- A 60-year-old male has struggled with depression for 40 years. Recently, his family noticed worsening symptoms. - Three key questions the provider would ask are about life changes, suicidal thoughts, and safety at home. - It's important to involve family by asking about dynamics, triggers, and the home environment. - Diagnostic testing and scales can help evaluate symptoms and rule out other causes, while follow-ups assess progression. - Differential diagnoses include adjustment disorder, dysthymia, and bipolar disorder.

1. Assignment:
Write a Respond to two of these #1&2 case studies using one or
more of the following approaches:
Share additional interview and communication techniques
that could be effective with your colleague’s selected
patient.
Suggest additional health-related risks that might be
considered.
Validate an idea with your own experience and additional
research.
Each must have at least 2 references no more than 5 years
old using APA Format
Response # 1
“The case of physician do not heal thyself”
Three questions I will ask the patient on a visit to my office and
rationale thereof.
Major depressive disorder (MDD) is defined as “feelings of
sadness and/or a loss of interest in activities once enjoyed. It
can lead to a variety of emotional and physical problems and
can decrease a person’s ability to function at work and at home”
and it is one of the most common reasons patients present for
medical care worldwide (McConnell, Carter & Patterson, 2019).

2. Childhood traumatic experiences, including physical, sexual,
and emotional abuse, neglect, and separation from caregivers,
they posit significantly increase the risk of developing mental
and physical illnesses later in life.
NO .1
Have you had any thoughts of death or suicide before? Are you
having them now? And do you have a current plan to harm or
kill yourself? What are the details of that plan?
McConnell,et .al, (2019) posit that clients with MDD often
presents with feeling sad or depressed; lack of interest or
pleasure in previously enjoyed activities; appetite changes
(unintentional weight loss or gain); sleep difficulty (too much
or little); lack of energy (fatigue); feeling of guiltiness or
worthlessness; moving more slowly or pacing (others observe);
difficulty with decision-making, concentration, and thinking;
and/or suicidal thoughts.
Patient safety remains a central concern in every healthcare
setting (Smith,2018). This patient did report several feelings of
Suicide Ideation and Homicidal ideation so patients’ safety
should be priority. Although the welfare of patients
encompasses a broad range of concerns, the increasing
prevalence of suicide in our society compels health care
workers to ensure a safe healthcare environment for patients
with suicidal ideation. These efforts include the elimination or,
at least, the mitigation of physical setting characteristics that
enable suicide attempts.
No 2.
Are you depressed? How does this problem make you feel?
What makes the problem better?

3. According to DSM-5 (2013) diagnostic criteria, MDD requires
five or more of the following symptoms during the same two-
week period and represent a change from previous functioning;
at least one symptom is either 1) depressed mood or 2) loss of
interest or pleasure (American Psychiatric Association [APA],
2013).
According to the patient’s file, he has experienced five or more
of the symptoms of MDD during the same two-week period, on
more than one occasion, including depressed mood, recurrent
suicidal ideation, and suicide attempts, and was diagnosed with
major depression for the first time when he was 23.
NO 3.
How often do you take your medication and how long did you
take them before stopping? The patient has a history of stopping
his medication, self-medication and non-adherent to treatment.
This question is necessary because most antidepressants take a
while to build up in the system.
Sources of information
From the social history, patient was married and divorced 3
times, currently single, has no children, nonsmoker no drug
abuse, rarely drinks, he’s a Physician and successful
businessman. We can elicit information from siblings, extended
relatives and even colleagues at work. childhood traumatic
experiences, including physical, sexual, and emotional abuse,
neglect, and separation from caregivers, significantly increase
the risk of developing mental and physical illnesses later in life
(
McConnell, et. al, (2019). Colleagues at work and close friends
can also be asked about his temperament and attitude at work as
this could help with diagnosis and treatment modalities. Also, if

4. patient has access to weapon at home, the relatives might have
to make sure it is locked in a safe place or removed if he is
currently suicidal.
Physical Exam and Diagnostic tests.
Health assessment will ensure a structured approach that
includes comprehensive history taking and meticulous physical
examination, carrying out these two parts consecutively enables
the examiner to assess the presenting complaint, establish an
accurate differential diagnosis and provide any necessary
interventions Kennedy & O’Connor, (2016). Physical
examination of a patient will include looking at the patient’s
overall appearance skin color, turgor and general assessment.
Skin for self-injury and discoloration, bruise, vital sign, BMI,
general appearance, nutritional status. Gait, balance
coordination, reflexes, and involuntary movements, mental
status for evidence of mental disorder and thought process.
Electroconvulsive therapy (ECT) according to Birrer & Vemuri,
(2004) is a first-line option in patients with depression and
psychotic features who have not responded to antipsychotic and
antidepressant medications, and patients with severe
nonpsychotic depression who have not responded to adequate
trials of two antidepressant.
I will in addition to the above check the Erythrocyte
Sedimentation Rate (ESR). A change in ESR between two visits
was also significantly correlated with a change in PGA, renal,
fatigue and joint VAS, (Stojan, Fang, Magder & Petri, 2013).
This test is vital to our study because most drugs are eliminated
through this media.
Differential Diagnoses
1. I think Major Depressive Disorder (MDD) is the main

