Mental Health Assessment and Management - Case Study Example

Mental Health Assessment and Management: The Case of Mrs. Johnson A List of Mental Issues Depression Suicide Anxiety Self Harm (Curtin University, n.d) List of Physical Health Issues Lacerations and a fractured right femur Mrs Johnson has a mental health problem which may have been the cause of the accident. She presents with poor appetite, low mood, weight loss, and early morning awakening. She is suffering from depression. Depression is the state of sadness and low mood. A depressed patient will experience regular low moods for more than two weeks. He or she will always feel overwhelmed, guilty, hopeless, frustrated, and disappointed. Depression will also always affect one’s thoughts. The person will tend to think negatively about the world, family, self and their future. They will think of life being hopeless, they will think of themselves being useless, and even think of taking their life (Roy, 2005; Lam, 2012). A depressed person will also either eat too much or not enough. Might have trouble sleeping or oversleep due to extreme tiredness. In the end, depression can affect one’s life, to a point that it results in serious problems with one’s family, at school, job and with friends (Roy, 2005; Lam, 2012). Mrs. Johnson is suffering from depression. She recently lost her job, which may be a sign of depression being the cause of losing the job. She feels worthless “She feels her children may be “better off” without her”. She also has a record of a three month worsening anxiety, which explains the depression. Anxiety is a cause, and also a symptom of depression. Other symptoms of depression identified from Mrs. Johnson’s report are; decreased appetite, decreased energy, and suicidal ideation (Roy, 2005; Lam, 2012). Another mental problem observed is suicide. Warning signs of suicidal person are; if the person is talking about suicide, if the person is depressed and feeling hopeless, if the person has low self esteem, if there is change in the person’s sleeping patterns, eating habits (eating less or more than usual), personality (withdrawn, less sociable or sad), and behavior (poor/ reduced concentration). Mrs. Johnson’s depression could be a cause of her lack of concentration that resulted in loss of her job. She is to be divorced, and worries about her children. She thinks she is a failure. She may also have to sell her house. All these negative thoughts are a source of the thoughts about suicide. It could also be that Mrs. Johnson’s accident could have been self inflicted. She tells all her experiences in tears after the accident. It could mean that she was trying to end it all. This could have been her first attempt to suicide, and so she was explaining the reason as to why she needed it. From NHS information, it is also clear that Mrs. Johnson was, and is still vulnerable to suicide. Mental health, life history, life style, relationships, employment, and genetics, are some of the factors that make one vulnerable to suicide (NHS, 2012). Mrs. Johnson has a family history of depression in his father and grandfather (paternal), and also has an uncle that committed suicide due to depression. She recently lost her job; her relationship with her husband is coming to an end, while that with her sons is filled with hopelessness as she perceives it. She is also depressed and has suffered anxiety for three months. Self Harm: The patient shows signs of self harm for example, stating that “suicide seems like an option”. Anxiety: It is stated that Mrs. Johnson has had a 3 month history of worsening anxiety. From the above symptoms, according to (DSM-IV), the patient is suffering from Major Depressive Disorder (Unipolar Depression). This is classified under mood disorders and has the following symptoms: Sleep disturbances (too much sleep or not sleeping well), reduced interest in activities that the patient previously enjoyed, feeling of emptiness and sadness (depressed mood), significant reduction in energy level or loss of energy, suicidal intentions or thoughts, and difficulty concentrating (AllPsychonline, 2011). Diagnosis of this kind of depression requires identification of one of the core symptoms among; Loss of pleasure or in most activities, or low mood everyday or persistent sadness, plus some of the symptoms among: Worthlessness Loss of energy or fatigue Inappropriate or excessive guilt Reduced ability to concentrate Suicidal thoughts or actual attempts Hypersomnia or Insomnia Weight loss or changes in appetite (X6) CPG (2007) guidelines