The Diagnostic and Statistical Manual for Mental Disorder - Essay Example

?Case Study Julie is a 50 year old patient who has been diagnosed of depression as she has been admitted to a psychiatric ward on a Section 2 of the Mental Health Act (MHA). The patient complains about feeling upset and out of control, stating that the severity of her depressive status has worsen over the year. Julie had shared that she is frightened by what is happening as she had already experienced two serious incidences of depression, during ages 18 and 30, wherein each depressive episode consisted of suicide attempts. The patient shared that the onset of her depression initially occurred when she failed to get good grades in her A levels when she was 18 years of age, thus resulting in her not being admitted at a University to study as a veterinarian. Another personal history that led to her low levels of confidence, self esteem and self worth was her parents' divorce when she was 14 years of age. At age 21, she got pregnant and decided to get married, which was ended by a divorce 3 years later. Prior to the divroce, she gave birth to her second child. She had gotten married again at age 28, wherein the marriage lasted for 2 years, leaving her with her third child. Since then, Julie had been a single parent who decided to dedicate her life to caring for her children. However, prior to the recent incidence of depressive episodes, two of her first children has gone abroad to work a year ago, wherein the youngest had recently moved out to study in a University. The result of the psychiatrist's home visit and Mental Health assessment led to the suggestion of her being admitted into hospital for further assessment and treatment. However, the patient would not conform with an admission as an informal patient; therefore, the psychiatrist admitted Julie under a section 2 MHA. Depression among Women Depressive disorders are considered more prevalent among females than the opposite sex, which can be attributed from the perspective of biological, socio-cultural, psychological and occupational factors (Creek and Lougher, 2008). The distinct facets of depression among women does not only comprise of variance in symptoms, but also in the process and intervention program for treatment. In addition, the outcomes of worsening symptoms among patients’ pose an obstruction towards recovery, as well as causing a more severe function impairment for female (Sundsteigen, Eklund, & Dahlin-Ivanoff, 2009). The Diagnostic and Statistical Manual for Mental Disorder (DSM-IV) comprises of major depressive disorder, dysthymic disorder and atypical depression, which are all under the umbrella of depressive disorders (DD) (American Occupational Therapy Association, 2008). The key feature in identifying depressive disorders is the two week period that entails an individual to feel depressed or to experience loss of interest or pleasure in daily activities (Pierce, 2003). Most individuals who suffer from depressive disorders are administered medications in the form of antidepressants, as coupled with psychotheraphy, which is considered as the most ideal form of treatment (Whiteford & Wright-St Clair, 2005). Studies present that the occurrence of depression among women is twice as the incidence among men. The rate between female to male in terms of relative lifetime risk of experiencing a major depressive incident is approximately 1.7, which initially begins during an individual's early adolescence period and continues up to the age of more than 50 years. The variance in gender can be culled from the difference between the biological, psychological and socio-cultural factors that influence each individual (llott, Taylor, & Bolanos, 2006). Biological theories stress on gender variance in regards to the structure and function of the brain. Another factor to be considered is the transmission of genes carrying mental illness (Duncan, 2006). In addition, women have a high tendency of experiencing depressive episodes due to their gonadal hormones and reproductive function. During a female's reproductive life cycle, females present vulnerability to mood shifts and disturbances, particularly during the following phases: premenstrual; puerperium; and perimenopause (Sundsteigen, et. al, 2009).The increased occurrence of depressive disorders among females transpires during years when they bear children, specifically between age 15 to 35 years. The aforementioned phase is also the period wherein women are involved in constructive roles in accordance with their relationships and careers (llott, Taylor, & Bolanos, 2006). The psychosocial factors of women affect occupational roles and behavior, thus leading to higher tendency of depression. The tendency of women to perform internalization and self-blame in a setting wherein the role of a woman is relatively low and holds no control in being involved in a constructive occupation leads to depression, as caused by stressful circumstances and environments (Larson, 1990). Women who suffer from depressive disorders manifest a greater amount of symptoms as opposed to men. In