There is no information about the subjective experience and perception of the client, whether he was assessed for suicidal ideation. There is also no information about the clientâ€™s prior health history regarding suicide and previous attempts. There is also n concrete information about the specific medication the client has taken in the past, duration, and its effectiveness (AgÃ¼era-Ortiz et al., 2020). There is no information about the diagnostic criteria used by the clientâ€™s previous provider.
Achievement and Vulnerabilities
The client has successfully come off of the antidepressant when he lost his limb years ago. This means that the client has successfully resolved the incident and coped positively to the loss of his limb. However, the recent death of his spouse has a negative impact on him and clearly, he is still in the grieving stage which has contributed to his depression. Because he is alone and is only visited by the home health care twice a week and refuse to socialize, he is potentially vulnerable to harming himself. His withdrawal from social interaction, his refusal to participate in previously pleasurable activities, his statement that he wants to be with his wife, and his report of purchasing a handgun are some signs that presents that he is vulnerable to self-harm and also exhibiting depression. His children becoming successful, have their own careers, and has successfully moved out from the home is a developmental achievement of a parent.
One factor is the death of his wife. Another is his apparent chronic condition such as diabetes, and chronic back pain. According to Avasthi and Grover (2018) ack of adequate management of chronic back pain can lead to depression. His social situation where his children are often too busy to pay him a visit may also have contributed to his current symptoms. His apparent need for assistance because of his disability (limb loss) can also contribute to the current symptom he is experiencing.
The differential diagnosis are;
Major depression â€“ this is validated by the symptoms such as suicidal ideation, social isolation and withdrawal, loss of appetite, lack of energy, refusal to participate in previously pleasurable activities, to name a few.
Dysthymic disorder â€“ defined as a low mood that occurs for at least two years and can occur with other symptoms of depression such as hopelessness, low self-esteem, anorexia, sleep changes, and etc (Kok & Reynolds, 2017).
Post-traumatic stress disorder – this can be contributed by the clientâ€™s motor vehicular accident years ago that caused him to lose his leg as well as the recent death of his spouse which seemed to trigger his current signs and symptoms (Kok & Reynolds, 2017).
Etiology of Major Depression
The exact mechanism for the development of depression is not completely understood but a combination of biological, genetic, and environmental factors is thought to play a role. An imbalance of the neurotransmitter serotonin and dopamine were thought to contribute to the development of major depression. However, recent studies indicated that the neurotransmitter GABA are found to be low in patients with major depression. Additionally, stresses from oneâ€™s environment such as the death of a loved one can trigger alteration in neuroendocrine responses (Obuobi-Donkor et al., 2021).
It is important to ensure a no self-harm contract for the client and to provide supervision to monitor for self-harm. The client must be communicated with to establish any suicidal plans and to address it promptly. Also, since the client has other co-morbidities, such as hypertension, psoriasis, and chronic back pain, providing adequate pain relief is important to relieve discomfort and promote positive mood and outlook. The client has type 2 diabetes mellitus and if the client loses interest in taking medication, he could experience complications of the disease (Obuobi-Donkor et al., 2021).
It is important to continue to monitor blood pressure, blood glucose level, do medication reconciliation and to ensure that the client is able to eat well-balanced meal. Assessment of the clientâ€™s blood pressure, blood glucose other vital signs, and pain level is important to identify complications. Some common complication associated with his co-morbidities are nephropathy, retinopathy, neuropathy, changes in urination, fatigue, exacerbation of his psoriasis, and cognitive decline (atypical) can be used as assessment approaches for complications.
Nonpharmacologic therapies include biofeedback, meditation and self-relaxation can help in reducing pain and promoting positive well-being. The utilization of cognitive behavior therapy can help the client in reducing suicide attempts and suicidal ideation (Obuobi-Donkor et al., 2021).
The best first-line medication for major depression in the elderly are SSRIs. Citalopram for example has the best safety profile for the elderly with depression. They have the lowest potential for drug-drug interaction and since the client has other co-morbidities, this is highly considered. Patients with diabetes and cardiovascular issues do not respond well with tricyclic antidepressants (Zenebe et al., 2021).
Safety risk include potential harm to self as well as use of the handgun. It would be important to develop a clear and direct communication with the client about a no suicide contract (Zenebe et al., 2021). Close supervision is important and a visit to the home health care as well as the family members to check the clientâ€™s situation. A consultation to check effectiveness of the medication is also important.
AgÃ¼era-Ortiz, L., Claver-MartÃn, M. D., Franco-FernÃ¡ndez, M. D., LÃ³pez-Ãlvarez, J., MartÃn-Carrasco, M., Ramos-GarcÃa, M. I., & SÃ¡nchez-PÃ©rez, M. (2020). Depression in the Elderly. Consensus Statement of the Spanish Psychogeriatric Association. Frontiers in Psychiatry, 11. https://doi.org/10.3389/fpsyt.2020.00380
Avasthi, A., & Grover, S. (2018). Clinical Practice Guidelines for Management of Depression in Elderly. Indian Journal of Psychiatry, 60(Suppl 3), S341â€“S362. https://doi.org/10.4103/0019-5545.224474
Kok, R. M., & Reynolds, C. F. (2017). Management of Depression in Older Adults. JAMA, 317(20), 2114. https://doi.org/10.1001/jama.2017.5706
Obuobi-Donkor, G., Nkire, N., & Agyapong, V. I. O. (2021). Prevalence of Major Depressive Disorder and Correlates of Thoughts of Death, Suicidal Behaviour, and Death by Suicide in the Geriatric Populationâ€”A General Review of Literature. Behavioral Sciences, 11(11), 142. https://doi.org/10.3390/bs11110142
Zenebe, Y., Akele, B., W/Selassie, M., & Necho, M. (2021). Prevalence and determinants of depression among old age: a systematic review and meta-analysis. Annals of General Psychiatry, 20, 55. https://doi.org/10.1186/s12991-021-00375-x