Running Head: MENTAL HEALTH CASE STUDY

Mental Health Case Study:

Transgender Patients and Suicidal Ideation

Jessica Wilhelm

Nursing, Youngstown State University

NURS 4842: Mental Health Nursing

Mrs. Peck

January 30, 2020

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Abstract

On January 30, 2020, A.H. was a patient at Mercy Health St. Eliabeth’s Psychiatric Unit.

She is a male transitioning to a female, which predisposes her to depression and suicidal

thoughts. A.H. was admitted for Suicidal Ideation with the Intent to Harm Self while at school.

She has been stabilized and feels that she has benefitted from her treatments at the psychiatric

unit. Overall, her objective data, psychiatric diagnoses, stressors that lead to her hospitalization,

and her history will be discussed in detail. Furthermore, nursing care, influences, evaluations of

patient outcomes, and nursing diagnoses will be covered throughout this case study.
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OBJECTIVE DATA

A.H. is an 18 year old transgender male transitioning to a female. She was admitted to

Mercy Health St. Elizabeth’s Hospital Psychiatric Unit on an involuntary hold on January 28,

2020. The date of care was January 30, 2020, so it was this patient’s third day on the psych unit.

The RN assigned to her was Lorah. Her psychiatric diagnoses were anxiety, depression, ADHD,

gender dysphoria, and suicidal ideation. Her medical diagnoses were PTSD, asthma, and

depression. She was primarily admitted due to Suicidal Ideation with the Intent to Harm Self.

She has a history of suicidal behavior. Previously, she was admitted to Belmont Pines. In

December 2019, she was admitted to ​Windsor Laurelwood Center for Behavioral Medicine.

On admission, the patient was supported by her mother and and her girlfriend. She was

depressed and wanted to harm herself. On the day of care, she was animated, relaxed, dressed

neatly, and displayed unkempt hair. She was restless and expressed to me that she had been

feeling more anxious since the doctor took her off one of her medications. A.H. was friendly and

stated that she felt “comfortable.” She told me that I could “ask her anything.” Overall, she had a

pleasurable affect. In regards to her mood, she told me that “has been feeling better” and

improved since being admitted. She has been feeling less depressed, but more anxious since

admission. A.H. was oriented X4 and displayed an excellent memory.

In regards to her lab work, all of her lab values were within normal range. Her T4 was 8.2

mcg/dL and her TSH was 1.340 mU/L, both of which rules out hypothyroidism or

hyperthyroidism as the cause of her anxiety and depression symptoms. The drug screen was

negative, so there were no substances present in her system to cause her symptoms. Furthermore,

her urinalysis was negative, so a UTI was ruled out. Her CBC lab values were all within normal
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range, specifically her WBC was 7.1 K/uL, so that rules out an infection as a cause for her

mental health symptoms. Her Hemoglobin was 14.2 g/dL and her Hct was 43.1%, so her oxygen

levels were adequate, thus low oxygenation did not cause her symptoms. Lastly, A.H.’s glucose

level was 90 mg/dL, so that rules out hypoglycemia or hyperglycemia.

To continue, A.H. has been prescribed several medications. For her depression, she is

prescribed Aripiprazole (Abilify) every evening and Bupropion (Wellbutrin XL) daily. For her

anxiety, she is prescribed Hydroxyzine (Vistaril) PRN. Escitalopram (Lexapro) has been

prescribed daily for both her anxiety and depression. A.H. takes benztropine mesylate (Cogentin)

PRN, which is an anticholinergic that treats the Extrapyramidal symptoms (EPS) that are a side

effect of antipsychotic medications. In her case, Aripiprazole (Abilify) and Olanzapine (Zyprexa)

are the antipsychotic medications that she takes that can cause these EPS side effects. She is

prescribed Olanzapine (Zyprexa) PRN for agitation. For sleep, she is prescribed Trazadone

(Desyrel) PRN, which is an antidepressant. Previously, this patient has overdosed on this

medication. Finally, she is prescribed Aldactone (Spironalactone), which is a potassium-sparing

diuretic, as a hormone blocker to suppress testosterone. She takes hormones and is currently

transitioning from a male to a female.

Treatments for this patient include group therapy, medication management, and wound

care. There are many group therapy sessions offered, with topics ranging from spirituality to

music therapy to education on coping skills. Safety measures maintained are checks every fifteen

minutes and no access to sharp objects that could be used as weapons. The unit has many safety

features, such as slanted doors to protect the patient from harming themselves. On admission,
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A.H. had superficial cuts on her bilateral wrists from self-harm, so prevention of infection is

vital.

