It is only through analysis of the person's behavior and communication can a psychiatrist identify the disorder. Major Depressive Disorder tends to exhist in people who have had depression for quite some time or have had recurring depression. Although it is difficult to identify it can be determined and identified. Treatment usually involves cognitive-behavioral therapy.

Mood- Incongruent psychotic features is a term used to describe the characteristics of psychosis. The psychosis usually consists of delusions and hallucinations. They tend to be consistent with an elevated mood such as experienced in Bi-Polar disorder or in depression such as Major Depressive Disorder.

Something such as Schizophrenia is a Mood-Incongruent Disorder. Mood- Incongruent psychotic features tend to be established in people with depression if the hallucination does not involve themes of personal inadequacies, death, or deserved punishment. When it comes to manic disorders the hallucinations would not consist of themes of inflated worth or a special relationship to a deity.

An example of Mood- Incongruent psychotic features would include self-derogatory or grandiose hallucinations. This would include thought insertion and broadcasting along with delusions of being controlled. People with Mood- Incongruent psychotic features tend to feel as though they are being judged in some way.

DSM-IV-TR Multiaxial Diagnosis

Axis I is used for disorders such as Major Depressive Disorder. Axis II in the DSM system is used for personality disorders such as Obsessive-Compulsive Personality Disorder. The patient Ms. Harlow demonstrated characteristics that would fall in this Axis. Although she was not suffering from catatonia, she did display some of the symptoms. "Catatonia is a syndrome of motor dysregulation characterized by mutism, immobility, negativism, posturing, staring, rigidity, stereotypy, mannerisms, echophenomena, perseveration, and automatic obedience, among others." (Fink & Taylor 2003)

Axis IV deals with environmental issues such as social issues and financial difficulties that might add to a person's existing mental issues. Studies have also linked age to display signs of difficulty in creating effective treatment for mental disorders. "Intolerance to antidepressant medications and the presence of medical conditions are known to be age related." (Fink et al., 1996) Ms. Harlow is at that age where an intolerance to medication can be an issue.

Referral

ECT or Electroconvulsive therapy seems to be a treatment that has had high success rates in treating most forms of depression. "Regarding subtypes of depression, ECT appears to be effective in treating both melancholic and severe nonmelancholic depression as well as bipolar and unipolar major depression. In addition it may be particularly effective in treating psychotic major depression. (Husain et al.) Ms. Harlow experienced bouts of depression before. A round of ECT might be beneficial to her.

There are some forms of delusional depressives that do not respond well to ECT. "The dichotomy lost its clinical significance after the introduction of ECT, as both groups were equally responsive. However, accumulating evidence indicates that unipolar delusional depressives are significantly less responsive to tricyclic anti-depressant therapy than non-delusional depressives. " (Kantor & Glassman, 1977) Some people who supposedly suffer from TRD or therapy-resistant depression are actually suffering from some other unrecognized illness. "Patients with what's called "therapy-resistant" depression (TRD) -- with subtherapeutic response to medications and psychotherapy -- are often actually suffering from unrecognized, inadequately treated psychotic depression."(Kellner, Fink, Knapp) Some studies have been done recognizing the high success rate of ECT as a means of therapy. "Among patients who completed the full ECT course (at least 12 sessions), remission rates were 96% for psychotic depression and 83% for nonpsychotic depression. The overall remission rate was 87%. " (Kellner, Fink, Knapp) " ECT was shown to be superior after a full course. The funnel plot showed the absence of publication bias. There was no exaggeration of effect size in the lower quality trials. No evidence was found for a superior speed of action of ECT or for a difference in efficacy between sine wave and brief pulse stimulation." (Kho et al. 2003)

Further studies analyzed delusional depression and ECT efficacy. "The treatment responses of 597 patients with delusional depression from 17 studies were compared. Patients were treated with either tricyclic antidepressants (TCAs), antipsychotics (APs), the combination of TCA/AP, or electroconvulsive therapy (ECT). The overall responses were 34% in the group treated with TCA, 51% in the AP group, 77% in the TCA/AP group, and 82% in the ECT group." (Kroessler 1985) Ms. Harlow was diagnosed with depression along with experienced delusions and hallucinations. ECT might help patients like Ms. Harlow in preventing recurrence.

