Alesha Fulton

Mental Health Case Study

Teresa Peck

October 30, 2018

Abstract
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The purpose of this study was to analyze the patient care of a mentally ill patient. A

variety of information was collected including admission history in which the patient has an

extensive history of admissions, including 30 day readmits. This pt has a history of chronic

depression and has many factors that contribute to it including health, financial, and social

issues. There are multiple treatment modalities that the pt receives to help with his illness. There

are multiple symptoms that a patient with Major Depressive Disorder exhibits. With having a

mental illness, many problems can occur in one’s life including social, physical, and emotional

problems. There are ways that patients cope with their illness and they can be positive or

negative. It is found that this pt has gone through a long journey of using up resources and now

will be set up with a group home. In discharge planning the pt has to have the will to want to

change and after burning bridges many times it will be a choice to get help.

Mental Health Case Study

Objective Data
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MM is a 49 yo. male admitted to the psychiatric unit on 09/16/2018, with a psychiatric

diagnosis of Major Depressive Disorder. He was cared for on 9/25/2018, and also on 10/30/2018.

The first day of caring for this pt, his behaviors were appropriate for his mood. He was relaxed

and open to conversation. His dress was careless and his clothing was inappropriate; he wore his

basketball shorts on the outside of his scrub pants. He showered that day but his hair was messy

and face unshaven. This pt had abnormal mouth movements when he would talk; it seemed as if

he could not control his tongue. His affect was sad and depressed. His communication was

slightly slurred and muffled, it was like he was slow to process but was able to get out what he

was thinking. This pt maintained eye contact and was calm and cooperative. His thoughts were

organized and oriented in reality. The second time in caring for MM, he seemed like a totally

different person. He was happy and in a positive mood. He was dressed appropriately, showered,

hair combed, and his face was shaved. He ate his entire meal. He was actually excited to talk to a

student and was very social with other people on the unit. This pt communicated clearly, and was

oriented to reality. His communication was direct and answered questions appropriately, he did

not veer away from any certain topics.

MM is also diagnosed with multiple medical conditions including epilepsy,

polysubstance abuse, bipolar 2, and had a craniotomy in 2017. His epilepsy is treated with

Tegretol 200 mg po TID. He is also prescribed Depakote 500 mg po daily as a mood stabilizer,

Atarax 50 mg IM/PO q6h prn for anxiety, Haldol 5 mg PO/IM Q6h prn for agitation, and

Trazodone 50 mg PO QHS prn for insomnia. In the first time caring for him on 09/16, his

Depakote level was 66.6 which was therapeutic. On admission on 10/16, his level was < 3. This

shows that he was not taking his medication. By 10/28, his level got up to 35. His Tegretol on
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9/16 was 9.5, and on 10/16 his level was 17.9. This was due to his overdose causing him to be

admitted. By 10/28 his level came down to 11.5 which is therapeutic.

While on the unit, this pt was put under suicidal, self harm, and seizure precautions.

Suicidal/self harm precautions includes removing anything that could be potentially harmful to

the pt including strings, sharp objects, matches, cigarette lighter, plastic bags, cleaning supplies,

etc. This also includes the unit being locked, Q 15 Min checks, and making sure medications are

taken and swallowed.

Summarize

MM is diagnosed with Major Depressive Disorder. This disorder is characterized by a

persistent depressed mood or a loss of interest in activities that causes a significant impairment in

daily life. There are a multitude of symptoms that present in MDD, including hopelessness,

worthlessness, flat affect, apathy, sadness, anhedonia, and loneliness. Some behavioral

symptoms include slumped posture, walking slowly and rigidly, no personal hygiene and

grooming, social isolation, and purposeless movements. Cognitive symptoms may include

confusion, inability to concentrate, excessive self-depreciation, self blame and thoughts of

suicide. A pt with this disorder also has physiological symptoms that may include general

slowdown of the entire body, constipation, urinary retention, anorexia, libido, difficulty falling

asleep and waking very early in the morning, and feeling worse early in the morning and feeling

somewhat better as the day progresses.

Identify

MM had multiple stressors going on in his life that have lead to his chronic depression.

