. Encouraging regular physical activity, a balanced diet, and sufficient sleep can help alleviate some depressive symptoms. Educating Ms. Z about the importance of maintaining social connections and engaging in pleasurable activities can also support her recovery (Briguglio et al., 2020). Additionally, providing resources for support groups or community activities can help her rebuild social connections and reduce feelings of isolation.

In conclusion, Ms. Z’s clinical presentation is consistent with Major Depressive Disorder, Single Episode, Moderate Severity. The recommended treatment plan includes pharmacotherapy with SSRIs and non-pharmacological interventions such as CBT or IPT. Health promotion interventions involving self-care practices, social engagement, and support systems will further support Ms. Z’s recovery. It is essential to regularly monitor her response to treatment and adjust the approach as needed to optimize her outcomes.

References

Briguglio, M., Vitale, J. A., Galentino, R., Banfi, G., Dina, C. Z., Bona, A. R., Panzica, G., Porta, M., Dell’Osso, B., & Glick, I. D. (2020). <p>Healthy Eating, Physical Activity, and Sleep Hygiene (HEPAS) as the Winning Triad for Sustaining Physical and Mental Health in Patients at Risk for or with Neuropsychiatric Disorders: Considerations for Clinical Practice</p> Neuropsychiatric Disease and Treatment, Volume 16, 55–70. https://doi.org/10.2147/ndt.s229206 

British Psychological Society (UK). (2010). The classification of depression and depression rating scales/questionnaires. Depression in Adults With a Chronic Physical Health Problem – NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK82926/ 

Karrouri, R., Hammani, Z., Benjelloun, R., & Otheman, Y. (2021). Major depressive disorder: Validated treatments and future challenges. World Journal of Clinical Cases, 9(31), 9350–9367. https://doi.org/10.12998/wjcc.v9.i31.9350