5. diagnoses for my client. Major depressive disorder (MDD) is
defined as “feelings of sadness and/or a loss of interest in
activities once enjoyed. It can lead to a variety of emotional and
physical problems and can decrease a person’s ability to
function at work and at home” and it is one of the most common
reasons patients present for medical care worldwide
(McConnell, Carter & Patterson, 2019). According to the
patient’s file, he has experienced five or more of the symptoms
of MDD during the same two-week period, on more than one
occasion, including depressed mood, recurrent suicidal ideation,
and suicide attempts, and was diagnosed with major depression
for the first time when he was 23 (APA, 2013; Stahl, 2011).
1. Borderline personality disorder. The Statistics Manual of
Mental Disorders (5th ed.; DSM-5), include fear of
abandonment, destructive impulsivity, self-harm, suicidality
(evidenced by threats or gestures of self-mutilation), and
intense, uncontrollable, or inappropriate anger (American
Psychiatric Association, 2013). Per report, patient has
depressive symptoms characterized as unhappiness and transient
depressed moods of a few days’ duration and with more anxiety
than depression, improving without treatment – Actively
suicidal and overdosed on his medications.
2. Bipolar II with mixed features; the Diagnostic and Statistical
Manual of Mental Disorders (DSM) version 5 stipulates that a
diagnosis of BP II disorder cannot be assigned unless the
patient has experienced hypomania for four days or longer,
however, many studies according to McCraw, S., & Parker,
(2016), have shown that the demographic and clinical features
of BP II patients with short (i.e. one to three days) hypomanic
states are similar to those of patients who meet criteria for
DSM-defined hypomania across a range of clinical variables
such as age at disorder onset, symptom severity, number of
previous episodes of hypomania, number of past
hospitalizations, presence of mixed states and family history.

6. Thus, it appears likely that patients with short hypomanic
episodes may benefit from the same treatments which are
effective for a DSM-defined BP II condition. Patient from
report did endorse that since age 23, he has had many episodes
lasting a week or more of irritability, inflated self-esteem,
increased goal-directed work activity, decreased need for sleep,
over talkativeness, racing thoughts, psychomotor agitation and
risky behavior; could also experience euphoria or expansiveness
to a significant degree but only for 2 or 3 days at most and
usually shorter.
Review of medication
With this patient experiencing MDD mixed with some
hypomanic episodes, my first choice of medication will be
Abilify (aripiprazole) 15 mg orally daily. This medication
exerts its effect by working on the CYP2D6 and 3A4 enzymes
which some variations of metabolism in different races (Dean,
2016). I will start low and titrate up to minimize the incidence
of side effects and improve patient’s compliance, incase my
patient is a poor metabolizer. According to McIntyre, Ng-Mak,
Chuang, Halperm, Patel, Rajagopalan, and Loebel (2017),
antidepressants should be chosen with caution because they can
induce mania and distort mood. The patient is already
experiencing mixed features of hypomania; thus, antidepressant
will not be initiated. Abilify, an atypical antipsychotic
according to Stahl (2014), is first line for MDD with mixed
features. Abilify has a monthly injectable, which will might
help with compliance. Symptoms may improve in a week, but it
takes at least 4-6weeks to determine drug efficacy (Stahl,
2014b). The patient has been non-compliant with his
medications, so the injectable might prove worthwhile.
2. My second drug of choice will be Lurasidone 20 mg (Latuda)
oral daily; This medication according to Stahl, (2013) treat
Bipolar depression, acute mania/mixed mania, other psychotic