When speaking with the pt on the first day of care, he explained that the reason for this
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admission was due to the fact that he took his meds and was still feeling depressed. He did not

know what to do or have the resources to get help, so he went to a gas station and called for an

ambulance to bring him to the unit. The second time in caring for him, he was admitted because

he had not eaten in over a week and overdosed on his Tegretol medication so went to his

neighbors and they called 911. When asking him to tell a little bit about himself and he explained

how he used to be a chef in the area for 20 years and after his craniotomy surgery in 2017, he

could no longer do his job due to peripheral vision loss. He had a very strong relationship with

his sister until she could no longer support his alcoholism. Because of his alcoholism, he has

difficulty forming relationships. He has another sister that lives in georgia that he does not have

contact with. MM has had 2 marriages, of which both have ended in divorce. He has no children.

His father died about 10 years ago, and his mother died this past january which has caused a big

stress on him because he had a very strong relationship with both of them. This pt has a limited

support system due to his choices.

This pt has tried to apply for disability multiple times but is denied due to substance

abuse. He has no money and not being able to qualify for government assistance is the biggest

stressor of them all according to the pt. This pt has a constant battle with having limited

resources. He states that he goes days without eating. He states that when he was about 9 or 10,

he first started smoking and drinking due to peer pressure and ever since, it has been a problem

of addiction for him. He has also had a history of drug abuse with cocaine and benzodiazepines.

In a study conducted by Fergusson (2009) states that “there is still no biological mechanism that

would appear to explain why someone would develop depression as a result of drinking”, “it is

possible to suggest social mechanisms in which the heavy use of alcohol leads to a wide range of
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personal problems with these problems increasing risks of depression”. In other words, it is

possible that this pts history of alcoholism starting at a young age has lead to his depression.

This pt states that to cope with his substance abuse/alcoholism, he goes to AA meetings

twice a week at a church that is on his block. He states that he also likes to go for walks and

watch tv. He also likes to sit on his porch.

Discuss

MM has a psychiatric history of depression, polysubstance abuse, and suicidal behavior.

He has an expansive history of hospitalizations over his life span for self harm, suicide attempts,

depression, intoxication, and intentional overdoses of medication. He has been seen at a variety

of hospitals including Trumbull Memorial and St Elizabeth's Medical Center. He has had

treatment at a variety of inpatient/outpatient centers including Coleman, Riverbend, etc. This pt

has a history of being noncompliant with treatment. He discontinues his meds, doesn't show up

for treatment and is known for his history of 30 day readmits. He also has not been going to his

AA meetings. As discussed in clinical it is possible that the reason he has so many readmits, is

because he's lonely due to lack of support.

When first speaking with this pt on Oct. 30th, he was being set up with Coleman for

evaluation in which they deemed that it was the best resource for admission. Now, when talking

to the pt for the second time, he is now appointed an Order of Protective Custody, who will take

over decisions for the patient. He is also being set up with a group home that he will live at for

free. He has been 1 month sober and seems to be on a good path at this time. He is very cheerful

and sounds like he has hope for the future.

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Describe

MM is under a variety of treatments for his depression. He is undergoing group

psychotherapy in which group counseling takes place to explore the patients feelings, to set

goals, and work towards personal change. There is a large amount of evidence based nursing

research on group psychotherapy for depression. In a study including 48 research reports on the

efficacy of group therapy conducted by Mcdermut, Miller, Brown (2006), research found that

“analyses of clinically significant change suggested that treated participants improved

substantially”. The study also showed that “group therapy is an efficacious treatment for

depressed patients”. In 15 studies, in which treated participants were compared to untreated

controls showed that “the average treated participant was better off than about 85% of the

untreated participants”.

MM is also receiving pharmacologic treatment of Depakote and Atarax. Depakote is an

anticonvulsant used as a mood stabilizer in the treatment of depression. Atarax is an

antianxiolytic for treatment of anxiety. This pt has a history of non compliance with medication

which is a problem that prevents treatment. As stated in a study conducted by Vuckovich (2010),

“ For patients’ long-term benefit the ultimate goal is adherence, but when involuntary patients

are very disabled by illness, the immediate objective is compliance”. “Compliance to treatment is

a major problem, especially for patients repeatedly hospitalized for psychiatric disorders”.

