Introduction
The patient’s main complaint at the presentation was that he had been depressed and gloomy for a while. He expresses a lack of interest in previously enjoyed hobbies and energy for even the most basic duties. The patient complains of having trouble falling asleep, focusing, and feeling unworthy. He claims to feel socially alienated and unsupported but deny having recently experienced any substantial life difficulties or catastrophic occurrences. The patient expresses worry that these symptoms are interfering with their capacity to carry out daily tasks, such as working and maintaining relationships. Although he tried committing suicide, the boy denied having the plans to take his own life.
History Of Present Illness/Interval History
The patient is a 17-year-old male with a continuous poor mood and lack of interest in activities for the past year. The symptoms have deteriorated over time and interfere with the patient’s daily functioning. The patient reports feeling depressed, hopeless, and unmotivated and having significantly less energy. He also has trouble concentrating and making judgments. Positive aspects to consider include emotions of worthlessness, guilt, and a loss of appetite (Gloster et al., 2020). Suicidal or homicidal thoughts, psychotic symptoms, or substance use disorders have not been documented.
Psychiatric Review of Systems
Depression: Positive for anhedonia, changes in appetite, sleep patterns, weariness, social isolation, decreased interest in activities, and depressed mood.
Anxiety: A contraindication for people who suffer from excessive concern, panic attacks, or phobias.
Mania: It has a negative impact on higher mood, grandiosity, enhanced energy, and risk-taking behaviors.
Psychosis: Negative for delusions, hallucinations, or irrational thought
ADHD: Negative for symptoms of inattention, hyperactivity, or impulsivity.
OCD: Negative for obsessive or repetitive thoughts or actions.
Trauma: Negative for PTSD or trauma history
Sleep Disorder: Positive for difficulty falling asleep and feeling fatigued.
Eating Disorder: Negative
No results point to any other possible psychiatric diagnoses, and the patient’s psychiatric review of systems is consistent with the diagnosis of major depressive illness.
Medical
Current medical issues: Depression
Past medical issues, surgeries, and procedures: The patient reports no significant past medical issues.
PCP: Dr. Dan at XYZ Clinic
Current medications:
- Sertraline is taken orally once daily; the patient started it two months ago.
- Melatonin is taken orally once daily when going to sleep; the patient started it one week ago.
Risk Assessment
Suicide: J.S. has disclosed having thoughts of suicide but does not have a particular plan or goal. The patient’s possible motivations for suicide are not reported. There is no discussion of the reasons for living.
Level of acute risk of suicide: Low
Level of chronic risk of suicide: Low
Homicidal Ideations and Aggression: Not present
Past Psychiatric History
J.S. does not have any documented psychiatric history from the past.
Clinical Impression/Formulation/Medical Decision Making
J.S. exhibits symptoms that support a major depressive disorder diagnosis. The patient has vague suicidal thoughts and moderately severe symptom severity. Some psychiatric conditions are not identified. Psychotherapy and antidepressant medication may be helpful for J.S (Akbari et al., 2022). The patient’s level of acute and chronic suicide risk has to be further assessed.
Diagnosis
Another diagnosis is not available to the patient.
Plan of Treatment
- Psychotherapy: Referral to a qualified therapist for depression-focused individual treatment, including CBT and mindfulness-based approaches (Gloster et al., 2020).
- Pharmacology: Begin treatment with a selective serotonin reuptake inhibitor (SSRI) antidepressant drug, such as fluoxetine, at 20 mg per day and increase the dosage as tolerated to 40 mg per day.
- Safety planning: With the patient, a safety plan was created that included identifying suicidal thinking triggers, warning indications of depression worsening, and what to do in the event of a crisis or suicidal ideation (Fonseca-Pedrero et al., 2022).
Treatment Goals:
- To decrease anxiety and depression symptoms to enhance general performance and quality of life.
- To avoid relapse, improve adherence to medication and therapy.
Prognosis: Good, provided the necessary treatment is received, and the treatment plan is followed.
Follow-up: Attendance at the primary care physician’s office weekly for the first month, followed by bi-weekly visits for the subsequent two months. If symptoms continue or worsen, referral to a mental health specialist should be considered (Akbari et al., 2022).
Evidence-Based Treatment
Medication
The first-line treatment for major depressive illness is selective serotonin reuptake inhibitors (SSRIs). Among the SSRIs, fluoxetine has successfully treated signs of anxiety and depression (Luo et al., 2020). Starting at 20 mg per day, the maximum daily dose of fluoxetine can be adjusted based on the patient’s response and tolerance.
Psychotherapy
CBT is an empirically supported psychotherapy approach for treating anxiety and depression problems. The primary goal of CBT is to pinpoint and change the harmful thought patterns and behaviors that the patient’s symptoms are caused by (Gloster et al., 2020). It has been demonstrated to be efficient in easing depression and anxiety symptoms in both individual and group settings.
Development
Establishing close bonds with people while forging a sense of self and purpose is the primary psychological job of young adulthood. Treatment should focus on enhancing the patient’s capacity to pursue goals and build meaningful relationships, as the symptoms may impede these activities.
Patient Education
The patient will get educated about the causes of depression and anxiety disorders, the benefits of psychotherapy and medication, and the significance of adhering to the prescribed course of action. He will be told about the medication’s possible negative effects and management techniques.
References
Akbari, M., Seydavi, M., Hosseini, Z. S., Krafft, J., & Levin, M. E. (2022). Experiential avoidance in depression, anxiety, obsessive-compulsive related, and posttraumatic stress disorders: A comprehensive systematic review and meta-analysis. Journal of Contextual Behavioral Science. Web.
Fonseca-Pedrero, E., Al-Halabí, S., Pérez-Albéniz, A., & Debbané, M. (2022). Risk and protective factors in adolescent suicidal behaviour: a network analysis. International journal of environmental research and public health, 19(3), 1784. Web.
Gloster, A. T., Walder, N., Levin, M. E., Twohig, M. P., & Karekla, M. (2020). The empirical status of acceptance and commitment therapy: A review of meta-analyses. Journal of Contextual Behavioral Science, 18, 181-192. Web.
Luo, Y., Kataoka, Y., Ostinelli, E. G., Cipriani, A., & Furukawa, T. A. (2020). National prescription patterns of antidepressants in the treatment of adults with major depression in the US between 1996 and 2015: a population representative survey-based analysis. Frontiers in psychiatry, 11, 35. Web.