addition, there is a high tendency that women experience longer depressive episodes, coupled with a high probability of developing a persistent and habitual pattern (Schene, Koeter, Kikkert, Swinkels, & McCrone, 2007). The range and the number of the manifestation of symptoms determine the profundity and importance of the interruption in engagement in constructive occupations for patients. In that light, women are deemed to go through a stressful life event 6 months before the manifestation of an episode of depression. These life events are crucial, such as the event of an unhappy marriage lead to depression (Pierce, 2003). Physical and Biological Subsystem Studies indicate that women present a higher plasma level of antidepressants, thus implying that they are susceptible to more side effects and could experience more frequent drug toxicity than the opposite sex. Oral contraceptives, which include exogenous hormones, have the capability of elevating women's antidepressant levels. In addition, other studies indicate that variations in a woman's menstrual cycle present modifications in antidepressant levels during the course of the premenstrual phase (Sundsteigen, et. al, 2009). In terms of gender variance concerning treatment responses, females present a better response towards the intake of selective reuptake inhibitors (SSRIs) or monoamine oxidase inhibitor (MAOIs). The interaction between the drug's chemical effects and an individual's reproductive status differs, wherein premenopausal women respond better to SSRis, while postmenopausal women significantly respond better to TCAs (American Occupational Therapy Association, 2008). Assessment The evaluation process of occupational therapy entails the discussion of both parties, focusing on the client's problems and strengths, inclusive of his or her principles and interests. Self-care Based on the case study, the patient has been experiencing depressive episodes over the year, particularly having negative thoughts, which lead to the apparent decline of her self-worth, confidence and self esteem. During the course of her episode, Julie had become increasingly unmotivated to carry out activities, such as reporting to work and socializing. She has spent most of her time in bed, rather than attending to her daily activities. The patient had also relied on friends and neighbors to fend for her, in terms of cleaning, cooking and shopping. Julie's children are unable to support her due to commitments of their own. Productivity When asked about her life and the distress she constantly feels, the patient shared sadness throughout the course of discussion. Her depressive episodes had worsen over the last 3 months, wherein the patient experienced severe difficulty to work and focus on her tasks. Julie had received 2 verbal warning and a written notice from her manager in regards to the quality and quantity of her work. The patient presents atypical depressive symptoms such as aches and pains, and constantly experiences fatigue and unmotivated. Leisure In spite of the patient's depressive episode for a year after her second divorce, she eventually emerged from her desolate status and had become a stronger person. She was able to acquire an occupation as a part time receptionist at a local veterinary surgery, as brought about by her love for animals. Julie believed that this part time work was suitable for her as it gave her enough time to attend to her children during evenings and weekends. As advised by her friends, Julie reluctantly decided to conform to a home visit from her General Practitioner. The G.P. had pointed out his concern in regards to the patient's psychological well being and had advised a home visit by a consultant psychiatrist, concerning her history of depression. During the consultation with the psychiatrist, Julie made minimal eye contact, wherein she consistently stared at her hands in her lap. Her responses are characterized by a low monotone as articulated by monosyllabic answers. The patient did not smile. Julie's eyed welled up with tears on instances when she shares her feelings of worthlessness and the hopelessness of her future. She had also presented suicidal tendencies, sharing that the only reason for her living are her children, whom she hardly sees anymore. The patient believes that the only means to resolve her distress is to commit suicide. Occupational Therapy Intervention Program COPM The role of occupational therapists in the treatment of individuals who suffer from depression concentrate on the developing the client's occupational performance in highlighting the importance of the following factors: productivity, leisure and self-care (Polatajko, 2001). The case of depression is usually associated with the failure of provisioning self-care, as accompanied by a decline of interest in pursuing leisure activities. The occurrence of depressive episodes among individuals is correlated with one's discernment as ineffectual in spite of the known mastery for competencies in certain activities prior to the incidence of morose conditions (Schene, et. al, 2007). Productivity is