depression - Nursing Case Study

Pathophysiology

• Primary mechanism: Neurotransmitter Imbalance - Depression is strongly linked to imbalances in neurotransmitters, particularly serotonin, norepinephrine, and dopamine. Lower levels of these neurotransmitters can lead to depressive symptoms. Medications like SSRIs, SNRIs, and NDRI work by increasing the availability of these neurotransmitters in the brain.

• Secondary mechanism: Neuroendocrine Dysfunction - Chronic stress can lead to an overactive hypothalamic-pituitary-adrenal (HPA) axis, causing an excess release of cortisol. This imbalance can affect mood and lead to depression. Antidepressants may help by normalizing the HPA axis function.

• Key complication: Neuroinflammation - Emerging evidence suggests that inflammation in the brain can also play a role in depression, possibly by affecting neurotransmitter systems and neuroendocrine function. Anti-inflammatory treatments are being explored as potential therapies for depression.

Patient Profile

Demographics:

45, Female, High School Teacher

History:

• Key past medical history: Diagnosed with mild depression 5 years ago, Postpartum depression after second childbirth, Family history of mental health disorders

• Current medications: Escitalopram (10mg daily), occasional use of Lorazepam for anxiety

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Increased feelings of sadness, hopelessness, and loss of interest in previously enjoyed activities, difficulty in concentrating and making decisions

• Key symptoms: Persistent low mood, increased anxiety, insomnia, significant weight loss, frequent crying spells, feelings of worthlessness, thoughts of self-harm

• Vital signs: Blood pressure 130/85 mmHg, Pulse rate 100 bpm, Respiratory rate 18 breaths per minute, Body temperature 98.6°F

Section 1

Change in patient status:

The patient returns to the clinic two weeks later complaining of worsening symptoms. Despite adhering to the prescribed medication regimen, she reports more severe feelings of sadness, anhedonia, and an increased frequency of self-harming thoughts. She now experiences significant agitation, restlessness, and a constant sense of impending doom. She also discloses that she has started to withdraw from her colleagues at work and has been calling in sick frequently due to her inability to concentrate and a lack of motivation. Her appetite has further decreased, and she has lost an additional 10 pounds since her last visit. Vital signs upon examination are: Blood pressure 135/90 mmHg, Pulse rate 110 bpm, Respiratory rate 20 breaths per minute, Body temperature 98.6°F.

New diagnostic results:

Given the severity of the patient's symptoms and non-response to the current treatment, the healthcare provider decides to further investigate and orders a full blood count, thyroid function tests, and cortisol levels. The results show an elevated cortisol level of 25 µg/dL (normal range: 6.2-19.4 µg/dL), suggesting a chronic stress response and HPA axis hyperactivity. Thyroid function tests reveal a slightly decreased T4 at 4.5 µg/dL (normal range: 4.5-12 µg/dL) and elevated TSH at 6.5 µIU/mL (normal range: 0.4-4.5 µIU/mL), indicating subclinical hypothyroidism which could be contributing to her depressive symptoms. The full blood count is within normal limits.

Clinical reasoning should now focus on the need to adjust the treatment plan considering the patient's worsening depression, elevated cortisol levels, and subclinical hypothyroidism. The healthcare provider must also address the patient's weight loss and evaluate for any underlying eating disorder or malnutrition. This scenario also underlines the importance of monitoring for potential adverse effects of SSRIs, such as increased anxiety and agitation, and the necessity to reassess the suitability of the current medication regimen.

Section 2

Change in patient status:

The patient continues to deteriorate, displaying more severe depressive symptoms and growing increasingly anxious about her health. She has become more withdrawn, avoiding social contact and has been increasingly absent from work. She also reports having trouble sleeping and experiences frequent nightmares. Despite reassurance, the patient expresses profound feelings of worthlessness and guilt. Her weight has dropped another 5 pounds, and she describes a lack of interest in food. Her vital signs are: Blood pressure 145/95 mmHg, Pulse rate 120 bpm, Respiratory rate 22 breaths per minute, Body temperature 98.6°F.

