Abstract

JL is a 36-year-old female that arrived on the Mental Health unit on

Tuesday, February 27th, 2018 due to an episode of recurrent major

depressive disorder without psychotic features. Multiple stressors in JL’s

life, which will be explained further in this case study, have led the patient

to attempt suicide. JL ingested an unknown amount of Tylenol PM, as

well as multiple glasses of wine, and was found by and brought by her

husband to the emergency department (St. E’s Youngstown). The date of

care this case study was compiled was on was Thursday, March 1st, 2018.

In this case study, the DSM axes I-IV, patient behavior during time of

interview, as well as compiled background information will be discussed.

Objective Data

Patient JL, a 36 year old female, arrived at St. Elizabeth’s

Youngstown ED on February 27th (Tuesday), shortly before midnight, from

Austintown. Wednesday morning (February 28th), patient was transferred

to the Mental Health unit. Patient states she was found unconscious by

her husband in their bedroom. Patient explained that she took Tylenol

PM and had been drinking wine before her husband found her

unconscious. Patient also stated that nothing like this has ever happened

in her medical history and that’s she’s very confused by her behavior. JL

initially seemed very compliant with giving information, and was very

compliant with the therapeutic staff as well as the nursing staff. When

discussing her admitting events, JL was adamant that her support system

was strong and that her only recent stressors had included an increased

workload. Pt stated that although she was concerned for herself, she felt

that this hospitalization was time for her to learn the coping mechanisms

she clearly needed. Pt looked happy and well kept. Data from patient

chart indicated that JL had a history of depression, and this time was

diagnosed with an episode of major depressive disorder without psychotic

tendencies.

DSM Axes I-IV:

I: Major Depressive Disorder

II: No personality disorder

III: History of Cancer, Multiple Sclerosis

 IV: Disruption of family; patient currently going through divorce

from husband, who is also her business partner. Increase of

workload as well as history of poor health.

Currently, patient is only prescribed Effexor 37.5mg TID with meals,

which she states helps her feel more alert. Patient is prescribed that

medication for depression. Per hospital protocol, patient also has PRN

Haldol ordered when necessary for agitation, but during time of visit JL

had not been administered the medication. Patient stated that she mostly

goes to group as she feels that it is the most helpful activity for her.

Regarding safety and security measures on the unit, doors to unit

remained locked, and the environment was made safe by removing any

possibly hazardous items from area.

Summary:

A disorder with many names; Major Depressive Disorder (also

known as unipolar depression and clinical depression) is defined as a

profound depressed mood that persists for longer than 2 weeks, severe

enough to cause noticeable problems with the patient’s ability to maintain

personal relationships, meet work or school obligations, and participate in

previously enjoyable social activities (Davis, 2017). Those that suffer with

this disorder can experience a range of symptoms, including but not

limited to: depressed mood, reduction in the interest in all or most of the

daily activities, a significant loss/gain of weight, difficulty in concentration

or decision making, and recurrent thoughts of death and suicidal

tendencies (Rahmati-Khameneh, 2011). Unfortunately, the incident of

MDD is two times more than that in men (Rahmati-Khameneh, 2011).

The exact cause of MDD is unknown, but physical or chemical changes to

the brain, hormone changes, and/or genetics are believed to play a role. A

schism exists in the patient’s diagnosis; at the time of collection, the

patient’s chart stated that she had MDD without psychotic tendencies,

however I observed delusions during our interview, which prompted my

thought that she could have MDD with psychotic features. A. J.

Rothschild observes that clinicians often miss the diagnosis of psychotic

depression by not recognizing the features it presents (Rothschild, 2013).

He also goes on to say that psychotic depression was most commonly

misdiagnosed as major depressive disorder without psychotic features

(Rothschild, 2013).

