Major Depressive Disorder: Case Study 1

Major Depressive Disorder: Case Study

Madeline Barbato

Centofanti School of Nursing, Youngstown State University

NURS 4842: Mental Health Nursing

Professor Teressa Peck

10-25-22
Major Depressive Disorder: Case Study 2

Abstract

The following case study describes a patient with major depressive disorder as well as the

care provided and treatments. The patient is M.R., a forty-five-year-old caucasian male

presenting to the psychiatric unit with symptoms of depression following a suicide attempt. The

patient is also diagnosed with alcoholism and other comorbid medical conditions also being

treated during the patient’s stay on the psychiatric unit. Academic articles were researched for

this case study using the MAAG Library resources, specifically CINHAL. This case study looks

at depression and its relation to grief, family support, and its impact on the grieving process, as

well as stigma related to alcoholism.

Major Depressive Disorder: Case Study 3

Major Depressive Disorder: Case Study

Objective Data

M.R. is a 45-year-old male that came to the psychiatric unit on October 12, 2022 and was

discharged on the day of the interview, which was October 18, 2022. He presented to the

psychiatric unit with a diagnosis of major depressive disorder and alcoholism. During the patient

interview, the patient spoke about his history and his experience in the psychiatric unit. He

appeared tired with large dark circles under his eyes and constantly yawned. The client also

appeared older than the age of forty-five years old. His mood appeared to be hopeful and excited,

and his affect matched his mood. He maintained eye contact and spoke openly about his

diagnosis and any question I asked him.

M.R. said that he had been feeling depressed for some time and was ready to kill himself

by hanging, but his sister found him and brought him to the E.D. M.R. had been depressed since

his father died when he was sixteen. M.R. said, “I was a happy kid always the class clown, but

after he died, I became so depressed.” The depression had worsened for him due to the loss of his

mother last April and the family stressors he had been experiencing. M.R. stated he had been

drinking since he was twenty-one years old and that he does not use any street drugs, which is

congruent with toxicology. M.R. was being discharged the day the interview took place, and we

discussed his plan when he left. When asked about his coping mechanisms for when he was

discharged, M.R. planned to “go to counseling, group therapy, and A.A. meetings.” He also

discussed getting a part-time job since he had not worked since 2007, and he is currently on

disability for depression but would like to “get back out there.” He is interested in applying at a

Goodwill near his home. M.R. also talked about picking up other positive coping mechanisms
Major Depressive Disorder: Case Study 4

such as meditation, bike riding, and playing the guitar. M.R. also expressed an interest in getting

a cat, so he would not feel so lonely at his apartment.

M.R. has a medical history of GERD, fatty liver, hypokalemia, BPH, and transaminitis.

M.R. spoke about his fatty liver disease during the interview, he stated, “My doctor said I have

fatty liver and that I need to lose weight.” M.R. also discussed starting the MyPlate diet his

doctor discussed with him as well as discontinuing alcohol use to lose weight. He disclosed that

he overeats when he feels his symptoms of depression leading to weight gain and that eating

“brings comfort.” The client’s stated goal was to lose fifty pounds in order to better his health.

M.R. is currently taking several medications for depression, anxiety, sleep and alcohol

withdrawal. For the diagnosis of depression, the client is taking Sertraline 75mg, Haloperidol

5mg, Hydroxyzine 50mg, and Trazadone 50mg as a sleep aid. M.R. is also on medications to aid

in alcohol withdrawal. M.R. is taking: Chlorthalidone 25mg, Oxcarbazepine 150mg, Thiamin

100 mg, and Folic acid 1mg. M.R. is also on Bacitracin topically for a skin abrasion on his neck.

M.R. is also on Amlodipine 10mg for an unknown reason; it could be due to an undocumented

hypertension diagnosis or to treat major depressive disorder. M.R. is also on Pantoprazole 150mg

for his diagnosis of GERD.

Labs were assessed on the patient, and most were in the normal range with the exception

of liver function, glucose, and alcohol screening. M.R.’s AST was 143 and ALT was 135, both

above normal range, indicating damage to the liver most likely due to frequent alcohol use.

Glucose was 105 which is slightly elevated and could be due to Haloperidol use or the stress of

being in the hospital. Alcohol screening came back positive which is congruent with M.R.’s

report of frequent alcohol use.

Major Depressive Disorder: Case Study 5

Summary of Diagnosis

Psychiatric Mental Health Nursing describes major depressive disorder as a mood

disorder and states, “major depressive disorder typically involves two weeks or more of a sad

mood or lack of interest in life activities, with at least four other symptoms of depression

(Videback, 2020, pg. 288).” Depression is seen to have an imbalance of serotonin or dopamine,

with the two being unusually low in persons with depression. While symptoms of depression can

clear in some persons, 20% of people who develop depression will develop a chronic form of

depression. There are several symptoms of depression that range from person to person. Some

include changes in sleep, loss of interest in life activities, weight loss or gain, insomnia, fatigue,

decreased concentration, decreased self-esteem, impairment in social functioning, and suicidal

ideation. While the DSM5 includes many more symptoms, the client must have five or more for

a two-week period to classify for the diagnosis of major depressive disorder (Videback, 2020).