7. disorders, bipolar maintenance and treatment-resistant
depression. This medication in addition to Olanzapine-
fluoxetine combination (OFC), quetiapine (either the standard
or the extended release preparation), and lurasidone are the only
FDA drugs granted (extended) approval for the (acute)
treatment of bipolar depression in adults (Fornaro, De Berardis,
Perna, Solmi, Veronese, Orsolini, Bartolomeis, 2017).
The medication exerts its effectiveness by blocking dopamine 2
receptors, reducing positive symptoms of psychosis and
stabilizing affective symptoms and blocking serotonin 2A
receptors, causing enhancement of dopamine release in certain
brain regions and thus reducing motor side effects and possibly
improving cognition and affective symptoms.
Lesson Learned
Taking care of patients in the medical field often pose a great
challenge. This patient is a typical case of the above. He is a
prescriber and is self-medicating and is initiating and ceasing
therapy and altering the doses of prescribed medications against
the advice from his psychiatric providers. Therefore, nurse
practitioners should be able to perform a thorough assessment
and conduct the necessary physical examinations on patients.
This patient has a history of noncompliance with medications
and self-medicates, he should be monitored weekly and relevant
diagnostic tests conducted to ensure compliance with treatment
modalities.
Response # 2
This discussion is about a case study of a 60-year-old male,
whom has struggled with depression for the past 40 years.
The male has done well with his current treatment until

8. recently. His family noticed that he was less active, not very
joyful, feeling hopeless, and worthless. Client has a family
history pf mental illness. His medical history includes
osteoporosis, hypertension, hypercholesterolemia, enlarged
prostate, and arthritis. He has been on different treatments in
the past. Diagnostic testing was performed.
Questions
Three questions I would choose the ask my patient would be
Are there any significant life changes that occurred in the last
five years to trigger an exacerbation in depression? This would
allow us to review if anything specifically exacerbated his
symptoms. Do you have suicidal thoughts or any past suicidal
attempts? We want to make sure that the patient is not at risk of
committing suicide (Fried & Nesse, 2015). Lastly, I would ask
the patient if they feel safe at home? This is important because
our patient’s safety is very important (Laff, 2016).
Family Questions
When assessing a patient, it is nice to allow the family to be
involved if they are supportive and want to help the patient’s
health improve. Some questions that the provider may want to
ask the family are: How are the family dynamics, Does the
patient’s symptoms get worse in certain environments, and
What does the family member suffering from depression in their
home environment? These are important questions to help
develop a picture of what is going on with the patient (Laff,
2016).
Physical Exam and Diagnostic Testing
When assessing the patient for Major depressive disorder you
want to examine the patients’ depressive symptoms. In the case
study the patient had lost interest in activities, feeling sad, no

9. joy, worthless, and hopeless. The patient was having trouble
concentrating. Scales are major when screening for depression.
The scale cannot diagnose a patient but can help confirm a
diagnosis and tell us the severity of the depression. Some
appropriate screens include patient health questionnaire (PHQ-
2), patient health questionnaire 9 (PHQ9), ZUNG scale, and
Beck depression inventory (BDI). Diagnostic testing is useful in
ruling out any other diseases/conditions that may be causing the
depression. We run a blood test such as complete blood count,
comprehensive metabolic panel, and thyroid panel. We want to
make sure the patient does not have organic disease, infection
or a thyroid disorder that may be causing the depressive
symptoms (Ng, How, & Ng, 2016).
Differential Diagnoses
The three differential diagnosis I have chosen are
adjustment disorder, persistent depression disorder (dysthymia),
and bipolar disorder. Adjustment disorder is an emotional or
behavioral reaction over several months of stressful events or
changes in a person’s life. Dysthymia is a chronic mood
disorder with a duration of at least two years, the person does
not experience pleasure, displays other depressive symptoms
that can affect the person's overall quality of life. Bipolar
disorder is a mood disorder that has relapsing and remitting
spells of mania and depression, the individual experiences
depression more than mania (Lee & Swartz, 2017).
Drug Therapy
In this case study, the patient was started on Abilify and
venlafaxine. Another good medication choice for initial
treatment would be SSRIs. Abilify has side effects of weight
gain, increased lipid levels, EPS, nausea, vomiting, and dry
mouth. Venlafaxine can increase blood pressure. SSRIs such as
Prozac Zoloft, or Celexa. This SSRI has fewer side effects and

10. is safe. The SSRIs turn off the production of new serotonin,
sending the message to the brain to continue making serotonin
(Edwards, 2018). SSRI’s are do not have dietary restrictions
like MAOIs, or cause heart disturbances and orthostatic
hypotension SSRI (Bressert, 2017).
Follow-ups
Follow-ups are used to evaluate the progression of the patient’s
symptoms. Practitioners evaluate medication side effects, the
effectiveness of the medication, and the patient’s symptoms. It
can take 4-8 weeks to know the effectiveness of a medication.
In the case study, they followed up with the patient every four
weeks. This case study taught the lesson of thinking outside of
the box and using diagnostic tools to help improve the patient’s
symptoms. The therapeutic dosages for venlafaxine, the initial
dosage is 37.5 mg, the maintenance dose is 75 mg -100 mg,
moderate depression is 225 mg, and severe depression is 375 mg
(Drugs.com, 2019). This practitioner used blood levels to find
the patient’s therapeutic dosage. By doing this the patient
developed remission.