SUMMARY OF PSYCHIATRIC DIAGNOSES

A.H. has several psychiatric diagnoses, many of which she shared and discussed on the

day of care. To begin, she has been diagnosed with anxiety. She shared that she has been feeling

more anxious since the doctor took her off one of her antianxiety medications. Anxiety is a

“vague diffuse apprehension that is associated with feelings of uncertainty and helplessness”

(Townsend, 2015, p. 898). Generalized anxiety disorder (GAD) is “characterized by persistent,

unrealistic, and excessive anxiety and worry, which have occurred more days than not for at least

6 months, and cannot be attributed to specific organic factors, such as caffeine intoxication or

hyperthyroidism” (Townsend, 2015, p. 532).

Additionally, A.H. has been diagnosed with depression. The National Center for Health

Statistics [NCHS], 2012) states that “Depression is a major cause of suicide among teens, and

suicide is the second leading cause of death in the 15- to 24-year old age group (as cited in

Townsend, 2015, p. 470). The World Health Organization (WHO) (2014) “recently reported that

depression is the main cause of illness and disability in adolescents worldwide” (as cited in

Townsend, 2015, p. 470). Common symptoms that adolescents diagnosed with depression

experience are aggression, “running away,” anger, delinquency, “sexual acting out,” social

isolation, restlessness, substance abuse, and apathy (Townsend, 2015, p. 470). Additionally, this

population frequently experiences a “loss of self-esteem, sleeping and eating disturbances, and

psychosomatic” symptoms (Townsend, 2015, p. 470). Furthermore, Townsend defines

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depression as a change in mood described by sad feelings, pessimism, and despair (2015).

“There is a loss of interest in usual activities, and somatic symptoms may be evident. Changes in

appetite and sleep patterns are common” (Townsend, 2015, p. 902).

Furthermore, A.H. has been diagnosed with Suicidal Ideation, which are suicidal

thoughts. There is a prejudice towards transgendered people that encompasses the school

systems abandoning them, violence within the family, and alterations in biology associated with

the transitioning of the body from one gender to another. All of these factors can precipitate

transgendered people to develop suicidal ideation (Silva, 2016). Silva’s (2016) study found that:

A study of transgender people and individuals undergoing the process of gender transit

performed in the United States showed that more than 41% of the sample (n=6,456)

had already attempted suicide, and this is the largest and one of the few studies

developed with this public so far. (p. 502)

Furthermore, A.H. has been diagnosed with Attention-deficit/hyperactivity disorder

(ADHD), which is “characterized by a persistent pattern of inattention and/or hyperactivity and

impulsivity, or both. Motor activity is excessive, and the ability to concentrate is impaired”

(Townsend, 2015, p. 899).

Additionally, A.H. has been diagnosed with Gender Dysphoria, which is a “sense of

discomfort associated with an incongruence between biologically assigned gender and

subjectively experienced gender.” (Townsend, 2015, p. 905). People who identify as transgender,

even though they have the anatomical features of one gender, perceive themselves as the other

gender. Transgendered people feel uncomfortable wearing clothes that society expects and

freqeuntly cross-dress. This population may perceive their genitals as being “repugnant”
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(Townsend, 2015, p. 634). They may desire hormones and surgery. Often, this population is

diagnosed with anxiety and depression, which is frequently precipitated by the person not being

able to live as the gender they prefer (Townsend, 2015).

Lastly, A.H. has been diagnosed with Posttraumatic stress disorder, which is

characterized by symptoms that occur after a “psychologically distressing event” that is not in

the “usual human experience (e.g. rape, war)” (Townsend, 2015, p. 910). This person cannot

“put the experience out of his or her mind, and has nightmares, flashbacks, and panic attacks”

(Townsend, 2015, p. 910).

STRESSORS AND BEHAVIORS THAT PRECIPITATED HOSPITALIZATION

A.H. described the stressors and behaviors that she exhibited that precipitated her

hospitalization. She stated that she started crying in class. Her chart displayed that she wanted to

take a sharp object from school with the intent to harm herself. This patient has been bullied at

school. She “came out” a few months ago as transgendered. Since then, she began dating a girl.

Arseneault et al. (2010), Fisher et al. (2012), Kaltiala-Heino et al. (2010), Sourander et al.

