Case Study: Kel

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Case study: Kel

Presenting Problems

Kel exhibits a wide range of problematic symptoms suggestive of a serious mental health problem, such as severe depression symptoms, which include unwavering melancholy and hopelessness, interest loss in once-enjoyed hobbies, and functional impairment. She also has a severe lack of energy and acute weariness, which interferes with her day-to-day activities, including employment and self-care. The severity of her disease is further highlighted by the significant weight loss she experienced over two months due to a decreased appetite, social separation from friends and coworkers, neglectful communication, work impairment as a certified public accountant, and excessive sleep combined with chronic weariness. These signs indicate a severe and complicated major depression disorder (MDD).

Primary and Differential Diagnosis

It is critical to evaluate a primary diagnosis and differential diagnoses during the diagnostic procedure to ensure a complete picture of Kel's mental health situation. According to the DSM-5 criteria, Kel's major diagnosis is Major Depressive Disorder (MDD). Kel has several classic MDD symptoms, including a prolonged and severe low temperament, forfeiture of interest in earlier liked actions, significant weight loss, exhaustion, social withdrawal, decreased work performance, and sleep difficulties. These symptoms match the MDD diagnosis, and the severity of her condition and its duration necessitates quick attention and management.

While MDD is the primary identification, it is critical to deliberate discrepancy diagnoses to rule out other potential illnesses that may present with similar symptoms. Bipolar Disorder is considered, but it is less likely because Kel has no history of manic or hypomanic episodes. Dysthymic Disorder, characterized by persistent, less severe symptoms over a longer time, is also considered, although Kel's symptoms are noticeably severe and incapacitating (Melrose, 2019). Adjustment Disorder, connected to specific stresses, is a possible alternate diagnosis, but it is less plausible given Kel's symptoms' persistence and intensity. Her severe Major Depressive Disorder is still treated with evidence-based treatments and strategies.

Treatment Plan

Collaboration with a mental health specialist is essential in building a treatment strategy for Kel. By merging several components, this holistic method addresses her Major Depressive Disorder (MDD). The symptoms of MDD are addressed with psychoanalysis, such as Cognitive-Behavioral Treatment or Interpersonal Remedy. Medication, mainly Selective Serotonin Reuptake Inhibitors (SSRIs), may be required depending on her reaction. Exercise, a healthy diet, and better sleep habits are all important lifestyle changes. It is critical to facilitate social support from friends and family. Regular symptom assessments, suicidal ideation monitoring, and frequent follow-ups allow for adjustments. The priority is to ensure Kel's immediate safety, stabilize her mood, and assist with her MDD management for a better quality of life.

Appropriate Screening Instruments

When diagnosing a patient like Kel, who shows evident indicators of suicide ideation, it is critical to use proper screening instruments to assess the severity and danger. Several validated instruments are available to help healthcare practitioners evaluate the existence and intensity of suicidal ideation. The Columbia-Suicide Severity Rating Scale (C-SSRS) is a commonly utilized tool for evaluating suicide ideation, behavior, and lethality (Brown et al., 2020). It classifies ideation intensity as low, moderate, or high risk, giving a more specific knowledge of the patient's state. The Beck Scale for Suicidal Ideation (SSI) is another useful measure focusing on the intensity of suicidal thoughts. Furthermore, while not specifically developed for suicide evaluation, the Patient Health Questionnaire-9 (PHQ-9) comprises an inquiry about suicidal thoughts. If Kel scores high on this item, she needs further in-depth treatment and attention for her suicidal ideation.

References

Brown, L. A., Boudreaux, E. D., Arias, S. A., Miller, I. W., May, A. M., Camargo Jr, C. A., ... & Armey, M. F. (2020). C‐SSRS performance in emergency department patients at high risk for suicide. Suicide and Life‐Threatening Behavior, 50(6), 1097-1104.

Melrose, S. (2019). Persistent depressive Disorder or dysthymia: An overview of assessment and treatment approaches. Sherri Melrose Publications: A Virtual Memory Box.