reduced during the episode of mild depression among individuals experiencing affective impairment, which are often manifested by loss of interest in work, experiencing work related emotional distress, and a pessimistic self assessment (Lloyd, Bassett, & King, 2004). In that regard, the series of an individual's decline performance implies isolation and alienation from social events, thus reduces the degree of social support available to patients suffering from depression. As a means to attend to the aforementioned discrepancies in occupational performance, the provision of occupational therapy is projected towards cultivating the patient's capability to take accountability for their actions, and their lives, in general. The goal is then to foster one's inner strength (Duncan, 2006). One means of intervention therapy program in helping patients recover from depression is the Canadian Occupational Performance Measure (COPM), which is inclined towards measurable results concerning the client. Through this approach, the problems identified and the outcomes to be measured are selected by the patient (Health Council of Canada, 2007). This approach is guided by the Canadian Model of Occupational Performance, following therapy guidelines and patient centric practice. The instrument in this approach concentrates on interventions applicable in the concept of occupational performance, particularly the three crucial factors: (1) self care; (2) leisure; and (3) productivity (Polatajko, 2001; Steinman, Frederick, Prohaska, Satariano, Dornberg-Lee, & Fisher, 2007). In that light, occupational performance must be identified by the patient, on the basis of his personal satisfaction as dependent on the facets of personal value. With that in mind, the Canadian Occupational Performance Measure mandates an association between the client and therapist, wherein the role of the latter follows the perception of therapy as a medium that releases the patient's existing capability in accordance with his potential competencies (Polatajko, 2001). The researcher would then choose to take the role of an enabler in the case study provided (Whiteford & Wright-St Clair, 2005). Intervention Program As an occupational therapist, the areas that the researcher chooses to assess are the factors of self care, leisure and productivity, as focusing on these areas would not only benefit the patient’s output at work, but would also improve her psychological well being in general (Hagedorn, 2001). Analyzing, evaluating and improving on how the patient cares for her self would help the patient to overcome suicidal tendencies and help increase her self-worth, self-esteem and confidence. Her distress can be alleviated through engaging in leisurely activities, and increased productivity would provide a meaningful purpose to her life and help the patient overcome depressive episodes. These areas can be evaluated through identifying the patient’s history, as well as her existing condition (Pedretti, 2001). Following the concept of the COPM, the assessment process can be carried out the first step, which is the problem definition. The occupational therapist would inquire the patient as to what activities she is required to accomplish, or those in which she would find pleasurable, concerning the three areas related to occupational performance (Health Council of Canada, 2007). The patient can provide a list of ideas of what she has in mind, wherein she must rate in accordance to each of the activity’s importance. Further discussion would present at least three key goals in which the patient would find the most value of performing (Fine, 2001). The second step of the assessment process is for the patient to weigh her problems. To help the patient rate the importance of her selected goals, a scale of 1 to 10 can be used, wherein the value of 1 pertains to “not important” and 10 as “extremely important”. It is important for the occupational therapist to discuss the means of the patient to develop her performance in each cited goal to help her attain satisfaction (Ay-Woan, Sarah, LyInn, Tsyr-Jang, & Ping-Chuan, 2006). This would allow the patient to focus on the tasks she intends to carry out. The third step pertains to the Scoring phase, wherein the patient must rate her performance in the activities she chose to carry out, using the scale of 1 to 10, the value of 1 being "not able to" and 10 as "able to do it very well". In accordance to her performance, the patient must also rate the level of satisfaction she has achieved from the same exercises using the similar scale (Ay-Woan, et. al, 2006). Through this approach, the role of the occupational therapist was to affirm the patient's evaluation based on her previous competencies, including her ability in problem solving. The choice of the therapy's objective depended on the patient's options, wherein the therapist played the role of a partner who guided her during the course of formulating feasible objectives (Steinman, et. al, 2007).This approach would allow the patient to generate personal objectives, while being able to identify and evaluate the significance