NR 603 Week 6 Mental Health Treatment Plan / Analysis–
Part 2
Dr. Deering,
Major depressive disorder (MDD) is considered one of the top reasons for disability in the United
States (WHO, 2018). Depression affects 350 million people worldwide. It is more prevalent in
women than men. This disorder can go undetected for many years, often leading to increased
morbidity from other physical illnesses, substance abuse, and increased suicidal ideations. As
healthcare providers, it is important to conduct a complete history and physical, and use appropriate
screening tools, such as PHQ-9, to diagnose depression. While many concerning histories should be
referred to a mental health specialist, healthcare providers can certainly initiate treatment to help
alleviate their symptoms. Keeping an open line of communication with patients who suffer from
depression will positively impact their lives and reduce the social stigma associated with MDD. The
following information is the full five-point treatment plan and analysis for D.W’s plan of care.
Primary Diagnosis: Major Depressive Disorder, first episode
Diagnostic Testing: At this time, it is important to rule out medical conditions and medication
regimens that may contribute to D.W’s symptoms. Unfortunately, there is no diagnostic testing for
major depressive disorder (MDD). The guidelines from the American Psychiatric Association (APA,
2017) recommends a comprehensive physical examination, as well as a thorough review of medical
history, medications, life stressors, and the presence of substance use disorder. D.W does not have
medications or history of substance use that may contribute to her symptoms. She also does not have
any family history of psychiatric disorders. However, D.W does have a couple life stressors. She was
recently divorced a month ago, and is now the sole caretaker of her twin daughters. She also reports
having increased stress with work deadlines as a human resources recruiter. The APA also
recommends ruling out differential diagnoses that may mimic D.W’s depressive symptoms (APA,
2017). Therefore, the next valid step is to obtain laboratory tests, including complete blood count
(CBC), comprehensive metabolic panel (CMP), thyroid-stimulating hormone (TSH), lipid panel,
vitamin B12, and vitamin D levels. Assessment and screening must include a work-up to exclude
other disorders, such as hypothyroidism, anemia, renal problems, cancers, or cardiac issues, that may
cause similar symptoms (APA, 2017).
Once differential diagnoses have been addressed, utilizing the patient health questionnaire (PHQ)
tool is the next step in D.W’s assessment. According to the US Preventive Services Task Force
(USPSTF), the PHQ screening tool is one of the most common, non-invasive screening tools that can
be performed to measure the severity of depression (Maurer, Raymond, & Davis, 2018). The PHQ
can be an important tool to monitor and address the patient’s potential for uncontrolled depression
because it encompasses a combination of the DSM-IV criteria for depression. If D.W’s screening is
indicative of depression, another essential step is to confirm diagnosis by using the DSM-IV criteria
for depression (Whooley, 2016). In addition to depressed mood or anhedonia in the past two weeks,
at least five of the following symptoms must be present for a diagnosis of depression: depressed
mood, appetite change/weight loss, insomnia, diminished ability to concentrate, fatigue/loss of
energy, feelings of worthlessness or excessive guilt, or recurrent thoughts of death (Whooley, 2016).
, In this case study, D.W reports loss of interest, and at least five symptoms including weight loss,
fatigue, lack of quality sleep, difficulting concentrating, and an overall depressed mood. Meeting the
criteria can confirm the diagnosis of depression.
Medications: For the treatment of MDD, the APA guideline recommends a first line treatment of a
selective serotonin reuptake inhibitor (SSRI) (APA, 2017). With D.W’s depressive symptoms and a
moderately severe PHQ-9 score of 14, I would initially start D.W on a low dose of fluoxetine at 20
mg once daily. I would then monitor her symptoms and modify by increasing 10-20 mg every 4-5
weeks (Kovich & Dejong, 2015). SSRIs are commonly the first line treatment for patients with
depression due to its fewer adverse effects (Kovich & Dejong, 2015). SSRIs increase the amount of
serotonin by blocking the presynaptic serotonin reuptake pump (Kovich & Dejong, 2015). Fluoxetine
is an appropriate drug of choice for D.W because SSRIs are associated with fewer adverse effects
and drug interactions compared with other classes of antidepressants.
Education: D.W should be educated on the common adverse effects of SSRIs, such as dizziness,
sexual dysfunction, nervousness, nausea, sleep disturbance, and weight changes (Hollier, 2016). D.W
should also be educated on not abruptly discontinuing her SSRI because of an adverse effect called
serotonin syndrome. Serotonin syndrome is a potentially life-threatening condition from excess
serotonin agonist activity (Hollier, 2016). Symptoms of serotonin syndrome may start out as diarrhea
and can progress to mental status changes and neuromuscular abnormalities (Hollier, 2016). This is
due to a rapid titration of the medication, overdose, or a drug interaction.