There are many treatments available to treat depression such as SSRIs, MAOIs, cyclic

antidepressants, and atypical antidepressants. The first line of treatment for many patients with

depression are SSRIs, which are serotonin reuptake inhibitors that help the brain uptake more

serotonin which is typically lacking in people with depression. SSRIs require patient education

due to their long onset time (4-6weeks) and they can cause an increase in suicidal thoughts and

behaviors. Many patients with depression are also treated with other forms of therapy such as

interpersonal, cognitive, and behavioral. According to the text, “Interpersonal therapy focuses on

difficulties in relationships such as grief reactions, role disputes, and role transitions” (Videback,

2020, pg. 294). Behavioral focuses on reinforcing positive actions and cognitive focuses on how

the client perceives themselves and changing their negative perceptions.

Stressors and Behaviors that Precipitated Hospitalization

Major Depressive Disorder: Case Study 6

When asked about precipitating events prior to being admitted, the patient disclosed that

his mother died last April and that he has been having a lot of conflict with his siblings. He

hoped that after his mom died, they would “come together as a family.” However, he said that

his brother is not around much and has “given up” on him. His sister lives nearby, but he states,

“she is very controlling and it’s hard to be around.” He said these events lead him to deeper

depression and feelings of hopelessness. M.R. has problems with alcohol use he was drinking six

packs of beer three times a week. He disclosed during the interview that his drinking worsens

with symptoms of depression. M.R. had tried to hang himself right before hospitalization, but the

rope broke, and his sister found him and brought him to the E.D. for treatment. M.R. also had

some disputes with neighbors in his apartment building who had been trying to provoke him.

Patient and Family History of Mental Illness

M.R. stated that no one in his family had a history of mental illness, which was congruent

with medical records. The patient history of mental illness started at sixteen years old with the

death of his father whom he was very close to. The patient has had multiple hospitalizations for

depression: one last April when his mother died and this current admission. M.R. stated, “I began

drinking so much at 21.” He was still currently drinking several packs of beer before this current

hospitalization. The patient did not mention how his siblings were handling the death of their

mother, but he did disclose that they are very frustrated with his alcoholism.

In the study titled Relationship Between Grief and Family System Characteristics: A

cross-lagged Longitudinal Analysis, it stated, “Cohesion was found to be the strongest predictor

of later grief symptoms” (Traylor et al., 2003). Cohesion means the closeness the family

members are to each other the better their ability to handle the loss of a loved one. This study

was mainly done on individuals who lost a spouse or a parent. The results indicated that working
Major Depressive Disorder: Case Study 7

with the family as a whole and their communication with each other could aid in the

bereavement process. The client demonstrated a distorted grieving process as evidenced by

worsening depression and suicidal thoughts and behaviors. The client also did not have a good

relationship or support from his siblings, and he also did not have any connection with any other

living relatives.

Milieu Therapy and Evidenced-Based Nursing Care

The client was staying in a psychiatric unit that had a multitude of safety features in

place. The client was at risk for suicide, so there were no materials that could be used for self-

harm such as shoelaces, glass, trash bags, lightweight chairs, bathroom doors, and many more.

There was also a strict schedule on the unit to help with familiarity. The client was frequently

utilizing group therapy on the unit where he spoke about his grief and feelings about his

alcoholism. The client would also talk with others on the unit including staff, students, and other

patients. Patients are treated with medications, therapy, group therapy, and activities to learn new

skills for coping. A research article titled, Advanced Practice Nursing Students Knowledge, Self-

Efficacy and Attitudes Related to Depression in Older Adults: Teaching Holistic Self Care stated:

Holistic APNs bring a body-mind-spirit approach to all patient situations. Depression

affects body, mind, and spirit. Diagnostic criteria of depression includes physical health

(loss of appetite, disturbed sleep, lack of energy), emotional status (depressed mood,

difficulty concentrating, loss of interest in activities that normally are pleasurable), and

spiritual health (hopelessness). Thus, a holistic educational and treatment approach for

patients and families is necessary to address the multidimensional effects of late-life

depression (Delaney & Barrere, 2012).

Major Depressive Disorder: Case Study 8

While this study was focused on depression in older adults a similar approach can be

used for the treatment of depression in all age groups. In this study, advance practice nurses were

educated on assessment and holistic approaches to depression care. Nurses at the RN level could

utilize these findings to educate themselves on holistic approaches of mind, body, and spirit to

better provide care in psychiatric settings for clients with depression (Delaney & Barrere, 2012).

This is a similar approach to what was done in the psychiatric unit for M.R. The client was

treated for his physical needs with medications, he was treated with therapy to help his emotional

needs, and the groups would work on spiritual needs with techniques such as mindfulness and

meditation.

Ethical, Spiritual, and Cultural Influences

M.R. is a Caucasian male born and raised in Ohio. He was not raised in any faith or

cultural group. M.R. stated, “I believe there is some God out there, but I do not go to church or

anything.” However, there are beliefs about mental illness and addiction in our society that

affects persons with addiction. In the research article titled Medical Disease or Moral Defect?