and value of each activity. The COPM process is directed towards a client centric measure as based on the strategies culled from the conventional approaches in psychotherapy, particularly from In Search of Solutions (Health Council of Canada, 2007). Through this approach, the occupational therapist would help the patient in identifying the significance of concentrating on tiny, but concrete steps, rather than aiming to resolve vague and ambiguous concepts, like lack of self confidence and low self-worth (Foster, 2002). This approach is directed towards empowering the patient through her own volition as guided by the therapist, by means of realizing her competencies and utilizing her capabilities. This approach is supported by the premise of channeling discussion into actions and solutions, and not negative perspectives (Polatajko, 2001). Utilizing the COPM approach would help ensure that the patient's therapy is based on her choice, wherein the activities she would perform in line with the areas of occupational performance are based on her exertions. Through this manner, the patient's objectives would be congruent to her intersts and principles, as well as her needs (Health Council of Canada, 2007). This would help the patient carry out her goals as her actions are sensitive to her experiences and are in line with her environment (Custer & Wassink, 1991). The COPM approach would present a clear and concrete approach in regards to the patient's behavior. The outcome of this intervention would present a client-centered result focusing on evaluation and satisfaction. However, this approach would not be chosen if the patient is in the phase of denying her illness, or in the phase of severe depression wherein the patient manifests cognitive deficits (Hale, Michalak, Hayashi, & Lam, 2005). The researcher believes that the COPM is a useful instrument in enabling patients to recover from depression, focusing on the concept that both parties are merely partners towards attaining a goal. This relationship between the therapist and the patient would establish an intervention program based on what the patient wishes to address and is in line with his or her environment (Polatajko, 2001). Through the COPM process, other occupational therapy interventions can be integrated in line with the objectives established by the patient (Polatajko, 2001). The following interventions can be used to alleviate the patient’s depression: 1. Vocational Intervention One means of performing a vocational intervention is through the application of a Cochrane systematic review, which evaluates the efficiency of interventions that decrease work impairment among patients who suffer from depression (Curtin, Molineux, & Supyk-Mellson, 2009). The process of evaluating the effect of occupational therapy, particular the vocational intervention on depression, can be examined through RCT in terms of the following: (1) depression; (2) time to work resumption; (3) hours worked; (4) work stress; and (5) health care costs. The intervention could be a means to explore the correlation between work and depression through and groups, focusing on the following facets: assertiveness; communication skills; stress; and boundaries (Hagedorn, 2001). 2. Stress Management Occupational therapy that would help manage the patient's anxiety levels, which consists of behavioral rehearsal, relaxation response, progressive relaxation, paradoxical intervention, and visual imagery (Devereaux & Carlson, 1992). 3. Social Support This intervention is directed towards depression, anxiety and social behavior. The activities are focused on building social support, communication skills, self concept and self esteem (Devereaux & Carlson, 1992). 4. Interventions for dysthymia Such an intervention can help address occupational engagement and employment, wherein cognitive behavioral therapy and group therapy can be used. 5. Occupation and depression A study conducted by Fine (2001) presented that depression can also be ascertained through analyzing the correlation between depression and work, as a means of reducing leisure activities. Through this intervention, one would be able to evaluate the patient's activity patterns and life changes (Foster, 2002). The provision of occupational therapy is directed towards promoting health through enabling patients as a means to carry out activities with value and purpose. Patients who suffer from disabling conditions concerning physical or mental health are treated in order to help the client recover or develop from his or her daily activities (Creek and Lougher, 2008). In that regard, the objective is to develop the client's basic motor functions and recover function impairment. The goal is for the patient to have a productive and satisfying life. This premise is supported by the key principle of occupational therapy which is occupational enablement (Curtin, et. al, 2009). Strategy to Evaluate Proposed Occupational Therapy Intervention Program The researcher would choose the strategy to assess the selected occupational therapy intervention program through identifying the outcome