also indicate that it is the existence of any among depressed mood, reduced energy, and loss of interest and enjoyment. The severity of Major Depressive Disorder depends on the number of typical symptoms (the three mentioned above) and common symptoms. Mild cases show at least two typical symptoms and two common symptoms. Moderate cases show at least two typical symptoms and three common symptoms. Severe cases show three typical symptoms and four common symptoms (CPG, 2007). Risk Assessment Risk Identification Form Clinical Assessment Point √ if present First Contact with the service √ Change or transfer of care N/A Change of legal status N/A Occurrence of significant life event N/A Change in mental state N/A 3 monthly review √ other N/A Factor’s in the Person’s History and Mental State that may increase risk Historical (When) √ If Current √ If not explored Harm to self-threat √-Suicidal thoughts √-Suicidal thoughts Harm to self-Actual threat Harm to self-with clear intent to die √-Possible cause of motor vehicle accident Harm to other-threat physical harm Harm to other-threat to kill others Harm to others-damage property Harm to others-actual physical harm Harm to others assault charge Fire setting Wandering disinhibition Other (e.g) abuse/bullying The above was/is secondary to: Low mood √- for the past three months √-Current low mood Elated mood Delusional or any other disorder of thought Hallucinations/altered perceptions Cognitive disturbance Impulsiveness Personality factors Other psychopathology (elaborate) Other factors that may increase risk √ If significant Parents/cares have significant physical/mental disability and /or substance abuse Relationship problems √ Physical illness of disability Absence of support/leaves alone/ Social Isolation Arrest or criminal charges Criminal Conviction Persecution or threat from others Loss, including death Financial stress √ Substance use/intoxication or withdrawal Past history of child abuse or other abuse Access to weapons Access to medication (risk of overdose) Other Concerns Lack of support systems Individual’s attitude √ Compliance √ Reliability Concern expressed by significant others ELABORATE ON RISK FACTORS IDENTIFIED She is at risk of self harm and of committing suicide. One of the consequences and even symptoms of major depressive Disorder is suicide. Mrs. Johnson is at risk of harming herself as well as attempting suicide. (X7) indicates that the possibility of a suicide attempt remains until lessening of the mood status happens. It is indicated that 15% of unipolar depression patients eventually commit suicide. This knowledge is very important in the management of Mrs. Johnson. She, therefore, requires constant supervision during therapy. Risk factors are as described in the table below: Risk Factor Mrs. Johnson’s Condition Suicidal ideation Present (Patient clearly states intention to commit suicide as an option) Hopelessness Present (Also stated by the patient) Financial or occupational difficulties Lost her job and may sell her house Poor social support Unclear Loss of relationship Evident (Patient set to divorce husband) Past suicide attempt Possible (may be the cause of her admission in the orthopedic section) Family history of suicide Present (Uncle committed suicide out of depression) Severity of depression Severe (The patient score is 26 out of 27 using the PHQ-9 severity measure (PHQ-9). Alcohol abuse/dependence None Low self-esteem Evident in her statements (for example feeling her children may be better off without her). RISK ALERTS Risk of self harm, risk of non-compliance to medication, and Severe depression From the above assessment, the mental issues of priority are suicidal thoughts and self harm. She suffers from depression and should receive treatment for Major Depressive Disorder, but consideration should be made on the risk factors that can lead to self harm and death. Considering the physical health issues, priority should be given to first aid and emergency steps towards prevention of infection of the wounds. Surgical repair of her right femur can be done later. Health Care Plan 1) Treatment of Lacerations and a Fractured Fight Femur This will be done alongside treatment of the Major Depressive Disorder Treatment of lacerations has to be done first considering that some cuts have to be treated within 6 hours, and some within 24 hours of injury. Surgical Repair For Her Fractured Femur There are various options. These are described below External fixation: These are used temporarily until the patient is in a stable condition to undergo surgery. They are normally used when the patient has multiple injuries. Intramedullary nailing: Done using a specially designed metal rod which is inserted into the marrow canal of the femur. Keeps the femur in position Plates and screws: bone fragments are held together with and metal plates and screws fastened to the bone’s outer surface (Orthopedic Trauma Association, 2011). 