(2010), and Ttofi et al. (2011) write that adolescents who are bullied report more often feelings

of depression, anxiety, and psychosomatic symptoms (as cited in Williams, 2017, p. 468).

Furthermore, Copper et al. (2012) and vanGeel et al. (2014) state that adolescents who have been

victims of bullying have a higher risk of suicide compared to those who were not bullied (as

cited in Williams et. al., 2017, p. 468).

PATIENT AND FAMILY HISTORY OF MENTAL ILLNESS

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A.H. has a history of mental illness throughout her life. Even as a young child, she did

not want to be alive. She attempted suicide as a child by trying to suffocate herself with a pillow.

She can now identify these feelings as depression. It can be assumed that her childhood suicide

attempt has caused her to have PTSD. Furthermore, A.H. has attempted to commit suicide by

overdosing on Trazadone, but she woke up. She was admitted to Belmont Pines as a child and

was recently admitted to ​Windsor Laurelwood Center for Behavioral Medicine.

Patient did not discuss her family history of mental illness on the day of care. A.H. did

discuss that her mother is very supportive of her and would “take in” her friends who are not

supported by their parents for identifying as LGBTQ.

PSYCHIATRIC EVIDENCE BASED NURSING CARE AND MILIEU ACTIVITIES

Nursing care provided for A.H. includes administration of antidepressants and therapeutic

groups, safety precautions, monitoring of labs, wound care, and correct use of patient’s preferred

pronoun. The medications she is prescribed will help to stabilize and manage her mood. The

therapeutic groups will aid her in learning coping skills. Safety precautions are in place to protect

her from self-harm. Labs will be periodically monitored for infection and oxygenation status.

Wound care will be performed to monitor the healing of the superficial cuts on A.H.’s bilateral

wrists and to prevent infection. Additionally, it is important to address this patient by the

pronoun that she identifies as. McDowell and Bower (2016) discusses that “gender-affirming

language” should be added to nursing curriculum to educate nurses in terms of caring for

transgender patients (p. 3).

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Although placed on an involuntary hold, A.H. has complied with the plan of care and is

thriving in the structured milieu environment. Overall, she feels that her mental health has

improved within the few days that she has been hospitalized. In the common room, ​she socializes

with other patients and has formed friendships. She is taking care of herself and her physical

needs are met. This patient has her own space designed to be a safe environment. There are

sensors above the doors and slanted doors to prevent patients from committing suicide. There are

no objects available to harm herself with. Nurses are continually checking on her to ensure she is

safe.

Furthermore, A.H. has attended many group therapy sessions. On the day of care, she

was present for the spiritual group and for the music therapy group. She participated by playing

her favorite song and by commenting on other patient’s favorite songs made her feel. A.H.

expressed that she has been attending as many group therapy sessions as she can to comply with

the plan of care, so she can be discharged soon. She hopes to meet her goal and to improve her

mental health.

A.H. stated that she has learned coping skills and strategies that aid in improving her

mental health. The most important coping skill she utilizes is to find someone to talk to that is

willing to listen. Additionally, other coping skills that she employs are writing a story, drawing,

and music therapy.

ETHNIC, SPIRITUAL, AND CULTURAL INFLUENCES

A.H. is influenced by ethnic, spiritual, and cultural influences. Her home life is affected

by her ethnic background. As learned in class, African American households are often run by
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women. In A.H.’s case, this is true. She does not have her father in her life for support. In

regards to spiritual influences, A.H. does not practice a specific religion. She stated that she is

“open to learning about others’ beliefs,” as evidenced by her attendance to the spiritual group

session. In terms of cultural influences, A.H. is influenced by the LGBTQ culture. She was very

comfortable sharing about her sexual orientation and her ongoing transition from a male to a

female. A.H. discussed how she takes hormones and would like to have surgery in the future.

EVALUATIONS OF PATIENT OUTCOMES

In regards to medication management for A.H.’s anxiety and depression, one possible

outcome is that patient will verbalize less anxious feelings during shift.This outcome was not

met, because A.H. verbalized feeling more anxious since the doctor removed one of her

medications from her regimen. This will take time to evaluate and the doctor will plan to

continue to monitor and adjust A.H.’s medications. Another outcome in regards to her

medication management is that the patient will verbalize that overall mood is better during shift.

