Different Types of Mental Health Disorders Assignment

Focused SOAP Note

Introduction

Different patients present with different types of mental health disorders in healthcare settings. Such patients need to participate in some form of treatment to achieve recovery. For the last 3 weeks, I have come across and provided care to diverse patients, with different diagnoses and varying mental health needs. The focus of this SOAP note is on a patient who presented to the clinic with complaints about having a sad mood and other symptoms after job loss.

Identifying Data

Mrs. X is a 42-year-old Caucasian female, born within the US. She lives with her daughter in Texas, United States. Currently, she is unemployed.

Subjective

Chief Complaint: “I lost my job three months ago and I have been feeling so sad since.”

History of Presenting Problem

Mrs. X is a 42-year-old Caucasian female who presented with complaints of having a sad mood after losing her job. She stated that few days after the job loss she has been having a sad mood, irritable, spending time alone, stopped attending social functions, having sleepless nights, stopped reading which is her hobby, and has noticed a loss of appetite. She is also concerned that she no longer cares about her hygiene. She reported that she has had similar symptoms during her university days. However, before she used to smoke marijuana and drink alcohol to relieve the symptoms. Currently, she is not using marijuana and alcohol to relieve symptoms due to lack of money, and also, she does not want the daughter to see her “high”. She states that she has been trying to find another job, but she noticed she has poor concentration, disinterested, and very fatigued when editing her CV and writing cover letters. She reported feeling very frustrated, hopeless, and worthless as sometimes she cannot meet the needs of the daughter. She denied any suicidal plans. When asked about how she feels, she responded “my life is in shambles. I’m tired of being so hopeless”.

Past Psychiatric History

Mrs. X started having symptoms such as sadness, social withdrawal, lack of sleep, loss of appetite, irritability, among other symptoms during her university education. She would use marijuana and alcohol to relieve the symptoms.

Hospitalizations: No previous hospitalization.

Medication: No medication for the current symptoms

Psychotherapy: N/A

Substance Use and History: Marijuana

Family Medical History: Mother has a history of major depressive disorder. Sister diagnosed with alcoholism.

Psychosocial History: Mrs. X, was born and raised in New York, United States. She currently lives in Texas, USA. She lives with her daughter who is a college student. She is currently single as she separated from her husband 10 years ago. She has 2 sisters. She relates well with them. She has several friends but lately, she does not like “hanging out” with them. She has a degree in social work. She was working as a social worker with a local NGO but unexpectedly lost her job a few months ago. She reports financial difficulties to cater to her basic needs and the daughter.

Relationship: Single

Educational Level: University degree in social work

Military: No military service.

Medical History: N/A

Current medications: N/A

Reproductive History: Regular menstrual cycle; LMP 15 May 2021. Has one child, through normal delivery.

 

Objective

Vital signs: Temp 36.8 o C; Blood pressure 122/90; RR 17; HR 84; Weight 72 kgs

The appearance of the client matches her age. She wore an oversize jacket. She maintains eye contact. Her behavior is calm, while her attitude is cooperative and calm. She looks sad and appears somewhat distracted during the interview.

Assessment

Mental Status Exam

Mrs. X dressed in an oversize coat. Her appearance matches her age. She is well oriented to time, person, place, and event. She displays a sad mood and is teary and the affect is congruent with mood. She appears very tired and keeps yawing during the interview. Her speech is clear, normal rhythm and volume, and goal-directed. The thought process is logical and goal-directed. She denies any visual or auditory hallucinations. Her abstraction is good and even if the cognitive is not formally tested, it is grossly within normal limits.

Differential Diagnoses

            Major depressive disorder: According to the DSM-5 diagnostic criteria, symptoms of major depressive disorder include sad mood, anhedonia, irritability, appetite changes, weight changes, fatigue, sleep problems; feeling guilty, hopeless, and worthless, poor concentration, social withdrawal, and suicidal ideation. A person should manifest more than 5 of these symptoms for two weeks or more. The symptoms should also impair the physical or social functioning of an individual (Kraus et al., 2019). Mrs. X exhibits more than depressive symptoms as indicated by the subjective and objective data, as well as by the mental status examination findings. Mrs. X reported that she is having difficulties seeking a new job since fatigue and poor concentration is hindering her ability to write cover letters and edit her CV. The patient has had the symptoms for more than 2 weeks. Therefore, the most likely diagnosis for Mrs. X is major depressive disorder.

            Bipolar type 2 disorder: This disorder is characterized by episodes of hypomania and depressive episodes of major depressive disorder. Symptoms of depressive episodes include loss of interest, appetite changes, weight changes, sad mood, sleep disturbances, fatigue. Poor concentration, suicidal thoughts, and feeling guilty, worthless, or hopeless. On the other hand, the hypomanic episodes are typified by symptoms such as high energy levels, hyperactivity, excessive talking, lack of sleep, engaging in risk behaviors, and inflated self-confidence (Baldessarini et al., 2020). Mrs. X manifests symptoms of depressive episodes in bipolar type 1 disorder but does not manifest any symptoms of hypomania. Therefore, the diagnosis of bipolar type 2 disorder is ruled out.

