Major Depressive Disorder Assessment

Major Depressive Disorder Assessment

Patient History

Demographics: The client is a 21-year old Female of American origin. She stays with her parents at their home in New York, and she communicates well in English. The client reports that the source of income is from the parents and she attends school. She is a Christian and attends mass regularly at the nearby Catholic Church.

Presenting Problems: The client says that, “I have lost interest in everything of late and I don’t sleep at all. I feel sad when people talk to me, have little appetite and sometimes become angry with no reason.”

History of Present Illness: The client appears calm and is oriented to time, place and person. The client reports that three weeks ago she came home to stay with her parents after closing school. She started feeling depressed, alone and sometimes angered. She has been experiencing sleepless nights irrespective of the effort to try sleeping. The client reports that sleep does not go beyond two hours. Usually, the patient sleeps for seven to eight hours a day. When talking with her parents and siblings, the client reports that she gets pissed off by little things and becomes angered a lot that she can hurt someone. For two weeks now, she has been eating less because of diminished appetite. She used to enjoy staying at home with her little brothers, but now she doesn’t feel like staying with the family at all.

Past Psychiatric History: The client has a history of depression reported having started at the age of 16 years where she was hospitalized due to mild depression. The patient reports that at that time, she lost interest in her studies and felt like staying alone. She could lock herself in the room for the whole day listening to music. She was discharged home on medication and got better after some time. The patient reports that in 2016, she was admitted to a psychiatric unit for the same symptoms and after three days of medication, she was discharged home. She was placed on Risperidone 1mg per day, and the medication worked well. She attended group therapy sessions at school but stopped when she got well.

Medical History: The client has been hospitalized twice in the past due to other problems apart from depression. Her first hospitalization was in 2012 due to pneumonia. She was treated and discharged home on medication. The second event was on 2017 when she was hospitalized in the county hospital for management of malaria. She had gone for a field trip when she fell ill. The patient is allergic to eggs, and she reports that sometimes cold weather affects her breathing. Her immunizations are up to date. The patient denies having hypertension, diabetes, cancer or any other chronic diseases or traumatic experiences. She goes for a medical checkup after every three months together with a psychiatric assessment every two months.

Substance Abuse History:  The client denies the use of illicit drugs in the past.

Differential Diagnosis

Mood disorder due to another medical condition: Patients diagnosed with chronic conditions like chronic hypertension, heart failure and cancer experience depression. The patients want to be alone, lack appetite and lose hope in life. However, the patient does not suffer from any of the conditions thus ruling out the diagnosis.

Substance abuse induced depressive disorder: Drugs such as Cocaine have adverse withdrawal symptoms that manifest as depressive disorders (American Psychiatric Association, 2013). The patients experience mood changes, lack of sleep, feeling of loneliness and they are irritable. The client does not have any history of substance abuse hence ruling out a diagnosis of substance abuse induced depressive disorder.

Adjustment disorder with depressed mood: Adjustment disorders present with symptoms of depression in many cases. The symptoms of the disorder are almost the same as MDD. The condition manifests with low mood and sadness together with a sense of hopelessness. Decreased self-esteem and episodes of anger are also present in patients suffering from the condition (American Psychiatric Association, 2013). The condition only manifests when there are certain situations, and the symptoms occur after the situation has occurred.  The client’s symptoms are not due to any bad events or occurrences thus the diagnosis of the major depressive disorder.

DSM-5 Diagnosis:

Major Depressive Disorder 296.31

The diagnostics and the statistical manual provides the criteria for the diagnosis of MDD. According to DSM-5, a major depressive disorder is characterized by the occurrence of discrete episodes of at least two weeks duration with symptoms of either depressed mood or loss of pleasure or interest (American Psychiatric Association, 2013). Major depressive disorder is characterized by several features or symptoms to include depressed mood, insomnia, diminished interest, psychomotor agitation, fatigue and recurrent thoughts of death or suicide. The condition also involves changes in cognition and vegetative symptoms. The patient has had one inpatient hospitalization due to depression. At the same time, the client manifests with low mood, lack of interest and diminished appetite. The symptoms are recurrent and have been manifested for the past three weeks. The above symptoms qualify for the classification of the condition as a major depressive disorder

Individualized Treatment Plan

Fluoxetine 20mg OD

Fluoxetine is a drug classified under Selective Serotonin Reuptake Inhibitors (SSRIs) used to manage depression. The drug is indicated for other conditions such as panic disorders, premenstrual dysphoric disorder, eating disorders and obsessive-compulsive disorders. The drug was chosen because of its ability to treat depression and increase the vegetative symptoms such as appetite. The low dosage of 20mg once a day was chosen so that assessment for subsequent visits can be done and relevant adjustments will be made after the assessment. SSRIs work primarily by increasing extracellular levels of serotonin neurotransmitter inhibiting its reuptake into the postsynaptic cleft.

Referrals with rationales: The client will return to the psychiatric clinic after four weeks for observation and checkup. The four-week plan gives enough time for monitoring of the progress and effectiveness of the medication. The medication will be adjusted depending on the improvement of the symptoms after four weeks. The patient is referred for psychotherapy sessions to help improve the coping mechanisms. Cognitive behavioral therapy (CBT) will work best for the client, and together with pharmacological interventions, the patient will recover fast. A CBT therapy of three months will improve the symptoms of the patient.

Therapy with Rationales: Cognitive behavioral therapy is a form of psychotherapy used to manage psychiatric conditions that alter the mood of people such as depression, PTSD and eating disorders (Dobson, 2016). The therapy is helpful in boosting happiness in many ways. It modifies emotions, thoughts, and behaviors by providing solutions to the current problems. CBT is effective for individuals, family or groups and it is found to be effective when combined with pharmacotherapy.

Legal and Ethical Implications of Counseling

The mental health field is diverse and for effective provision of services, legal and ethical considerations must be present to guide the practice. The first legal consideration is informed content. Informed consent defines the relationship between the client and the therapist. It gives the client the opportunity to feel that they are part of the team trying to offer a solution for the problem (Kaplan, 2014). Confidentiality is the duty of the therapist where information is kept between the two counseling parties. It forms the trusting foundation of counseling in all healthcare encounters. Before information is shared with friends and the family members, the patient should be informed so that the privacy rights are not violated.

The health protection and portability act (HIPPA) advocates for good record keeping as part of the standards of practice (Kaplan, 2014). The information of the patient should remain in the healthcare setting all the time for protection. Ethical decision making lies in the hands of the healthcare provider, and considerations like reflection and evaluation should be made before decision making. Counseling offers clients with an opportunity to express their worries and fears to the therapist thus the use of ethical rules and guidelines protects the client. The safety of patients is guaranteed through physical and emotional care. The moral principles of reasoning should be used by therapists during client counseling to evaluate the course of action. Autonomy, beneficence, justice, nonmaleficence, and fidelity should be used to make decisions during difficult situations.


Wheeler, K. (Ed.). (2014). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice (2nd ed.). New York, NY: Springer Publishing Company.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

American Psychiatric Association. (2016). Practice guidelines for the psychiatric evaluation of adults (3rd ed.). Arlington, VA: Author. Retrieved from

Kaplan, D. M. (2014). Ethical implications of a critical legal case for the counseling profession: Ward v. Wilbanks. Journal of Counseling & Development, 92(2), 142-146.

Dobson, D., & Dobson, K. S. (2016). Evidence-based practice of cognitive-behavioral therapy. Guilford Publications.