2) Treatment of Major Depressive Disorder Overall plan is to: Establish an appropriate setting (restrictive) for the patient’s treatment. This is aimed at ensuring the patient’s safety, plus promotion of the patient’s condition. To improve the quality of life of the patient and ensure reduced functional impairment. This will be achieved through selected interventions such as educating family members, monitoring of patient status, encouraging the patient to set own goals that will help improve her status, and other interventions described below. To monitor the patient’s status; this will involve monitoring of response to medication and any occurring medical conditions, and treatment plans developed. To ensure the treatment plan is integrated into the patient’s psychiatric management To enhance adherence to treatment; this will involve evaluation of potential barriers (for example excessive pessimism, problems in the therapeutic relationship, lack of motivation, and side effects to treatments, among others) to treatment adherence, and appropriate steps taken to reduce such barriers. To provide the patient and family with education to enhance understanding of the patient, and in turn, response to treatment and outcome (American Psychiatric Association, 2013) Treatment Options There are three treatment options to Major Depressive Disorder. These form the basis of the treatment plan. Based on these three options, each plan will incorporate the above objectives, and one type of treatment. A. Pharmacotherapy This will involve the use of antidepressants such as the SSRIs, SNRIs, TCSs, Atypical antidepressants, and Monoamine Oxidase Inhibitors (MAO) (Lippincott Williams & Wilkins, 2006). This is a recommended initial treatment. Monitoring of side effects should be done (APA, 2013). B. Other Somatic Therapies ECT is also another choice of treatment. This is always recommended for patients with urgent need for response, such as suicidal patients, those who have not responded to pharmacological and or psychotherapeutic interventions, and those with associated psychotic or catatonic features (APA, 2013) C. Psychotherapy Plus Antidepressant Medication The combination of psychotherapy and antidepressant has additional medical effect on patients with interpersonal or psychosocial problems, co-occurring Axis II disorder or intrapsychic conflict (APA, 2013). Assessment should be done in all treatment options to determine the patient’s treatment response. If non-response is observed, assessment should be done on the side effects of the drug, its effects and possible reasons for failure and the treatment option reconsidered (APA, 2013). References AllPsychonline. (2011). Psychiatric Disorders: Major Depressive Disorder (Unipolar Depression). Retrieved on 26th May 2013 from: http://allpsych.com/disorders/mood/majordepression.html. American Psychiatric Association. (2013). American Psychiatric Association Practice Guideline For The Treatment Of Patients With Major Depressive Disorder. (Third Ed.). Updated Version of American Journal of Psychiatry 2000. 157(4):1-45. Retrieved on 26th May 2013 from: http://www.guidelines.gov/content.aspx?id=24158 CPG. (2007). Management of Major Depressive Disorder. Clinical Practice Guidelines. Curtin University. (n.d). Identifying Mental Health Problems And Conditions. Retrieved on 26th May 2013 from: http://unilife.curtin.edu.au/health_wellbeing/mental_health_identify.htm---X4 Lam, R. (2012). Depression. (2nd Ed.). Oxford, UK: Oxford University Press. Lippincott Williams & Wilkins. (2006). Straight A's In Psychiatric And Mental Health Nursing, Volume 1. New York: Lippincott Williams & Wilkins. NHS. (2012). Suicide – Causes. Retrieved on 26th May 2013 from: http://www.nhs.uk/Conditions/Suicide/Pages/Causes.aspx. Orthopedic Trauma Association. (2011). Femur Shaft Fractures (Broken Thighbone). Retrieved on 26th May 2013 from: http://orthoinfo.aaos.org/topic.cfm?topic=A00521 Patient Health Questionnaire (PHQ-9). Retrieved on 26th May 2013 from: http://www.integration.samhsa.gov/images/res/PHQ%20-%20Questions.pdf. Roy, J. R. (2005). Depression. Tarytown, New York: Marshall Cavendish. Read More