Initial assessment findings:

Upon further evaluation, the healthcare provider notes that the patient's speech is slow and her responsiveness has reduced. She lacks energy and has difficulty making decisions, indicative of psychomotor retardation. Her self-care has also declined, as she appears unkempt and disheveled. The patient's Beck Depression Inventory (BDI) score has escalated to 35 (severe depression). Mental status examination reveals the presence of suicidal ideation, highlighting a need for immediate crisis intervention.

These findings suggest that the patient's depressive symptoms have escalated to severe depression with concurrent anxiety. The healthcare provider should now consider a comprehensive management strategy involving medication adjustment, psychotherapy, and close monitoring for suicidal risk. The patient's escalating blood pressure and pulse rate, along with her continuing weight loss, also warrant close monitoring and intervention.

Section 3

Response to interventions:

The healthcare provider initiated a medication adjustment, increasing the dosage of her selective serotonin reuptake inhibitors (SSRIs) to manage her escalating depressive symptoms. She was also introduced to cognitive-behavioral therapy (CBT) and encouraged to participate in group therapy sessions. However, after two weeks, the patient shows minimal improvement. Her BDI score remains high at 32 and she continues to express suicidal ideation. Her sleep patterns have not improved, and she reports continued nightmares.

New complications:

Moreover, new concerns have arisen regarding her physical health. Her blood pressure readings have continued to rise, now averaging 155/100 mmHg, and her pulse rate remains elevated at 125 bpm. Lab results indicate elevated total cholesterol at 240 mg/dL and LDL cholesterol at 160 mg/dL, both of which are risk factors for cardiovascular disease. Additionally, her BMI has dropped to 16.5, which is classified as underweight. The healthcare provider now faces the challenge of managing the patient’s severe depression and anxiety while also addressing her worsening physical health status. The next steps would involve a review of her medication regimen, potential introduction of a second-line antidepressant, and consultation with a dietitian for nutritional intervention.

Section 4

Change in patient status:

Despite the increased dosage of SSRIs, the patient's depressive symptoms show no significant improvement. Her BDI score remains elevated and her suicidal ideation has become more frequent. She reports increased feelings of hopelessness and worthlessness, and she has begun to isolate herself from others, refusing to attend group therapy sessions. She has also developed an aversion to food, contributing to her weight loss and declining BMI.

New Complications:

In addition to her psychological symptoms, the patient's physical health continues to deteriorate. Her hypertension remains uncontrolled with her blood pressure spiking to 160/105 mmHg. It's suspected that her elevated pulse rate, now consistently around 130 bpm, may be due to increased anxiety or possibly a side effect of her SSRIs. Furthermore, her cholesterol levels continue to rise, with her LDL cholesterol reaching 170 mg/dL. Her BMI has further decreased to 16.0, indicating severe malnutrition. The healthcare provider is now faced with the additional challenge of managing the patient's risk for cardiovascular disease and malnutrition, on top of her uncontrolled depression and anxiety. This new development may necessitate a complete review of her current treatment plan, which could potentially include changes in her medication regimen, dietary interventions, and more intensive psychotherapy.

Section 5

Initial Assessment Findings:

Upon further assessment, the patient's physical symptoms appear to have significantly worsened. Her blood pressure readings have continued to fluctuate, with recent readings averaging around 170/110 mmHg. Cardiac monitoring reveals T-wave inversions, indicating possible myocardial ischemia. The patient's pulse rate has also increased to 140 bpm, which may be a combination of her worsening anxiety and potential cardiac complications. Her lipid profile has further deteriorated with her LDL cholesterol reaching 190 mg/dL, well above the ideal range.

The patient's mental status examination reveals a severe depressive state, with anhedonia, persistent feelings of worthlessness and recurrent thoughts of death. She appears malnourished and weak, with her BMI now at 15.5. Her poor nutritional status has led to decreased energy levels and increased lethargy. She has developed noticeable bags under her eyes due to insomnia and looks significantly older than her age. The patient seems to have given up on life, with a flat affect and minimal interaction with healthcare providers. The complex interplay of her mental and physical health issues calls for a comprehensive, multidisciplinary approach, combining medical, psychiatric and nutritional interventions.