            Adjustment disorder with depressed mood: People with adjustment disorder with depressed mood manifest symptoms of major depressive disorder; however, the symptoms are in response to an event that is stressful (O’Donnell et al., 2019). Mrs. X reported that the loss of employment was a very stressful event and it triggered the current symptoms. However, Mrs. X reported that she began having similar symptoms while in university many years ago but she would relieve the symptoms by smoking marijuana. This indicates the loss of the job is not the cause of the current symptoms but a trigger to depressive symptoms. Accordingly, this rules out the diagnosis of adjustment disorder with depressed mood.

Treatment Plan

Cognitive Behavioral Therapy (CBT)

CBT is the selected psychotherapy for Mrs. X. Cognitive theory hypothesizes that it is not the events that mentally affect an individual, but the perception of the event by the individual is what affects the person (Gautam et al., 2020). Therefore, how a person perceives and analyses an event is what leads to impaired cognitive reactions due to the maladaptive thinking pattern. The maladaptive thinking pattern leads to impaired cognition because the affective and behavioral domains are affected leading to symptoms such as sad mood, loss of interest, poor concentration, irritability, sleep problems, among other symptoms (Ling et al., 2020). For example, negative automatic thoughts cause maladaptive thinking patterns, triggering depressive symptoms.       Therefore, CBT can help identify the negative automatic thoughts that cause symptoms of depression for patients. The individual is then taught to replace the negative automatic thoughts with more positive and adaptive thinking patterns. Additionally, Mrs. X was trained regarding coping strategies that can assist her in handling adverse life events like loss of employment. According to Gautam et al, (2020), people with depressive symptoms may use negative coping strategies to deal with the unwanted symptoms. This is evident where Mrs. X uses marijuana to relieve the depressive symptoms. However, such coping strategies are temporary relievers, and unhealthy as well.

The CBT treatment was started by developing a warm therapeutic relationship with the patient and then listing the client’s specific concerns and treatment goals. The client is then educated regarding the cognitive model to be aware of the form of treatment. The behavioral interventions are then used to reduce ruminations while monitoring the client’s activities aiming to decrease the negative thinking pattern (Lim et al., 2018).

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As the health promotion activity, Mrs. X was advised to engage in exercises such as attending the gym. Exercises trigger the release of feel-good endorphins that improve the mood. Additionally, exercises help an individual take their mind away from the cycle of negative thoughts that trigger depression (Belvederi et al., 2019). Moreover, exercises will increase the client’s social interactions as she can get opportunities to socialize with other individuals while exercising. Finally, exercising is a healthy way to cope with life stresses (Belvederi et al., 2019). For instance, instead of Mrs. X smoking marijuana to cope with life stresses, she can exercise a way to cope with stress.

As an education strategy, the patient was educated on the importance of adhering to the prescribed treatment regimen. She was also be educated on how to identify triggers to the depressive symptoms in order to avoid the triggers. She was also be educated about coping strategies such as engaging in hobbies to cope with stressful events.

Pharmacotherapy

Antidepressants are the recommended medications for the treatment of major depressive disorder. The type of antidepressant should be selected depending on the patient’s clinical characteristics like symptoms, tolerability profile, comorbidity, potential drug interactions, and cost. SSRIs, SNRIs, bupropion, and mirtazapine are the first-line treatment choices when it comes to major depressive disorder as these medication classes have a good safety profile (Huang et al., 2018). Tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors are not recommended as first-line treatment choices in depression due to low tolerability and numerous side effects (Huang et al., 2018).

For Mrs. X, sertraline 50 mg once per day was prescribed. The medication was titrated to a full therapeutic dose depending on her response to treatment, tolerability, and reported side effects. The patient was monitored closely to determine if she was responding adequately to the medication and assess if she was experiencing any unwanted or adverse side effects from the medication.

Reflection notes:

Mrs. X was very determined on getting better as she was very willing to start the treatment. This assured me that she would adhere to the treatment plan, and thus increase the possibility of her recovery. Additionally, Mrs. X is well educated as she is a social worker and thus, she is aware of the importance of adhering to treatment and fully participating in the treatment plan; therefore, she is likely to cooperate and adhere to the prescribed treatment plan. Mrs. X’s follow-up was scheduled after four weeks to assess her response to the treatment plan. I believe that I engaged the client well in the treatment plan as I began by creating a safe environment to allow her to express herself adequately and freely. I greeted the client and assured her that her privacy and confidentiality would be maintained. I listened keenly and actively throughout the session to assure her I was genuinely interested in her concerns and recovery.