This outcome was met. To continue, in terms of safety, an outcome is that the patient will not

harm herself during shift. This outcome was met. In regards to group therapy, an outcome is that

the patient will verbalize coping skills learned in group therapy during shift. This outcome was

met. Furthermore, an outcome regarding infection is that patient will no show signs and

symptoms of infection during shift. This outcome was met. Her labs showed that her WBC was

within normal range. Additionally, an outcome for wound care is that patient’s wounds will show

signs of healing (well-approximated, no new drainage, no foul odor) during shift. This outcome

was met. Lastly, an outcome is that the patient will verbalize feeling accepted during the
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interview. This outcome was met by utilizing non-judgemental care. A.H. stated that she felt

“comfortable” and that I could “ask her anything.” Overall, most of the outcomes were met

during this shift.

PLANS FOR DISCHARGE

“The root cause of suicide attempts is a lack of initial assessment risk, lack of repeat

assessments, and inadequate management of at-risk patients.” (Grimley-Baker, 2019, p. 20). It is

very important for A.H. to follow up with her treatment, because she is very likely to self-harm

again. She was admitted to Mercy Health St. Elizabeth’s Psychiatric Unit only a month after

being hospitalized at ​Windsor Laurelwood Center for Behavioral Medicine. A.H is very at-risk

for suicide as she continues her transition from male to female.

Plans for discharge for this patient would include outpatient treatment. A.H. will see a

psychiatrist for medication management and a counselor for therapy. A.H. will be supported by

her mother. This patient’s motivation for discharge is an upcoming school dance that she hopes

to attend.

PRIORITIZED LIST OF ALL ACTUAL NANDA DIAGNOSES

1. Self-Mutilation related to Depression as evidenced by superficial cuts on bilateral wrists

2. Disturbed Thought Process related to Depression as evidenced by Suicidal Ideation

3. Anxiety related to Generalized Anxiety Disorder as evidenced by verbal expressions of

increased anxiety
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4. Disturbed Personal Identity related to Gender Dysphoria as evidenced by prescribed

hormones to transition from male to female

LIST OF POTENTIAL NURSING DIAGNOSES

1. Risk for Suicide related to suicidal ideation

2. Risk for Noncompliance related to increased anxiety from alteration in medication

regimen

3. Risk for Disturbed Body Image related to cost of surgery

4. Risk for low-self esteem related to bullying

CONCLUSION

A.H. is a transgender psychiatric patient who has been diagnosed with anxiety,

depression, ADHD, gender dysphoria, and PTSD. She is at a high risk for suicide due to her

transition from male to female, bullying at her high school, and her previous suicide attempts.

Her care will need to be carefully managed, so that she can benefit from outpatient treatment and

not be hospitalized again. Throughout this case study, her objective data, psychiatric diagnoses,

stressors that lead to her hospitalization, and her history have been investigated. Furthermore,

nursing care at the hospital, influences, evaluations of patient outcomes, and nursing diagnoses

were covered in depth. Overall, A.H.’s mental health has improved from her hospitalization.

Hopefully, she will comply with her treatment plan and use the coping strategies in the future.

References
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McDowell, A., & Bower, K. M. (2016). Transgender Health Care for Nurses: An Innovative

Approach to Diversifying Nursing Curricula to Address Health Inequities. ​The Journal

of nursing education,​ ​55(​ 8), 476–479. doi:10.3928/01484834-20160715-11

Grimley-Baker, K. (2019). Preventing Suicide Beyond Psychiatric Units. ​Texas Nursing,​ ​93(​ 2),

20–21. Retrieved from

https://search.ebscohost.com/login.aspx?direct=true&AuthType=ip,uid&db=rzh&AN=

136823108&s​ite=ehost-live&scope=site

Silva, G.W.S., Sena, R.C.F., Lins, S.L.F., & Miranda, F.A.N. (2016). Suicidal ideation among

transvestites and transsexuals: a social representations and analytical study. ​Online

Brazilian Journal of Nursing,​ ​15,​ 501–504. Retrieved from

https://search.ebscohost.com/login.aspx?direct=true&AuthType=ip,uid&db=rzh&AN=

120561707&site=ehost-live&scope=site

Townsend, M. (2015). ​Psychiatric mental health nursing: concepts of care in evidence-based

practice.​ 8th ed. Philadelphia: F.A. Davis Co.

Williams, S. G., Langhinrichsen-Rohling, J., Wornell, C., & Finnegan, H. (2017). Adolescents

Transitioning to High School: Sex Differences in Bullying Victimization Associated

With Depressive Symptoms, Suicide Ideation, and Suicide Attempts. ​Journal of School

Nursing​, ​33​(6), 467–479. https://doi.org/10.1177/1059840516686840