Identify:

When questioned, initially JL stated that her only stressor was her

work life. JL runs an insurance business with her husband, and at the

time of hospitalization, patient stated that it was the “busy season,” and

that she had a larger than normal amount of clientele. During the night

of the incident, JL mentioned that she was to attend a work benefit, in

which there would be wine and food served. Patient states that normally

she’ll have one or two beers, and a glass or two of wine and then stop.
However, for circumstances unbeknownst to JL, she drank considerably

more than she normally does. On top of this, JL noted that she has three

daughters which can also exhaust her daily. JL stated she did not have

any other excessive stressors going on throughout her life and that this

was an isolated incident. After finishing my interview with JL, I asked the

nursing staff for more information about her and they stated that she was

in the middle of a divorce with her husband, who had been cheating on

her with the secretary from their business together.

Discuss

Patient stated that there is no previous history of mental illness or

related hospitalization in her family. Pt stated that her family, as well as

extended family are very supportive of her mental health regarding this

singular incident. Upon entering JL’s chart, a more extensive history of

mental illness was found, including previous hospitalizations.

Describe

The Mental Health unit at Saint Elizabeth’s Youngstown campus

uses various facets of evidence based practice to ensure that their patients

receive top quality care. Group sessions are run daily, with two different

times so that they are more easily attended by the patients who want to

utilize them. Patients receive their medications in a timely manner,

adhering to the routine-like schedule the unit employs. Other amenities

include a TV and sitting section for patient socialization, workout

machines, a library, a sensory room, as well as an open drawing area.

The nursing staff works together as a unit, as well as with the doctors to

utilize themselves in an efficient way to provide patients with whatever

they would need to stay healthy.

Analyze

When JL was asked about her religious identity, she stated that she

was a non-denominational Christian and that religion didn’t play heavily

into her outlook on life, but that sometimes it helped her to go to church

or to pray. As previously stated the patient uses her family as a resource

for support, as well as her extended family.

Evaluate

During the interview, JL stated that initially she was confused and

nervous regarding her admission to the unit. Eventually though, she

stated that she opened up during group therapy and was able to work

through her emotions. JL stated that she learned new coping

mechanisms by being here and that she has other methods of coping

outside the unit, like yoga and running.

Summary of Discharge

JL still had a few days to go before her discharge was upon her.

She didn’t have a structured plan, but expressed to me that there were

definitely things she planned on doing differently once she was

discharged. She plans to cut back on the drinking and maybe take on a

lesser role at work, hoping to relieve some stress and also a negative way

of dealing with it. The patient also expressed that she enjoyed having

therapy here and wanted to continue seeing someone, but did not have an

idea who yet. Patient expressed that her husband and family were very

supportive of her and would continue to be throughout her journey to

wellness, however it was found later that her husband is not a reliable

source of support for her after discharge.

List of Nursing Diagnoses

- Risk for Suicide d/t depression, evidenced by suicide attempt and

history of mental illness

- Risk for Injury d/t depression, evidenced by history of MH

hospitalization, suicide attempt

- Ineffective Denial d/t depression, evidenced by attempted suicide

and falsification of facts during interview

- Ineffective Coping d/t depression, evidenced by increased alcohol

consumption, risky OTC drug use, attempted suicide

- Ineffective Relationship d/t divorce, evidenced by increased risk

taking behavior, suicide attempt

- Interrupted Family Process d/t depression, evidenced by impending

divorce, current hospitalization, suicide attempt, history of mental

illness
 References

Davis, C., & Lockhart, L. (2017). Not just feeling blue. Nursing Made

Incredibly Easy!,15(5), 26-32. doi:10.1097/01.nme.0000521805.31528.75

Rahmati-Khameneh, S., Mehrabi, T., MSc, Izadi-Dehvani, M., MSc, &

Zargham-Boroujeni, A., PhD. (2011). The process of major

depressive disorder (MDD) in women referred to the health

centers. Iran Journal of Nurse Midwifery. Retrieved March 15, 2018.

Rothschild, A. J. (2013). Challenges in the Treatment of Major Depressive

Disorder With Psychotic Features. Schizophrenia Bulletin,39(4), 787-

796. doi:10.1093/schbul/sbt046