Mrs. X appears to have a good prognosis if she adheres to the treatment plan. Her history of depressive symptoms and use of marijuana is a worry but does not seem to hinder her from achieving full symptom remission if she adheres to the treatment plan.

In the future, I would ensure that her daughter is consulted to advise her to provide a support system to the mother. I would also refer the patient to a local support group so that she can interact with people facing similar challenges. This would encourage her to adhere to the treatment plan and also adopt a more positive approach towards life. It would have been appropriate to enquire about how she is financing her treatment to assess if she would require any financial help, especially now that she is unemployed. Finally, since lack of employment is a trigger to the current depressive symptoms, it would have been necessary to link her with organizations that can help her in accessing employment.

Conclusion

The client is Mrs. X is a 42-year-old Caucasian female, who presented with complaints about having a sad mood. She reported that she started experiencing the symptoms after job loss. According to the DSM-5 diagnostic criteria, the patient was diagnosed with major depressive disorder as she manifested symptoms such as sad mood, poor concentration, sleep disturbances, fatigue, anhedonia, social withdrawal, among other symptoms. CBT was used as the psychotherapy treatment choice while sertraline was the selected antidepressant. The patient is likely to achieve full symptom remission as she is determined to adhere to the treatment regimen.

References

Belvederi Murri, M., Ekkekakis, P., Magagnoli, M., Zampogna, D., Cattedra, S., Capobianco, L., Serafini, G., Calcagno, P., Zanetidou, S., & Amore, M. (2019). Physical Exercise in Major Depression: Reducing the Mortality Gap While Improving Clinical Outcomes. Frontiers in psychiatry, 9, 762. https://doi.org/10.3389/fpsyt.2018.00762

Baldessarini, R. J., Vázquez, G. H., & Tondo, L. (2020). Bipolar depression: a major unsolved challenge. International journal of bipolar disorders, 8(1), 1. https://doi.org/10.1186/s40345-019-0160-1

Gautam, M., Tripathi, A., Deshmukh, D., & Gaur, M. (2020). Cognitive Behavioral Therapy for Depression. Indian journal of psychiatry, 62(Suppl 2), S223–S229. https://doi.org/10.4103/psychiatry.IndianJPsychiatry_772_19

Huang, J., Wang, Y., Chen, J., Zhang, Y., Yuan, Z., Yue, L., Haro, J. M., Moneta, M. V., Novick, D., & Fang, Y. (2018). Clinical outcomes of patients with major depressive disorder treated with either duloxetine, escitalopram, fluoxetine, paroxetine, or sertraline. Neuropsychiatric disease and treatment, 14, 2473–2484. https://doi.org/10.2147/NDT.S159800

Kraus, C., Kadriu, B., Lanzenberger, R., Zarate, C. A., Jr, & Kasper, S. (2019). Prognosis and improved outcomes in major depression: a review. Translational psychiatry, 9(1), 127. https://doi.org/10.1038/s41398-019-0460-3

Lim, J. A., Lee, Y. I., Jang, J. H., & Choi, S. H. (2018). Investigating effective treatment factors in brief cognitive behavioral therapy for panic disorder. Medicine, 97(38).

Ling, C., Evans, D., Zhang, Y., Luo, J., Hu, Y., Ouyang, Y., … & Kuang, Z. (2020). The effects of cognitive-behavioral therapy on depression and quality of life in patients with maintenance hemodialysis: a systematic review. BMC psychiatry, 20(1), 1-14.

O’Donnell, M. L., Agathos, J. A., Metcalf, O., Gibson, K., & Lau, W. (2019). Adjustment Disorder: Current Developments and Future Directions. International journal of environmental research and public health, 16(14), 2537. https://doi.org/10.3390/ijerph16142537.

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  • Select a patient of any age (either a child or an adult) that you examined during the last 3 weeks.
  • Create a Focused SOAP Note on this patient using the template provided in the Learning Resources.
  • Subjective: What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis? What is the duration and severity of their symptoms? How are their symptoms impacting their functioning in life?
  • Objective: What observations did you make during the psychiatric assessment?
  • Assessment: Discuss their mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses and why you chose them. List them from highest priority to lowest priority. What was your primary diagnosis and why? Describe how your primary diagnosis aligns with DSM-5 diagnostic criteria and supported by the patient’s symptoms.
  • Plan: What was your plan for psychotherapy? What was your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan. Also be sure to include at least one health promotion activity and one patient education strategy.
  • Reflection notes: What would you do differently with this patient if you could conduct the session again? If you are able to follow up with your patient, explain whether these interventions were successful and why or why not. If you were not able to conduct a follow up, discuss what your next intervention would be Different Types of Mental Health Disorders Assignment.
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