It is also important to educate D.W that antidepressants have a delayed therapeutic effect. Therefore,
D.W should expect clinical improvement within two weeks and achieve full therapeutic effect within
four to eight weeks (APA, 2017). Lastly, D.W will need to be educated on when to seek emergency
treatment, such as neurological status changes (seizures, extreme lethargy, disorientation, or slurred
speech) and severe side effects such as severe headache, dizziness, and chest pain (APA, 2017).
In addition, non-pharmacologic treatments should also be encouraged. Deep breathing, medication,
massage, acupuncture, and aromatherapy can provide some benefits to improving mood and
promoting positive emotional responses (Fulcher et al., 2014). Although these therapies may not cure
depression, they aid in triggering positive emotional and physical responses by stimulating the
body’s limbic system, which is important in regulating depression (Fulcher et al., 2014). Physical
exercise may also benefit patients with depression by improving mood, reducing anxiety, boost self-
esteem, and lower rates of depression. D.W. should be educated on reducing caffeine consumption,
especially in the afternoon or at least six hours before bed in order to improve sleep hygiene. She can
also try melatonin at night to improve and regulate sleep.
Referrals/Consults:
In terms of MDD, cognitive behavioral therapy is considered first-line non-pharmacological
intervention (APA, 2017). The APA guideline recommends psychotherapy in conjunction with
pharmacotherapy. Therefore, I would strongly refer D.W to a mental health specialist, who can
initiate a psychiatric evaluation and provide psychotherapy to focus on underlying thoughts and
behaviors. Based on evidence and research, cognitive behavioral therapy, or CBT, is one of the most
effective treatments in changing cognitive patterns and behavioral actions (Fekadu, Shibeshi, &
Engidawork, 2017). CBT is a form of psychotherapy that focuses on improving emotional regulation
and developing personal coping strategies to solve behavioral problems. The therapist often works
and encourages the patient to focus on solutions in modifying negative emotions, behaviors, and
thoughts (Fekadu et al., 2017). Thus, CBT can benefit D.W in identifying stress and behaviors that
Part 2
Dr. Deering,
Major depressive disorder (MDD) is considered one of the top reasons for disability in the United
States (WHO, 2018). Depression affects 350 million people worldwide. It is more prevalent in
women than men. This disorder can go undetected for many years, often leading to increased
morbidity from other physical illnesses, substance abuse, and increased suicidal ideations. As
healthcare providers, it is important to conduct a complete history and physical, and use appropriate
screening tools, such as PHQ-9, to diagnose depression. While many concerning histories should be
referred to a mental health specialist, healthcare providers can certainly initiate treatment to help
alleviate their symptoms. Keeping an open line of communication with patients who suffer from
depression will positively impact their lives and reduce the social stigma associated with MDD. The
following information is the full five-point treatment plan and analysis for D.W’s plan of care.
Primary Diagnosis: Major Depressive Disorder, first episode
Diagnostic Testing: At this time, it is important to rule out medical conditions and medication
regimens that may contribute to D.W’s symptoms. Unfortunately, there is no diagnostic testing for
major depressive disorder (MDD). The guidelines from the American Psychiatric Association (APA,
2017) recommends a comprehensive physical examination, as well as a thorough review of medical
history, medications, life stressors, and the presence of substance use disorder. D.W does not have
medications or history of substance use that may contribute to her symptoms. She also does not have
any family history of psychiatric disorders. However, D.W does have a couple life stressors. She was
recently divorced a month ago, and is now the sole caretaker of her twin daughters. She also reports
having increased stress with work deadlines as a human resources recruiter. The APA also
recommends ruling out differential diagnoses that may mimic D.W’s depressive symptoms (APA,
2017). Therefore, the next valid step is to obtain laboratory tests, including complete blood count
(CBC), comprehensive metabolic panel (CMP), thyroid-stimulating hormone (TSH), lipid panel,
vitamin B12, and vitamin D levels. Assessment and screening must include a work-up to exclude
other disorders, such as hypothyroidism, anemia, renal problems, cancers, or cardiac issues, that may
cause similar symptoms (APA, 2017).
