Assessment and treatment of workplace-related depression in a case study

¶ … Treatment of Psychological Disorders

The patient is a 46-year-old man who is experiencing difficulties at work to which he attributes the symptoms he is experiencing. Presenting symptoms include feelings of depression, difficulty sleeping, loss of appetite, difficulty concentrating, anxiety, and three episodes of panic-attack. The patient's wife is very worried about her husband and reports that their communication is practically non-existent over the past three weeks.

Schema for Diagnosis, Treatment, and Management

New patient procedures include brief intake conversation, taking patient history, screening with appropriate instruments, confirmation of diagnosis, jointly establishing a treatment, and follow-up focused on lifestyle changes and treatment plan extension. The early tasks are to determine if there are any existing medical conditions or substance abuse that would contribute to the patient's symptoms. Fundamental tasks are to consider the clustering of the symptoms and symptom duration, to determine if there have been primary mood episodes at other times in the patient's life, and to provide for subsequent observations following abstinence of any substance believed to be contributing to the depression because of withdrawal or intoxication. Confirmation of the diagnosis may reasonably not occur until some passage of time, following serial evaluations, or sequential treatment trials. A detailed discussion of each element of the schema follows.

Intake and Patient Assessment

Patient History

In taking the patient's history, two pivotal tasks are to review the patient's family history and to establish if any primary mood episodes have previously occurred.

Intake of caffeine and/or medication. Taking the patient's history will identify any substances that could be impacting the patient's mood. Symptoms such as breathlessness, racing heart, and anxiety could be caused by excessive caffeine intake. Some people find that coffee and other forms of caffeine (e.g., diet cola drinks, energy drinks) can impact moods and even aggravate depression. A review of medications will reveal if any over-the-counter or prescription medications are contributing to the patient's feelings of depression. In addition, it is possible that the patient could have prescriptions from other physicians or psychiatrists that include tranquilizers, sleeping pills, antihistamines, and even narcotics. And it is important to determine if there is any use of recreational drugs or controlled substances, including alcohol, marijuana, amphetamines, "downers," or ecstasy.

Patient Assessment -- Diagnosis

Completion of a basic screening process and taking the patient's history provides a basis for confirmation of the suspected diagnosis. One of the important decision points inherent in confirmation of a diagnosis of depression is to determine whether the depressive state is situational or clinical. A second decision point is whether anxiety disorder is co-morbid to the depressive state. The Diagnostic and Statistics Manual 4th edition, Text Revision (DSM-IV-TR) is the foundation for diagnosis of mood disorder (First, et al., 2002). Under mood disorders, the DSM-IV-TR describes mood episodes (which include Major Depressive Episode, Manic Episode, Mixed Episode, and Hypomanic Episode) which are not independently diagnoses and do not have diagnostic codes, but they do serve as a foundation for the disorder diagnosis or diagnoses (First, et al., 2002). Mood Disorders (which include Major Depressive Disorder, Dysthymic Disorder, Bipolar I Disorder) are listed after the mood episodes (First, et al., 2002). It is important to note that the Mood Disorder criteria sets require either the presence or the absence of the mood episodes (First, et al., 2002). The last part of the Mood Disorders section covers the specifiers that describe either a course of recurrent episodes, assuming the patient history manifests more than one mood episode, or the most recent mood episode that is the focus of the patient's complaint (First, et al., 2002).

Given the presenting symptoms, three disorders are considered: Major Depressive Episode, Major Depressive Disorder and Dysthymic Disorder (First, et al., 2002). These three disorder criteria sets are a fair representation of the spectrum of mood disorders that the patient is likely to have experienced (First, et al., 2002). The rationale for delineating these as possible diagnoses is as follows: Assuming the patient and his wife are accurately portraying the patient's problems as a three-week episode, then a diagnosis of mood episode is likely (First, et al., 2002). If the patient has experienced underlying dysthymic disorder -- which is characterized by a lower symptom threshold than for Major Depressive Episode -- and his work situation has deteriorated because of it -- recently coming to a crisis point which is reflected in his present complaints which include anxiety and panic attacks -- then serial evaluations and the passage of time should provide clarity (First, et al., 2002). If the middle ground is the best fit, that, too, should become evident with follow-up (First, et al., 2002).

A Major Depressive Episode requires a "minimum duration of at least two weeks of depressed mood for most of the day, nearly every day (First, et al., 2002).Also, the depressed mood must be accompanied by at least four additional symptoms over the same period" (e.g., weight change, sleep changes, motor activity changes, and suicide ideation) (First, et al., 2002, p. 47).

A diagnosis of Major Depressive Disorder requires the inclusion of two or more major depressive episodes, and the diagnostic criteria are as follows: The patient must report or show evidence of "depressed mood and/or loss of interest or pleasure in life activities for at least two weeks and at least five of the following symptoms that cause clinically significant impairment in social, work, or other important areas of functioning almost every day." The required symptoms include: "(1) Depressed mood most of the day; (2) Diminished interest or pleasure in all or most activities; (3) Significant unintentional weight loss or gain; (4) Insomnia or sleeping too much; (5) Agitation or psychomotor retardation noticed by others; (6) Fatigue or loss of energy; (7) Feelings of worthlessness or excessive guilt; (8) Diminished ability to think or concentrate, or indecisiveness; and, (9) Recurrent thoughts of death" (First, et al., 2002, p. 356).