"The study group consisted of 125 women and 62 men, 180 (96%) of whom were Caucasian. The mean age of the subjects was 62 years (SD=18). The median length of the episode of depression before ECT was 25 weeks (range=2 -- 416 weeks), and the median number of medication trials was four (range=0 -- 30). Psychotic features were present during the index episode of depression in 53 patients (28%). Despite receiving a comparable number of medication trials before ECT, patients with psychotic depression were significantly less likely than those with nonpsychotic depression to have received at least one adequate pharmacotherapy trial (rated 3 or higher) (table 1). (Mulsant et al. 1997) ECT appears to be a means of effective treatment for different types of depression. It also appears to treat elderly patients who might be intolerant to medications.
Presenting Problems

Axis I: Primary presenting problem (such as major depressive disorder or bipolar disorder). Patient Jean Harlow demonstrated signs of disinterest in social activities as well as daily activities such as work, hobbies, etc. These problems were then followed by signs of dissatisfaction.

Obessive-Compulsive Disorder was also noted in the patient displayed by wanting constant reassurance and having cyclical, negative thoughts. Patient demonstrated desire to end life even if it was not through self means, but rather by chance. Overall Jean's behavior and daily routine presented signs of depression.

Hallucinations and delusions made up some of Jean's problems. She stated they were recurring and noted that it affected her as they worsened. All or most of the hallucinations and delusions were negative and judmental towards her. They all felt very real for her and increased her depressive state.

Goals (long-term)

The long-term goals or Ms. Harlow is to establish coping mechanisms that positively deal with sudden stressors in life and improving her overall self-image. Self-esteem seems to be crucial in developing a better reaction to stress and social interactons. Medications can be used for management of the hallucinations and delusions as well as anti-depressants to stimulate more daily activity and promote less anxiety. This in turn will provide a better outlook on the situation.

Overall Ms. Harlow should be able to deal with any mental distress seeing as her depression is recurring and could happen again during a tragedy or health scare. Poor self-image stemming from her past and her obsession with her appearance must be dealt with in order to create a positive mindset for her. A better understanding and awareness is crucial for the patient to readily identify any problems should they arise.

Reality is a difficult thing to face. A lifetime goal for Ms. Harlow is to better deal with life as a whole and to better know herself. Increased awareness, increased acceptance of who she is and what has happened will lead to a better overal outlook. This will then lessen depressive incidents.

Objectives (describes what will be accomplished in order to meet longer term goals)

Behavioral-cognitive therapy to establish more awareness and better understanding.

Increased exposure to perceived stressors and situations that cause anxiety to lessen its effect.

Relaxing techniques to keep the patient level-headed when faced with anxiety and struggle.

Group therapy to express and communicate stress and anxiety.

Methods or Interventions

Interventions are needed if patient is not responding well to treatment. Signs of not responding to treatment involve: regression to old habits, disturbances in sleep or eating habits, and increased hallucinations and delusions. One such intervention could be done with the psychatrist followed by a re-evaluation of medications to see which ones are not working and which ones are. This would be followed up by blood tests to observe any changes in patient's body. Lastly close monitoring a few days after the intervention to see if any progress is made.

Group therapy can be an effective method because it lets the client know he/she is not alone. It's helpful to know there is a person having the same exact problems as you. It also teaches patients about what not to do when faced with dilemmas and improves their overall communication and ability to convey thoughts and emotions.

Estimated Length of Treatment

It takes a long time to effectively treat patients with recurring mental health problems. In patient treatment where the patient is in a psychatric facility lasts anywhere between 4-6 weeks Out patient treatment follows for 6-12 months with monitoring of the medication dosages and gradual lessening of visits and medications.

Patient needs to be taught effective coping strategies and self-esteem buidling. Behavioral therapy…