CASE STUDY

DEPRESSION

A.INTRODUCTION

Depression (major depressive disorder) is a common and serious medical illness that negatively

affects how you feel, the way you think and how you act. Fortunately, it is also treatable.

Depression causes feelings of sadness and/or a loss of interest in activities once enjoyed. It can

lead to a variety of emotional and physical problems and can decrease a person’s ability to

function at work and at home.

B.HISTORY COLLECTION

HISTORY COLLECTION
I. IDENTIFICATION
Name: I. N

Sex: Female

Age: 28 years old

Marital status: Single

Place of birth: Western Province

Nyabihu District

Bigger Sector

Arusha Cell

Ngamba village

Sibling’s position: 6th

Profession: Accountant

Religion: ADVENTIST

Nationality: Rwandese

Admission date:

II. CHIEF COMPLAINT

The patient has been brought by her brother because of having physical and verbal aggressively,
total insomnia, and logorrhea.

III. ANTECEDENT/PEVIOUS MENTAL HISTORY

It is the 3rd crisis and all were trigged by stopping medications.

IV. FAMILY HISTORY: The client was born in a family of six children, three boys and three
girls, and she occupies the 6th place her both parents and her 2 brothers with 1 sister have been
killed in 1994 Genocide and remained five children who are all married except the client who
lives with her brother who is married having two children.

Her Uncle was mentally ill but died in 2008 with other medical condition not mental problem.

Genogram: 1994 1994

+ +

+ + +
1994

Live together
V. MEDICAL AND SURGICAL: None

VI. GYNECOLOGICAL HISTORY: She is still single with no gynecological problems.

VII. JUDICIAL HISTORY: None

VIII. PERSONAL HISTORY

The patient was born in 1988 in a family of six children and grew up normally with her both
parents. She started primary school on time in 1995 without any difficulty. But 1994 when she
was 6 years old, her parents and her brother have been killed in Genocide. After that she
continued to study and succeeded the primary six examinations and she entered secondary
school. In 2004 when she was in senior three ,she had fallen sick and brought to prayers for this
reason she lost one year of study fortunately she continued until she successfully finished her
senior six in accountancy in 2007 promotion.

After finishing her studies, in 2007 she found a job of being a manager in motel at Rubavu
district. Worked there without any problem .In 2011, she had fallen sick and suspected that she
had been poisoned and she passed about three months at home without working and for that
reason she had been replaced temporally by another. When she came back to her job a control
had been done and found that there was a loss of the money that she was in charge of, saying that
the loss took place before her sickness and that she is the one to pay it from her own. This
brought many conflicts between her and her employer and became the reason of the first crisis
.Since that time she is facing many problem like the loss of money that she lends to her friends
who refused to bring back. Apart from that she doesn’t have the common understanding with her
family members which refused her relationship with some of her boyfriend. After that crisis they
brought at ndera after recovery she back home. The following crisis is because of stopping
medications and start thinking her parents who were died in Genocide.
IX. PHYSICAL EXAMINATIONS

i) General appearance: she is weak due to side effects of drugs.

ii) HEENT: Patient does not have any problem in eyes with no jaundice, moisture mouth; pink
tongue with no sore throat neck is flexed, proper hairs, etc.
iii) Respiratory system: no any problem in respiration presented or observed to the client.
iv) Cardiovascular system: no problem indicated to the heart with normal heart sounds.

v) Nervous system: normal sensations, shaking due to side effects of drugs, pupils are reacting
to light, with GCS of 15/15.

vi) GI: No abdominal tenderness or distended

vii) Urinary system: no complaints of urination with normal urine output.

viii) Integumentary system: she has scars on the legs and left arm due to wounding during 2nd
crisis.

ix. Vital signs: Blood pressure: 118/75mmhg

Pulse: 88 bpm

Temperature: 36.70c

Respiration rate: 18 bpm

X. PSYCHIATRIC CONDITIONS

General appearance: she is a middle size girl who is well dress compared to the time of
admission. She appears her stated age, with no agitation or hyperactivity compared to before.

Affect and mood: Appropriate affect, and labile mood.