A diagnosis of Dysthymic Disorder requires the inclusion of two or more major depressive episodes, and the diagnostic criteria are as follows: The patient must report or show evidence of "depressed mood for more days than not, for at least two years and the presence of two or more of the following symptoms that cause clinically significant impairment in social, work, or other important areas of functioning." The required symptoms include: "(1) Poor appetite of overeating; (2) Insomnia or sleeping too much; (3) Low energy or fatigue; (4) Low self-esteem; (5) Poor concentration or difficulty making decisions; (6) Feelings of hopelessness" (First, et al., 2002, p. 380).

Once the diagnosis has been established, the next processes involve the joint establishment of a treatment plan (Rothbaum, et al., 2000). Deep participation from the patient is necessary as treatment includes defining and implementing appropriate lifestyle changes which must be initiated and sustained by the patient (Rothbaum, et al., 2000). For this reason, it is imperative to have a clear idea of what the patient is willing to entertain with regard to plans for behavior and lifestyle changes (Rothbaum, et al., 2000). The hub of the treatment schema is cognitive-behavior therapy (Rothbaum, et al., 2000). The patient will be presented with a menu of options to include in the treatment and management plan, most of which he will select according to their individual appeal, but cognitive-behavior therapy is not optional (Rothbaum, et al., 2000). Cognitive-behavior therapy is the platform for treatment and the patient must agree to actively participate in the implementation of its steps, stages, and processes (Rothbaum, et al., 2000).

Treatment & Management Plan

Therapeutic Intervention

If the patient is willing, he will be introduced to cognitive behavioral therapy (CBT) in order to begin challenging and learning to neutralize the negative intrusive thoughts that may precipitate his anxiety and panic-attack episodes, as well as his feelings of being hurt and misunderstood due to feedback and treatment at work ("Cognitive-Behavioral Therapy," 2010). Cognitive-Behavior Therapy can help a patient understand how our thoughts bring about our feelings and behaviors, rather than things external to us ("Cognitive-Behavioral Therapy," 2010). This empowers the patient to change the way he or she thinks -- in order to feel better and to act "better" -- even if a situation does not change ("Cognitive-Behavioral Therapy," 2010). Cognitive-Behavior Therapy requires a patient to practice the learned techniques in order to become more proficient and have stronger impact on their lives ("Cognitive-Behavioral Therapy," 2010).

Lifestyle Change Recommendations

In keeping with a the cognitive behavioral therapy (CBT) which focuses on changing intrusive negative cognitions that occur in a depressive state, the therapeutic plan entails making changes that bring the patient progressively closer to the behaviors that will achieve the goals he has identified for himself (Rothbaum, et al., 2000). A menu of lifestyle changes will be offered to the patient for his consideration (Rothbaum, et al., 2000). He will be encouraged to choose two or three to start, and be encouraged to keep other lifestyle choices in mind as he progresses ("Cognitive-Behavioral Therapy," 2010; Rothbaum, et al., 2000).The options are listed below:

Meditation. Meditation is an optimal choice for a depressed patient, but it requires a long-term commitment and the willingness to practice meditative techniques on a daily basis (Weil, 2011). The roots of depression can be addressed through meditative techniques and the benefits can carry over to quotidian events, such that, the patient would eventually experience improvements in his workday experience (Weil, 2011). The patient will be encouraged to include this lifestyle change in his daily repertoire (Weil, 2011).

Exercise. According to numerous studies, symptomatic treatment of depression can be alleviated through regular aerobic exercise (Weil, 2011). Emotional health is improved and self-confidence gets a boost through vigorous pleasant exercise of about 30 minutes every day (Weil, 2011).

Acupuncture. Although it is not for everyone, acupuncture has been show to be useful in treating depression and several other types of mood disorders (Weil, 2011). It should be offered to the patient for consideration as it entails less commitment than meditation but can be beneficial (Weil, 2011).

Medication counseling. If the patient has shown any inclination to self-medicate, discussion about substituting cognitive behavior therapy for the substances should proceed (Weil, 2011). In addition, if the patient has previously been prescribed anti-depressant medication -- or requests it -- the findings from British researchers published in February 2008 in which commonly prescribed anti-depressant pharmaceuticals were found to have limited effectiveness" should be provided to the patient (Weil, 2011).

Nutrition and food supplements. The patient will be encouraged to examine diet as a means of supporting good brain function (Weil, 2011). Recommendations are as follows: (1) B. vitamins, particularly folic acid and B6, may alleviate mild depression and they also are known to increase anti-depression efficacy; (2) St. John's wort is helpful with mild to moderate forms of mood disorders with effects experienced in about eight weeks of treatment (Weil, 2011). Extracts can be as effective as Prozac, in some instances, however, it must not be taken with anti-depressants (particularly not SSRIs like Celexa or Prozac), anti-retroviral medications, or birth control; (3) SAMe, or S-adenosy-L-methionine, works faster than St. John's wort, but only the butanedisulfonate form in enteric-coated tablets should be taken; (5) Fish oil (omega-3 fatty acids) are helpful in maintaining a healthy mind and could be helpful with depression (particularly DHA or docosahexaenoic acid, which is an essential fatty acid found in healthy brain and nerve tissue); and (6) a well-balanced diet that includes multiple antioxidant and multi-vitamin and mineral supplements can ensure that all the essential nutrients for a healthy body and mind are being consumed daily (Weil, 2011).

Focused follow-up. Because a constellation of behavior and lifestyle changes will have been recommended to the patient, it is important to ensure that focused follow-up takes place and that extensions of the treatment plan calibrated as needed, and as the patient indicates readiness (Rothbaum, et al., 2000).