Once differential diagnoses have been addressed, utilizing the patient health questionnaire (PHQ)
tool is the next step in D.W’s assessment. According to the US Preventive Services Task Force
(USPSTF), the PHQ screening tool is one of the most common, non-invasive screening tools that can
be performed to measure the severity of depression (Maurer, Raymond, & Davis, 2018). The PHQ
can be an important tool to monitor and address the patient’s potential for uncontrolled depression
because it encompasses a combination of the DSM-IV criteria for depression. If D.W’s screening is
indicative of depression, another essential step is to confirm diagnosis by using the DSM-IV criteria
for depression (Whooley, 2016). In addition to depressed mood or anhedonia in the past two weeks,
at least five of the following symptoms must be present for a diagnosis of depression: depressed
mood, appetite change/weight loss, insomnia, diminished ability to concentrate, fatigue/loss of
energy, feelings of worthlessness or excessive guilt, or recurrent thoughts of death (Whooley, 2016).
, In this case study, D.W reports loss of interest, and at least five symptoms including weight loss,
fatigue, lack of quality sleep, difficulting concentrating, and an overall depressed mood. Meeting the
criteria can confirm the diagnosis of depression.
Medications: For the treatment of MDD, the APA guideline recommends a first line treatment of a
selective serotonin reuptake inhibitor (SSRI) (APA, 2017). With D.W’s depressive symptoms and a
moderately severe PHQ-9 score of 14, I would initially start D.W on a low dose of fluoxetine at 20
mg once daily. I would then monitor her symptoms and modify by increasing 10-20 mg every 4-5
weeks (Kovich & Dejong, 2015). SSRIs are commonly the first line treatment for patients with
depression due to its fewer adverse effects (Kovich & Dejong, 2015). SSRIs increase the amount of
serotonin by blocking the presynaptic serotonin reuptake pump (Kovich & Dejong, 2015). Fluoxetine
is an appropriate drug of choice for D.W because SSRIs are associated with fewer adverse effects
and drug interactions compared with other classes of antidepressants.
Education: D.W should be educated on the common adverse effects of SSRIs, such as dizziness,
sexual dysfunction, nervousness, nausea, sleep disturbance, and weight changes (Hollier, 2016). D.W
should also be educated on not abruptly discontinuing her SSRI because of an adverse effect called
serotonin syndrome. Serotonin syndrome is a potentially life-threatening condition from excess
serotonin agonist activity (Hollier, 2016). Symptoms of serotonin syndrome may start out as diarrhea
and can progress to mental status changes and neuromuscular abnormalities (Hollier, 2016). This is
due to a rapid titration of the medication, overdose, or a drug interaction.
It is also important to educate D.W that antidepressants have a delayed therapeutic effect. Therefore,
D.W should expect clinical improvement within two weeks and achieve full therapeutic effect within
four to eight weeks (APA, 2017). Lastly, D.W will need to be educated on when to seek emergency
treatment, such as neurological status changes (seizures, extreme lethargy, disorientation, or slurred
speech) and severe side effects such as severe headache, dizziness, and chest pain (APA, 2017).
In addition, non-pharmacologic treatments should also be encouraged. Deep breathing, medication,
massage, acupuncture, and aromatherapy can provide some benefits to improving mood and
promoting positive emotional responses (Fulcher et al., 2014). Although these therapies may not cure
depression, they aid in triggering positive emotional and physical responses by stimulating the
body’s limbic system, which is important in regulating depression (Fulcher et al., 2014). Physical
exercise may also benefit patients with depression by improving mood, reducing anxiety, boost self-
esteem, and lower rates of depression. D.W. should be educated on reducing caffeine consumption,
especially in the afternoon or at least six hours before bed in order to improve sleep hygiene. She can
also try melatonin at night to improve and regulate sleep.
Referrals/Consults:
In terms of MDD, cognitive behavioral therapy is considered first-line non-pharmacological
intervention (APA, 2017). The APA guideline recommends psychotherapy in conjunction with
pharmacotherapy. Therefore, I would strongly refer D.W to a mental health specialist, who can
initiate a psychiatric evaluation and provide psychotherapy to focus on underlying thoughts and
behaviors. Based on evidence and research, cognitive behavioral therapy, or CBT, is one of the most
effective treatments in changing cognitive patterns and behavioral actions (Fekadu, Shibeshi, &
Engidawork, 2017). CBT is a form of psychotherapy that focuses on improving emotional regulation
and developing personal coping strategies to solve behavioral problems. The therapist often works
and encourages the patient to focus on solutions in modifying negative emotions, behaviors, and
thoughts (Fekadu et al., 2017). Thus, CBT can benefit D.W in identifying stress and behaviors that