Perception: she no longer has hallucinations and no illusion as before.

Thought and speech: Has a normal flow of speech compared to before where she had logorrhea.
Her thoughts full of hopelessness and low self-esteem but no delusions.

Orientation: she is oriented to time, place and to person.

Memory and concentration: she has the ability to recall past and recent history of her life.

Judgment and impulse control: she has ability to plan for his future

Insight: negative

Vegetative symptoms: normal level of energy

Maintains normal sleep cycle

MULTIAXIAL DIAGNOSIS
Axis I: Bipolar disorder

Axis II: neither mental retardation nor personality disorder

Axis III: NONE

AXIS IV: Job stress and excessive losses

XI. COMPLEMENTARY EXAMS

-Full blood count (FBC): NORMAL RESULTS

-HIV Test: Neg.

XII. PROBABLE DIAGNOSIS/ Differential diagnosis

1. Bipolar I disorder: Favorable elements: insomnia, logorrhea, physical and verbal

aggressivity, instability, labile Mood, auditory hallucination, visual hallucination, persecutory
delusions, distractibility, and suicidal ideation.

2. Shizoaffective disorder: Favorable elements: instability, insomnia, logorrhea, aggressivity.

Labile mood, auditory hallucination, visual hallucination, persecutory delusions

Defavourable elements: Non persistence of psychotic symptoms to meet its criteria.

3. Depression

XIII. PSYCHOPATOLOGICAL ANALYSIS

Biologically, the patient is vulnerable to mental disorder because in her family there many
persons who suffered from a mental disorder including her uncle, knowing that having a
psychiatric antecedent is one the risk factors to develop a mental disorder. Furthermore
according to the stress vulnerability model the patient may be affected by the stress of the job she
has because it seems that most of the relapses that she came to have, are in connection with that
job. Also the fact that the client has lost her both parents and her brothers and sister may also
have a negative impact on the client by developing a mental disorder. Sigmund Freud states that
the loss of a beloved one may expose someone to mental illness.

DEPRESSION

Depression (major depressive disorder) is a common and serious medical illness that negatively
affects how you feel, the way you think and how you act. Fortunately, it is also treatable.
Depression causes feelings of sadness and/or a loss of interest in activities once enjoyed. It can
lead to a variety of emotional and physical problems and can decrease a person’s ability to
function at work and at home.

Depression symptoms can vary from mild to severe and can include:

 Feeling sad or having a depressed mood

 Loss of interest or pleasure in activities once enjoyed
 Changes in appetite — weight loss or gain unrelated to dieting
 Trouble sleeping or sleeping too much
 Loss of energy or increased fatigue
  Increase in purposeless physical activity (e.g., hand-wringing or pacing) or slowed
movements and speech (actions observable by others)
 Feeling worthless or guilty
 Difficulty thinking, concentrating or making decisions
 Thoughts of death or suicide

Symptoms must last at least two weeks for a diagnosis of depression.

Also, medical conditions (e.g., thyroid problems, a brain tumor or vitamin deficiency) can mimic
symptoms of depression so it is important to rule out general medical causes. Depression affects
an estimated one in 15 adults (6.7%) in any given year. And one in six people (16.6%) will
experience depression at some time in their life. Depression can strike at any time, but on
average, first appears during the late teens to mid-20s. Women are more likely than men to
experience depression. Some studies show that one-third of women will experience a major
depressive episode in their lifetime.

Depression Is Different From Sadness or Grief/Bereavement

The death of a loved one, loss of a job or the ending of a relationship are difficult experiences for
a person to endure. It is normal for feelings of sadness or grief to develop in response to such
situations. Those experiencing loss often might describe themselves as being “depressed.”

But being sad is not the same as having depression. The grieving process is natural and unique to
each individual and shares some of the same features of depression. Both grief and depression
may involve intense sadness and withdrawal from usual activities. They are also different in
important ways:
In grief, painful feelings come in waves, often intermixed with positive memories of the
deceased. In major depression, mood and/or interest (pleasure) are decreased for most of two
weeks.

