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Therapy with Older Adults

The client in this case study is a 69-year-old, widowed, African American man. He is self-referred to the clinic to get help with his anxiety and depression. After listening to the clients concerns and getting his background information, I would give him the diagnosis of major depressive disorder (MDD). The complete diagnosis with coding would be major depressive disorder, recurrent episode, severe, without psychotic features, with anxious distress, and melancholic features (Association, 2013). According to the DSM IV, in order to be diagnosed with MDD there must be five or more symptoms from the list of criteria, it should represent change from the individuals usual behaviors and be present over at least a two week time period (2013).

The client is experiencing at least eight symptoms, making the MDD severe, from the listed criteria that have negatively impacted important areas of his life and are not directly correlated with a substance or medical condition. His history does not indicate that any of the symptoms he is currently experiencing can be classified as a mixed episode, manic or hypomanic episodes, and he is not showing signs of schizophrenia or any psychotic features (Substance Abuse and Mental Health Services Administration, 2016). This is also recurrent; the client has had episodes of depression and anxiety in his past. He reports that he feels depressed at least most of the day which is also noticed by his son, he has lost interest in activities that used to bring him pleasure like volunteering at the nursing home and being with his family, the client is experiencing insomnia which is exhibited by him stating that it is hard to fall asleep at night, he is experiencing psychomotor changes exhibited by feeling like he is moving in slow motion, he says that he feels tired all the time, during the assessment it is noted that he is showing signs of guilt and rumination, he states that he has been having trouble concentrating while reading, and he also very preoccupied with the anticipated death of his father and previously his own death when he was diagnosed with prostate cancer (Substance Abuse and Mental Health Services Administration, 2016). The symptoms that he is experiencing fit the criteria for the diagnosis to be specified as anxious distress and melancholic features.

Diagnosing and identifying the severity of MDD accurately and in a timely manner is imperative to initiate treatment. There are several physical exams and diagnostic tools that are routinely used to rule out other medical conditions, confirm a diagnosis of MDD, and identify the severity. Physical exam that focuses on the neurological and endocrine systems should be done to rule out any medical causes for the depression that the client is experiencing, and blood tests to check for anemia, thyroid function tests, levels of calcium, hormones, and vitamins should also be completed low levels of these can cause depressive symptoms (Giannelli, 2020). Diagnostic tools include the Patient Health Questionnaire-2 (PHQ-2), Patient Health Questionnaire-9 (PHQ-9), the Beck Depression Inventory (BDI), and the Geriatric Depression Scale (GDS) (Ng & et al., 2016). The PHQ-2 is a two-question tool that can be used in a busy primary care setting. The PHQ-9 is usually more readily used as the results are easily interpreted and understood, it is easy to administer, and highly accurate (Costa & et al., 2016). The BDI cover affective, cognitive, and somatic aspects of major depression, it is typically used in the outpatient setting it is also highly sensitive to accurately identifying MDD (Ng & et al., 2016). And finally the GDS has been proven to be reliable when screening and identifying major depressive disorder specifically in the elderly population, it is rather lengthy which would make it difficult to use in a busy office setting (Ng & et al., 2016). I would use the PHQ-9 for this client, I am familiar with this assessment and find it useful in detecting depressive symptoms.

Differential diagnosis to consider would be persistent depressive disorder, adjustment disorder with depressed mode, and sadness. The has been experiencing these symptoms over a long period of time, feels hopeless, and is having trouble concentrating (Association, 2013). Psychoeducation should be provided to the client and his family, it should include depression signs and symptoms, the side effects of the pharmacological intervention, and information about the different treatment options to give the client the opportunity to be actively involved in his treatment (Guatam & et al., 2017).

There are different treatment options for management of depression which includes antidepressants, electroconvulsive therapy (ECT) and psychosocial interventions (Gautam & et al., 2017). The success of any of these treatment options requires compliance and cooperation from the client. All antidepressants have been proven to be effective, but they all work differently depending on the client. Selective serotonin reuptake inhibitors (SSRIs) are typically the first line of antidepressants used, they are relatively safe and have less severe side effects (Gautam & et al., 2017). The client has been prescribed three different SSRI’s and two NSRI’s over the years which he reports as having little or no effect. The client denies suicidal ideations his safety is not in immediate danger currently. However, the immediate initiation of an antidepressant is warranted in this situation. I would start him out with a low dose of Trazodone at bedtime and taper up, it has been shown to cause drowsiness in some individuals which can aid in treating the client’s insomnia as well as his depression (Jaffer & et al., 2017).

“Cognitive behavioral therapy (CBT) and interpersonal therapy are the psychotherapeutic approaches that have the best documented efficacy in the literature for management of depression” (Gautam & et al., 2017). As the PMHNP I would recommend using IPT to treat the client’s depression. The goal of this treatment is immediate symptom relief, improved relationships with his family, and to give the client tools and tips that he can use when stressors arise after treatment (Wheeler, 2014). IPT is structured and time limited acute treatment, usually 12-16 weeks of treatment is recommended (Cuijpers et al., 2016). Depression is common in the elderly, but it is not a normal part of aging, recognizing the symptoms of depression in older adults can sometimes be difficult but treatment of this disorder is imperative (Wheeler, 2014).

References

Association, A. P. (2013). Diagnostic and statistical manual of mental disorders, 5th edition: Dsm-5 (5th ed.). Washington, DC: Author.

Cuijpers, P., Donker, T., Weissman, M. M., Ravitz, P., & Cristea, I. A. (2016). Interpersonal psychotherapy for mental health problems: A comprehensive meta-analysis. American Journal of Psychiatry, 173(7), 680–687. https://doi.org/10.1176/appi.ajp.2015.15091141

Giannelli, F. R. (2020). Major depressive disorder : Journal of the american academy of pas. LWW. https://journals.lww.com/jaapa/Citation/2020/04000/Major_depressive_disorder.2.aspx

Gautam, S., Jain, A., Gautam, M., Vahia, V. N., & Grover, S. (2017). Clinical Practice Guidelines for the management of Depression. Indian journal of psychiatry, 59(Suppl 1), S34–S50. https://doi.org/10.4103/0019-5545.196973

Jaffer, K. Y., Chang, T., Vanle, B., Dang, J., Steiner, A. J., Loera, N., Abdelmesseh, M., Danovitch, I., & Ishak, W. W. (2017). Trazodone for Insomnia: A Systematic Review. Innovations in clinical neuroscience, 14(7-8), 24–34.

Ng, C. W., How, C. H., & Ng, Y. P. (2016). Major depression in primary care: making the diagnosis. Singapore medical journal, 57(11), 591–597. https://doi.org/10.11622/smedj.2016174

Substance Abuse and Mental Health Services Administration. (2016). DSM-5 Changes: Implications for Child Serious Emotional Disturbance [Table 9, DSM-IV to DSM-5 Major Depressive Episode/Disorder Comparison]. https://www.ncbi.nlm.nih.gov/books/NBK519712/table/ch3.t5/

Wheeler, K. (Ed.). (2014). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice (2nd ed.). New York, NY: Springer Publishing Company.