measures based on two factors: positive change and change in daily occupation. The first factor, which is positive change, would comprise of the following aspects to evaluate: (1) timing; (2) belonging; (3) involvement; (4) challenge; (5) meaningful occupation; and (5) a balance of focus on disease. On the other hand, the second factor to be measured, which is changes in daily occupation, would comprise of the following: (1) to manage and (2) to dare more (Haglund & Henriksson, 2003). The patient would be able to perform the teachings acquired from the therapy into one's daily life with the help of an occupation based intervention as incorporated by a reflective process. The application of the therapy would initiate once the patient experiences the need to apply changes in daily life patterns (American Occupational Therapy Association, 2008). Timing This factor is one of the means to evaluate the effectiveness of the treatment on the basis of when it started and when the therapy stopped. This sub-factor relies on the willingness of the participant not only as to the proper initiation of the treatment. The patient's volition is also necessary to accept changes and modify behavior for the apposite stop time of the treatment (Taylor, 2007). Belonging This sub-factor can be associated with the leisurely objective of the COPM process, wherein the patient would be enjoined to spend time with people whom she has something in common (Health Council of Canada, 2007). Isolation can be penetrated through group therapy or focus group discussion that would encourage a harmonious venue of differences among individuals to be accepted (Fine, 2001). Involvement This is perhaps the most important factor in the concept of the COPM process, as this would encourage the patient to establish an active role in the treatment process. However, lack of motivation, energy and health restricts one's involvement (Taylor, 2007).The COPM process enables the patient to seek her personal comfort level and exert effort in helping themselves recover. Through assessing this sub-factor, the patient would be able to acknowledge and make use of the available resources, in terms of experiences and judgment as a means to maintain one's health (Health Council of Canada, 2007). Challenge This sub-factor pertains to an occupation that generates a more comprehensive understanding, a clearer perspective which produces a resolution. It also exemplifies positivity and relaxation during the process of forming new constructive roles and routine for the patient that are deemed of value and meaningful (Frederick, Steinman, Prohaska, Satariano, Bruce & Bryant, 2007). This aspect of the evaluation would present the effectiveness of therapy in terms of connecting the individual's intent for a meaningful occupation and the purpose of the desired occupation. This can be assessed through identifying the patient's level of engagement in meaningful activities that produce performance modifications, as well as increased well-being and self-efficacy (Hale, et. al, 2005). A balance focus on disease The core aspect of the treatment lies on improving the mental health of the patient. It is important to understand the symptomology of the diagnosis as this would help in identifying coping strategies (Fine, 2001). A balanced focus on disease implies the ability of the patient to become aware, accept and decide to recover from the depressive disorder (Foster, 2002). The change in daily occupations pertains to the patient's heightened competence when dealing with daily activities. This is the client's capability of seeking solutions and having the ability to identify his or her actions, ideas and emotions within a specific situation (Haglund & Henriksson, 2003). To manage This sub-factor pertains to the manifestation of the patient's energy and will to act. The ability to manage entails faith, possibility, and hope, as a means to go through internal and external impediments throughout life. An individual's well being is associated to one's ability to balance actions and rest within the framework of one's habits (Lloyd, et. al, 2004). Such an objective can be attained through managing one's occupation, which would help patients identify their capabilities in terms of accomplishment, as well as being able to determine personal needs (Taylor, 2007). The two aforementioned factors must be constantly attained through balance. Evaluating this sub-factor concerns the following aspects: time management; knowing when to ask for help when necessary; and establishing limits (Custer & Wassink, 1991). To dare This sub-factor can be evaluated through a patient's ability to encounter challenging situations, without bothering with the implications. A patient's capacity to open up to dare can be identified through self knowledge and acceptance of the existing situation (Frederick, et. al, 2007). This enables the client to have a reduced perspective in regards to environmental threats and inadequacies. This would enjoin the patient to manage challenging situations (Pedretti, 2001). 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