In grief, self-esteem is usually maintained. In major depression, feelings of worthlessness and

self-loathing are common.

For some people, the death of a loved one can bring on major depression. Losing a job or being a
victim of a physical assault or a major disaster can lead to depression for some people. When
grief and depression co-exist, the grief is more severe and lasts longer than grief without
depression. Despite some overlap between grief and depression, they are different.
Distinguishing between them can help people get the help, support or treatment they need.

Risk Factors for Depression

Depression can affect anyone—even a person who appears to live in relatively ideal
circumstances.

Several factors can play a role in depression:

Biochemistry: Differences in certain chemicals in the brain may contribute to symptoms of

depression.

Genetics: Depression can run in families. For example, if one identical twin has depression, the
other has a 70 percent chance of having the illness sometime in life.

Personality: People with low self-esteem, who are easily overwhelmed by stress, or who are
generally pessimistic appear to be more likely to experience depression.

Environmental factors: Continuous exposure to violence, neglect, abuse or poverty may make
some people more vulnerable to depression.

How Is Depression Treated?

Depression is among the most treatable of mental disorders. Between 80 percent and 90 percent
of people with depression eventually respond well to treatment. Almost all patients gain some
relief from their symptoms. Before a diagnosis or treatment, a health professional should conduct
a thorough diagnostic evaluation, including an interview and possibly a physical examination. In
some cases, a blood test might be done to make sure the depression is not due to a medical
condition like a thyroid problem. The evaluation is to identify specific symptoms, medical and
family history, cultural factors and environmental factors to arrive at a diagnosis and plan a
course of action.

Medication and treatment

Medication: Brain chemistry may contribute to an individual’s depression and may factor into
their treatment. For this reason, antidepressants might be prescribed to help modify one’s brain
chemistry. These medications are not sedatives, “uppers” or tranquilizers. They are not habit-
forming. Generally antidepressant medications have no stimulating effect on people not
experiencing depression. Antidepressants may produce some improvement within the first week
or two of use. Full benefits may not be seen for two to three months. If a patient feels little or no
improvement after several weeks, his or her psychiatrist can alter the dose of the medication or
add or substitute another antidepressant. In some situations other psychotropic medications may
be helpful. It is important to let your doctor know if a medication does not work or if you
experience side effects. Psychiatrists usually recommend that patients continue to take
medication for six or more months after symptoms have improved. L

Psychiatrists usually recommend that patients continue to take medication for six or more
months after symptoms have improved. Longer-term maintenance treatment may be suggested to
decrease the risk of future episodes for certain people at high risk.

Psychotherapy: Psychotherapy, or “talk therapy,” is sometimes used alone for treatment of mild
depression; for moderate to severe depression, psychotherapy is often used in along with
antidepressant medications. Cognitive behavioral therapy (CBT) has been found to be effective
in treating depression. CBT is a form of therapy focused on the present and problem solving.
CBT helps a person to recognize distorted thinking and then change behaviors and thinking.
Psychotherapy may involve only the individual, but it can include others. For example, family or
couples therapy can help address issues within these close relationships. Group therapy involves
people with similar illnesses.

Depending on the severity of the depression, treatment can take a few weeks or much longer. In
many cases, significant improvement can be made in 10 to 15 sessions.

Electroconvulsive Therapy (ECT) is a medical treatment most commonly used for patients
with severe major depression or bipolar disorder who have not responded to other treatments. It
involves a brief electrical stimulation of the brain while the patient is under anesthesia. A patient
typically receives ECT two to three times a week for a total of six to 12 treatments. ECT has
been used since the 1940s, and many years of research have led to major improvements. It is
usually managed by a team of trained medical professionals including a psychiatrist, an
anesthesiologist and a nurse or physician

XIV. TREATMENT:

-Tigerton tab 200mg BID

- Haldol tab 5mg OD.