Analyze

MM dropped out of highschool two weeks before graduation. As mentioned before, he

was married and divorced two times. Pt now lives alone. He has two sisters, nieces, and nephews

which do not speak to him. Never had children of his own. He had a dog, but when he had his

surgery his wife took everything out of his house including his dog. He worked as a chef for
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approx. 20 yrs before having a craniotomy in 2017 which caused him peripheral vision loss, he is

now unemployed. He then applied for government assistance, in which he was denied due to his

substance abuse. He has chronic alcoholism that has caused a variety of problems including poor

relationships, used up resources, financial problems, increased anxiety/depression, etc. The pt did

not mention any specific ethnic, spiritual, or cultural influences that impact him.

Evaluate

MM has come to a point of surrender to his mental health. He seems as though he is on a

path of recovery and is finally accepting help. He has been down this road many times and

hopefully he is strong enough to continue on the path that he is going on. This pt is now 1 month

sober and able to qualify for government assistance. As said before, he is trying to get into a

group home that he will be able to live at for free. He now has an Order of Protective Custody

who will be able to make his decisions for him, this will benefit him in many ways. He is now

feeling positive and looking to the future. On 9/25 when caring for this pt, he was down in the

dumps and acted like he was helpless. He would not participate in group discussions, if he did it

was short and to the point. He would not receive a paper to write down his goals stating “I don’t

need one I can’t see it” implying to his peripheral vision loss. On 10/28 he was accepting and

even wrote on his paper and it was legible. He even volunteered to read it aloud to the group.

This pt was becoming more concerned about his future, and the future seems to be his source of

motivation in this round of treatment.

Summarize
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MM has a long road ahead of him. On 9/25 when caring for this pt, his discharge plans

included being sent to Coleman Professional which provides mental health, drug, and alcohol

services. He was also to be assigned a case manager whom he never met up with. Plans for

discharge from 10/16 admission included his assignment of the Order of Protective Custody. He

is also awaiting to hear if he will be accepted in the the Washington House group home where he

will live at for free. He has also applied again for government assistance, which he is waiting to

hear back from.

Prioritized List

MM had multiple psychiatric diagnoses that applied to him. The most important one that

applies to him is risk for suicide r/t depressed state as evidenced by statements of “I have

nothing”. The second nursing diagnosis chosen was hopelessness r/t absence of support systems

as evidenced by rejection by family due to life choices. The last diagnosis chosen was low self-

esteem r/t feelings of abandonment as evidenced by expressions of worthlessness and decreased

affect.

List

There are multiple other nursing diagnoses that could apply to this pt if his condition

would change. One could be imbalanced nutrition r/t unwillingness to eat as evidenced by

decreased intake. Another one could be impaired social interaction r/t low self esteem as

evidenced by inability to develop satisfying relationships. With his substance abuse, it could lead

to risk for injury r/t cns agitation secondary to withdrawal from alcohol or other cns depressants
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as evidenced by withdraw from alcohol. Lastly, one could be ineffective coping r/t inadequate

coping skills as evidenced by use of substances as a coping mechanism.

Conclusion

MM has been through alot throughout his life. Many things have caused his depression

and many things have come from his depression. Depression can impact multiple aspects of a

person life including physical health, relationships, thought processes, etc. This pt has been

admitted multiple times for a variety of reasons. He has been given every resource possible over

and over again. Upon this discharge, this pt is in a good place to accept change for his future.

Now that he has an Order of Protective Custody, hopefully he will be directed in the right

direction towards treatment and rehabilitation.

References

McDermut, W., Miller, I. W., & Brown, R. A. (2006, May 11). The Efficacy of Group

Psychotherapy for Depression: A Meta‐analysis and Review of the Empirical Research.

Retrieved November 12, 2018, from

https://onlinelibrary.wiley.com/doi/full/10.1093/clipsy.8.1.98
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Serobatse, M., Du Plessis, E., & Koen, M. (2014). Interventions to promote psychiatric patients’

compliance to mental health treatment: A systematic review. Health SA Gesondheid, 19(1), 10

pages. doi:https://doi.org/10.4102/hsag.v19i1.799

Study finds alcohol abuse or dependence causes depression, not vice versa. (2009). Alcoholism

& Drug Abuse Weekly, 21(10), 1–3. Retrieved from

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