Major Depressive Disorder - Case Study Example

aSSESSMENT case study on major depressive disorder scenario Isabel templar Introduction: This case study concerns Isabel, a 28-year-old mother of two, who was hospitalised with depression when her second child was six months old. He is now two and severe symptoms have returned, necessitating further hospital treatment. Her history and symptoms indicate a wide range of treatments and the need for support from all relevant agencies. As her nurse, my role is to establish a therapeutic relationship that will enable treatments to assist, and support her to achieve well-being. Diagnosis and epidemiology: The patient presented with a sustained sad mood and tearfulness, loss of interest (anhedonia), energy, appetite, self-esteem, and with sleep disturbance. She feels worse in the mornings, guilty and hopeless, with suicidal ideation and has developed increased psychomotor retardation. She thinks she is ruining her family, who would be better off without her. These signs and symptoms indicate that she has Major Depressive Disorder (MDD), as defined by criteria in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision (DSM-IV-TR) (American Psychiatric Association [APA], 2000). The criteria state that more than one important aspect of MDD, such as sustained depressed mood, anergia, anhedonia, disturbed appetite and sleep, psychomotor retardation, suicidal thought, negative thought, hopelessness, or poor concentration, should be present for no less than two weeks and not related to somatic effects, caused by substance abuse or adverse reactions to medication. Depression is the most widespread disorder in relation to mental health. According to World Health Organisation [WHO] (2001), people suffering from depression account for 5 to 10% of the population. The 'Bettering the Evaluation and Care of Health' survey (AIHW, 2007) reported that it accounted for 33.7% of mental health disorders managed by general practitioners in Australia in 2003-04. Most studies show that the development of MDD has a higher incidence in females than males in their life time, being found in females twice as much as in males (APA, 2000; Varcarolis, 2006, pp.326-327; WHO, 2001). Typically, MDD is more likely to occur in females aged between 20 and 40 years old (WHO, 2001). Causes assumed include responsibilities of multi-tasking, for instance, domestic and office work, wife and parenting roles, or the menses might contribute to the prominent prevalence of depression in females (APA, 2000; WHO, 2001). However, race, earnings, education or matrimony are not related to the frequency of MDD (APA, 2000; Varcarolis, 2002. p.454; WHO, 2001). 2. Pathophysiology of depression: Depression arises due to multifactorial causes, including biochemical, cognitive, hereditary and environmental factors, and sleep abnormalities (Varcarolis, 2002, pp.456-460; Varcarolis, 2006, pp.330-333). In Isabel's case, a reasonable assumption would be that the major pathophysiologic causes might be biochemical, cognitive factors, and sleep abnormality. There are many studies to indicate that biochemical imbalance can cause depressive disorders, in relation to certain neurotransmitters, mainly serotonin, noradrenaline and dopamine in the brain, which are known to play a role in the regulation of mood (Varcarolis, 2002, pp.456-460; Varcarolis, 2006, pp.330-333). The dysfunctional regulation of serotonin is related to decreased sex drive, appetite and sleep disturbance, as serotonin is particularly important in controlling sleep, appetite and sexual drive (Varcarolis, 2006, p.331; Zarate & Charney, 2003, pp.464-468). Reduction of noradrenaline can lead to loss of energy, interest, concentration, and decreased sexual drive (Varcarolis et al., 2006, pp.460-464; Zarate & Charney, 2003, p.464-468). The depletion of dopamine can be associated with loss of motivation and interest, because it contributes to the stimulation of the system of circuits of motivational behaviour in the brain (Praag, Kloet, & Os, 2004, p.114-128; Zarate & Charney, 2003, p.468-473). Not everyone with sleep abnormalities, e.g. restless sleep, decreased rapid eye movement sleep, and early morning awakening is depressed, but over 60% of patients with MDD present various patterns of broken sleep, similar to Isabel's. (Antai-Otong, 2003, p.198; APA, 2000; Varcarolis, 2006, p.332). Cognitive errors, like negative emotions and thoughts about themselves, can result in depressive disorders (Cornwell, 2006, p. 583; Varcarolis, 2006, p.333). Depressive people tend to view their future pessimistically and may be unable to respond positively, evidenced by Isabel's feelings of guilt and hopelessness. (Cornwell, 2006, p. 583; Varcarolis, 2006, p.333). These, combined with possible biochemical factors, could explain her depression. 3. Five issues relevant to Isabel and rationales for nursing interventions: Suicidal ideation, low self-esteem, sleep disturbance, lack of appetite and anhedonia are the five issues relevant to Isabel, with suicidal ideation as a life-threatening priority. Suicidal behaviour is serious, suggesting a high risk of suicide (Horsfall, 2005, p.238; Stuart, 2005, p.367; Shoemaker & Varcarolis, 2006, pp.473-477). Her second problem is low self-esteem, resulting in feelings of guilt, hopelessness and helplessness, and a deterioration of social relationships or even suicide (Stuart, 2005, pp.308-309). The third issue is the change in her sleep pattern, particularly early morning awakening, contributing to fatigue and anergia (Shoemaker & Varcarolis, 2006, pp.473-477; Stuart, 2005, p.367). The fourth is her decreased appetite, which may cause certain physical problems, such as anorexia, dehydration and constipation (Varcarolis, 2006, p.366). The fifth problem is anhedonia, because she may not only lose interest in biological pleasures, such as eating and sex, but also her ability to feel and reciprocate others' feelings, which may develop into social isolation and loneliness (Varcarolis, 2004, p.164). 