-Nominal tab 100mg OD

-Educational therapy
-Ergo therapy

NURSING MANAGEMENT
I. List of patient problem
1. Low self-esteem
2. Fear r/t phobic stimulus
3. Disturbed thought processes

II.Priority
1. Low self-esteem
2. Fear r/t phobic stimulus
3. Disturbed thought processes
 NURSING CARE PLAN

Assessment Nursing Diagnosis Goals Intervention Rationale Evaluation

Subjective data Low self-esteem related Short term Ask what client would These Shows After nursing
She says” it is better to changes in health After five days like to be called. respect and intervention,
to die, I do not know status as evidenced by of Assess degree to acknowledge the patient improving
why am still alive let negative feedback intervention which patient feels person. and show a
me die” about self through ,she will loved and respect by The manner in confidence some.
Objective data client’s status like identify one or others. which one is Continue
She has low self- being worthless two strengths Encourage treated by others monitoring a
esteem with negative owned verbalization of may influence patient and giving
insight, has also feelings, accepting her self-esteem. a prescribed
logorrhea and Long term what is said. Helps the client drugs.
agitation to her After three Provide non- to adapt to
mother who brought weeks of threatening change, and
to hospital. intervention environment, listen reduces anxiety
the client will and accept client as about altered
identify the presented. function/lifestyl
skills and Identify age and e
Vital signs positive aspect developmental level Promotes
BP=119/78 mmHg that are owned feelings of
Pls= 72 BpM by the patient Reflect back to client safety,
T0=37.2 0C what has been said encouraging
RR=18 BpM verbalization
Acknowledge efforts
at problem solving and Age is an
future planning. indicator of the
stage of life
patient is
Determine client experiencing,
awareness of own e.g.,
responsibility for adolescence,
dealing with situation middle age.
Clarification and
verification of
what has been
heard promotes
understanding
and allows client
to
Assessment Nursing Objectives Planning Rationale Evaluation
diagnosis
S:“Whenever I’m Fear stimulus as After 3 hours 1 . Establish rap ➢ To gain After 3 hours of
surrounded with manifested by of nursing port client’s nursing
too many people Diminished intervention the 2 . Discuss cooperation intervention the
either I know activity, client will client’s client was able to
them or not I still Avoidance, and acknowledge and perception/fearf ➢ Promote acknowledge and
feel scared and Narrowed focus discuss fears, ul feelings. atmosphere of discuss fears and
restless” as on the source recognizing Listen to client’s caring and recognized healthy
verbalized by the of fear healthy versus concern permits vs. unhealthy fears
patient unhealthy fears as explanation/c as manifested by:
manifested by 3. orrection 1.Stated5/5example
Objective data: State at least 3/5 Provideinformat of mispercepti of fears
•Diminished example of fears ionin verbal and on 2.Summarized the
activity Understanding written form. whole discussion
➢ Facilitates
•Avoidance of what have Speak in Goal partially met
understanding
•Narrowed focus discussed by simplest due to lack of time
and retention
on the source of summarization sentences.
of information
fear 4 . Provideoppor
➢ Enhances
tunity for
sense of trust
questions and
and nurse-
answer honestly
client
relationship
Assessment Nursing Objectives Planning Rationale Evaluation
diagnosis
Disturbed That after 3 1. Interact with the client on -interacting about Patient was
Subjective data: thought weeks of Nursing the basis of real things; do not reality is healthy to recognize
processes Care dwell on the hallucination for the client presence
“I am seeing a related to Management, material. of hallucina
snake here” as psychological Patient will be -determines ability and verbaliz
verbalized by the and cognitive able to 2 . Assess attention to participate in feelings
client. disturbances Demonstrate span/distractibility and ability planning/executing of comfort,
Objective data: as manifested behavior/lifestyle to make decisions/problem care wanted to go
-wearing a ninja- by limited changes to solution home and
like outfit attention span, prevent, -provides continue his
-with the visual hallucination, minimize 3 . Schedulestructuredactivity stimulation while work
hallucination and laughing changes in and rest periods reducing fatigue
-limited attention and talking to mentation and
span himself Respond to 4.Reduce provocative stimuli, -to avoid triggering
-laughing and without any reality-based negative criticism, arguments fight/fight
talking to reason interactions and confrontation responses
himself without initiated by
apparent reason others