Stigma Attribution and Cultural Models of Addiction Causality in a University Population stated,

“People are significantly more likely to have negative attitudes toward individuals with

substance use disorders than toward individuals with other behavioral and emotional disorders”

(Henderson & Dressler, 2017). People tend to view addiction in a negative manner, believing

that the person has a choice and can stop whatever they are addicted to whenever they choose

rather than believing it is a disease process. These cultural ideas aligned with what M.R. was

experiencing with his family because they “gave up” on him because of his battle with

alcoholism and he no longer had support or empathy from them.

Evaluation of Patient Outcomes

Major Depressive Disorder: Case Study 9

M.R. had many positive outcomes related to his care on the psychiatric unit. The client no

longer has thoughts of suicide and he did not have any sustain any injuries and remained safe

while on the unit. The client has been put on Sertraline 75mg, which he believes is helping him.

The client verbalized the importance of stopping binge drinking and going to AA meetings. M.R.

also had community resources for available after discharge. The client also reported fewer

feelings of hopelessness and sadness on his last day on the unit. There was a unmet outcome, the

client did not improve the quality of sleep while on the unit. M.R. averaged about four hours of

sleep pre-hospitalization and that remained the same on the day of discharge. He said screentime

keeps him from sleeping at home and the “freezing” temperatures made it difficult to sleep on

the unit.

Summarized Plans for Discharge

M.R. was planned to be discharged on the day of care midafternoon and was being

discharged home alone to his apartment. M.R. plans to have all his medications delivered to his

home, which will aid in compliance. He also is going to continue treatment in the community

setting. The client is going to start going to AA meetings to aid in his treatment for alcoholism.

The client will be attending a grief support group in his community to further treat his grief and

he will be attending private counseling. The patient expressed an interest in applying for a job

near his home and getting a cat for companionship.

Prioritized List of Actual Nursing Diagnosis

Insomnia related to inactivity as evidenced by four hours of sleep per night at home and on the

unit.
Major Depressive Disorder: Case Study 10

Imbalanced nutrition: more than body requirements as evidenced by overeating when

experiencing feelings of depression.

Risk for complicated grieving related to lack of previous resolution of former grieving process as

evidenced by the patient not properly grieving over the loss of his father at sixteen and loss of his

mother in the present.

Chronic sorrow related to unresolved grief as evidenced by the client’s unable to properly grieve

over the death of his parents.

Social isolation related to unacceptable social behaviors as evidenced by siblings not wanting to

be a part of his life due to alcoholism.

Dysfunctional family processes related to substance abuse as evidenced by siblings not wanting

to be a part of his life due to alcoholism.

Potential Nursing Diagnosis

Risk for loneliness related to unacceptable social behavior patient has lost contact with friends

and states he has trouble making friends which could put him at risk for loneliness.

Hopelessness related to long-term stress; patient has had long-term stress due to grief which

could cause a repeating feeling of hopelessness.

Self-neglect related to depression while the client is currently able to perform self-care due to the

chronic nature of major depressive disorder the client has the potential for self-neglect.

Powerlessness related to alcohol addiction the client has plans to go to AA meetings and quit

alcohol the client could also have the potential for relapse and cravings to begin drinking again.
Major Depressive Disorder: Case Study 11

Sexual dysfunction related to loss of sexual desire. The client is currently taking an SSRI for the

diagnosis of depression and a common side effect of the drug is decreased sexual desire.

Conclusion

M.R. was admitted to the psychiatric unit with the diagnosis of major depressive disorder

accompanied by suicidal thoughts and alcoholism. The client has had a history of alcoholism

beginning in early adulthood. He also had a history of depression beginning in adolescence after

the death of his father. His current exacerbations in stress were due to family stressors and

grieving the death of his mother. The grief support group the client is involved in will play a

large role in his recovery since a majority of his depression was brought on by grief. The group

will be a way for M.R. to connect with others in his community who are grieving and learn

positive ways of coping with grief. The AA meetings will help the client in a similar way by

connecting with others going through a similar experience and learning positive coping

mechanisms that are not alcohol use. Individual therapy will aid the client in expressing feelings

privately to help cope with depression, alcoholism, grief, and family communication.
Major Depressive Disorder: Case Study 12

References

Delaney, C., & Barrere, C. (2012). Advanced practice nursing students' knowledge, self-efficacy,

and attitudes related to depression in older adults. Holistic Nursing Practice, 26(4), 210–

220. https://doi.org/10.1097/hnp.0b013e31825852aa

Henderson, N. L., & Dressler, W. W. (2017). Medical disease or moral defect? stigma attribution

and cultural models of addiction causality in a University population. Culture, Medicine,

and Psychiatry, 41(4), 480–498. https://doi.org/10.1007/s11013-017-9531-1

Traylor, E.S, Hayslip, B. Kaminski, P. & York, C. (2003). Relationships between grief and

family system characteristics: A cross lagged longitudinal analysis. Death Studies, 27(7),

575–601. https://doi.org/10.1080/07481180302897

Videbeck, S. L. (2020). Chapter 17. In Psychiatric-Mental Health Nursing. essay, Wolters

Kluwer.