4. Nursing intervention for Isabel Because Isabel has a high risk of committing suicide, expressed by her suicidal ideation, the most immediate and prioritised nursing intervention is to reduce this. (Varcarolis, 2004, p.152). In addition, many studies show that suicidal patients with intensive assessment and care can be influenced towards effective outcomes (Shoemaker & Varcarolis, 2006, p.481). I would frequently observe and monitor Isabel's physical and mental states for 24 hours, without her being aware of this. Because her potential suicide risk is unpredictable, all aspects should be accurately documented every 15 minutes, and information shared with all nursing and allied health staff (Shoemaker & Varcarolis, 2006, p.481; Varcarolis, 2004, p.453). In addition, nurses should maintain a safe environment (NSW Department of Health, 2004; Shoemaker & Varcarolis, 2006, p.481-482; Varcarolis, 2004, pp.452-456). For example, unexpected hazards, such as glass and metal items should be removed, she must not be left alone, and should receive one to one nursing supervision. Nurses should ensure Isabel knows they are available to help her (NSW Department of Health, 2004; Shoemaker & Varcarolis, 2006, pp.481-482; Varcarolis, 2004, pp.452-456). The therapeutic relationship between Isabel and myself, as her nurse, must be established and maintained, to assure her of care and support. The next important intervention is to improve low self-esteem by encouraging strong and positive behaviour, which can help to reduce a risk of suicide (Cornwell, 2006, p.613; Stuart, 2005, pp.308-309). I would encourage Isabel to discuss her negative thoughts and feelings with me, which would provide a good nursing assessment of her current mental state. By verbally expressing her feelings, this would help alleviate cognitive distortions. Visualisation techniques, such as peaceful imagery, can be used, as such images aid relaxation and reduce physical and mental impacts of stress (Cornwell, 2006, p.613; Stuart, 2005, p.325; Varcarolis, 2004, p.161). The nurse may experience difficulties communicating with a depressive patient, so must recognise the need for meaningful time to work with her (Varcarolis, 2006, p.339). This can build trust, in an emotionally 'safe' place and help to form the therapeutic relationship. 5. Therapeutic relationship and collaborative partnerships: Collaborative partnerships, like family and community services involvement, is important for Isabel, who is on an involuntary admission. Her family will need help to understand and support her if her condition deteriorates. They need to be educated to look for signs and symptoms of depression and to access psychosocial and cognitive care for the ongoing stages of her depression (Conn & Stuart, 2005, pp.170-182; Varcarolis, 2006, p.339). Moreover, her family should be given psychopharmacological and clinical therapeutic information regarding prescribed antidepressant drugs and electroconvulsive therapy. This will help them understand and prepare for any adverse reactions Isabel might experience from the treatments (Varcarolis, 2006, p.339). As she is a high suicide risk, Isabel's family should be given information to help them understand and take steps to reduce the risks. In addition, social workers and community services should be provided for her family's care and support (Conn & Stuart, 2005, pp.170-182). Telephone counselling can be used to relieve emotional difficulties and resolve other problems; this is convenient and totally confidential. Psychiatric and community nurses use telephone counselling for individuals and unexpected incidents (Palmer, 2005, p.385). Group psychotherapy is commonly used in health care and community services. Isabel and her family could share their issues and ideas with others coping with the same or similar problems. This often produces a more effective outcome than individual therapies. People can network, share and obtain information, so setting up their own social network (Palmer, 2005, p.392; Shoemaker & Lala, 2006, pp. 718-729). Therefore, family and social community support services can assist in improving Isabel's condition (Conn & Stuart, 2005, p.170-182). The partnerships between health professionals such as GP, psychiatrist, nurses, occupational therapists and social workers, provide effective patient management. All of them are required to be responsible and work within a comprehensive framework. In order to monitor her high risk of suicide, all health staff must evaluate and inform through information sharing, coordination, interconnected communication, and collective clinical decisions. Collaborative partnerships can be the best form of management for prevention of suicide for people with this condition. (NSW Department of Health, 2004). While in hospital, a vital aspect of treatment lies in the therapeutic relationship with Isabel, gaining trust and giving her time and space to explore the way forward. This should be extended to her family and carers, along with all the necessary literature and information on support available. This will aid her recovery process. CONCLUSION: Isabel must be viewed as a person whose illness, MDD threatens her life, not just a 'case', but as someone who can be helped if all correct procedures are applied. She should be given the opportunity to achieve positive outcomes within a therapeutic relationship, aided by all relevant interventions. These should be agreed through collaborative partnership working and involve the patient, her family and all support networks. With proper medical, psychiatric and social support, Isabel can get well again, regaining her self-esteem, reducing her risk of suicide and reclaiming her life. Reference List American Psychiatric Association [APA]. (2000). Diagnostic and Statistical Manual of Mental Disorders (4th ed., text reversion): Mood disorders. Arlington; American Psychiatric Publishing Incorporated. Retrieved August 27, 2007, from Psychiatry Online web site: http://blackboard.newcastle.edu.au/webapps/portal/frameset.jsptab=courses&url=/bin/common/course.pl Course_id=_52595_1 Antai-Otong, D. (Eds.). (2003). Psychiatric Nursing: Biological & behavioural concepts. Australia: Thomson Delmar Learning. Australian Institute of Health and Welfare [AIHW]. (2007). Mental health Services in Australia 2004-05. Canberra: Australian Institute of Health and Welfare. Retrieved August 29, 2007, from http://www.aihw.gov.au/publications/hse/mhsa04-05/mhsa04-05.pdf Conn, V., & Stuart, G. W. (2005). Families as resources, caregivers, and collaborators. In G. W. Stuart., & M. T. Laraia. (Eds.). Principles and practice of psychiatric nursing (8th ed.) (pp. 170-182). St. Louis: Mosby. Cornwell, C. J. (2006). The client with a mood disorder. In W. K. 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