Adolescent Depression.
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Case Presentation
Justin is an 18-year-old African-American male presenting to the clinic per his mother’s persuasion. His mother reports that he has had fatigue, loss of energy, irritability, lack of motivation, decreased ability to concentrate, poor hygiene, low selfesteem, and weight loss. Justin refuses to interact with friends. His mother states: “He goes to school and then comes home and goes to bed or lays on the couch.” His mother says she has noticed a gradual decline in his hygiene and lack of motivation over the last six months. She also reports that his grades have dropped from A’s and B’s to B’s and C’s this quarter. His mother denies Justin having learning problems.
Past Medical History
Currently, Justin does not have a primary care provider. Justin denies any food, environmental, or drug allergies. He admits to smoking a half pack of cigarettes on weekends for the last year and marijuana on occasion or when “I can find someone selling pot.” Justin also admits to drinking beer when at social activities. His mother states he is up to date on immunizations. Justin denies constipation, diarrhea, dry skin, or heart palpitations.
Development and Growth History
Justin exhibits normal growth and development (weight and height) for age and sex.
Family and Social History
Justin’s family medical history consists of diabetes, cancer, depression, and hypertension. Both of Justin’s grandfathers have a history of hypertension and diabetes. Justin’s father’s paternal uncle has a history of depression. Justin’s grandmother has had breast cancer. Justin’s parents have been married for 20 years. He has two younger sisters who live in the home. In the past, Justin was involved in soccer and football; however, he does not express any interest in sports now. Justin states he had a “break up” with his girlfriend six months ago.
Nutritional History
Justin’s appetite has decreased over the last six months, and he has experienced a 10-pound weight loss.
Physical Assessment Findings
General appearance: Justin comes to the clinic today at the urging of his mother due to her concerns for his mental health. He is awake, alert, and oriented to person, place, and time.
He is cooperative and appropriately responsive to questions.
Vital signs: Temp: 98.6, Height: 69.5 in, Weight: 57.1 kg (126 lbs), HR: 72, RR: 16, BP: 128/82. BMI: 18.3.
HEENT: Normocephalic, conjunctiva clear, sclera clear bilaterally, EOMI, PERRLA, TM pearly gray with normal cone of light, no TM inflammation, no sinuses tenderness to palpation frontal, maxillary sinuses rhinitis, uvula midline, neck supple, no anterior cervical submental and submandibular tenderness or lymphadenopathy, thyroid not palpable, trachea midline, and full range of motion of neck.
Integumentary: Skin warm and dry to touch without lesions and/or cuts. Multiple red papules, open and closed comedones present to face. No bruises, rashes, or scars; erythema; discoloration; ecchymosis; or skin lesions noted.
Respiratory: Normal shape of chest with no obvious deformities. Respirations even and non-labored. Breath sounds clear bilaterally upon auscultation. No stridor, wheezes, crackles, or rubs. Good air movement.
Cardiovascular: RRR (regular, rate, and rhythm), without murmurs, rubs, or gallop, positive cap refill, 2+ pulses in all extremities noted.
Abdomen: Abdomen is soft, nontender, and nondistended; no hernias, masses or lesions noted. Active bowel sounds in all four quadrants. No hepatosplenomegaly.
Neurological/psychiatric: Oriented to person, place, and time. Makes appropriate eye contact and conversation. Speech and cranial nerves 1-X11 normal. Mood and affect are confluent and full range. Thought process is linear and goal-directed. Denies suicidal/homicidal ideation, auditory and/or visual hallucinations. Insight and judgment are good. Has poor grooming and hygiene. Is cooperative. Speech is spontaneous and normal.
Musculoskeletal: Full range of motion (ROM). 5/5 strength UE/LE bilaterally. No edema noted, ambulates with a steady gait, good ROM in all major joints, 5/5 strength against resistance. Normal, equal strong dorsi/plantar flexion.
Genitalia: Tanner Stage V noted. Extensive assessment not completed at this visit. Denies dysuria and/or urgency.
What Do You Suspect?
Justin is an 18-year-old male being seen for fatigue, loss of energy, irritability, lack of motivation, decreased ability to concentrate, poor hygiene, low self-esteem, and weight loss.
Differentials
Depression
Depression is a condition that includes disruptive mood disorders and major depression disorder, and is characterized by fatigue, sadness, and irritable mood, with impaired functioning (Lacuesta & Gladwell, 2018). Depression and anxiety also represent the second and fifth leading causes of years lived with a disability and losses in work productivity (Kroenke et al., 2016). Common systems are fatigue, weight loss or gain, loss of energy, diminished interest or pleasure, agitation, feeling of worthlessness, recurrent thoughts of death or suicide, decreased ability to process thoughts, and lack of motivation.
Diagnostic tests are crucial for prompt interventions and improved outcomes. The Patient Health Questionnaire Anxiety-Depression Scale (PHQ-ADS) and the Depression, Anxiety and Stress Scale (DASS) diagnose anxiety and depression. According to Thapar, Collishaw, Pine, and Thapar (2012), depression in adolescents is often missed more than in adults.
Suicide Ideation
Suicide refers to a self-inflicted, willful, life-threatening act that has resulted in death (Berman, Silverman, & Bongar, 2000). According to the Centers for Disease Control and Prevention (CDC) (2018), suicide is a major public health concern that affected over 45,000 individuals in 2016 in the United States. Risk factors can include substance abuse, family history of suicide, physical illness, depression similar to an adult, and not feeling connected with friends and family (Shain, 2016). Identification of suicidal behaviors is essential. Active strategies to include general screening programs, training in schools to help identify suicidal behaviors, and education about suicide, crisis centers, and hotlines numbers are available for clients and families (Shain, 2016).
Management Plan and Recommendations
Justin was diagnosed with depression. Lab test ordered are Total and Free Testosterone, TSH, Vitamin D3, CBC, CMP, TSH Total T4, and Free T3. According to the National Institute of Mental Health (2018), most people benefit from therapy or counseling to discuss thoughts, feelings, and issues regarding what is happening currently in life. Justin should return to clinic in two weeks to recheck, but if concerns of suicidality emerge, he is to return to clinic sooner. There should be a careful screening to identify any recent thoughts or actions about suicide. See Figure 1 for the full recommended treatment plan.
Conclusion
Justin will return to the clinic in two weeks to reevaluate the effectiveness of medication. Counseling will be arranged for Justin to allow him to talk about his thoughts and feelings. His mother will monitor nutritional intake to help improve his overall well-being. Encouraging daily exercise can reduce the risk of chronic disease and promote overall health. Justin and his mother were given the National Suicide Prevention Lifeline 1-800-273-TALK (8255), which provides free, 24-hour confidential help to people in crisis. They were also instructed to dial 911 in case of emergency. Education for Justin and his family about the causes, symptoms, and treatment will be essential.
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Case Study Report structure:
This case study explores the presentation of Justin, an 18-year-old African-American male, who is exhibiting symptoms suggestive of depression. The analysis discusses the possible differentials, the diagnostic process, management plan, and recommendations for addressing Justin’s mental health concerns.
Justin’s symptoms, including fatigue, irritability, low self-esteem, and weight loss, are indicative of potential depression. According to Lacuesta and Gladwell (2018), depression is characterized by mood disturbances, fatigue, and impaired functioning. These symptoms align with Justin’s gradual decline in hygiene, poor motivation, and reduced academic performance.
The nurse plays a pivotal role in recognizing and addressing adolescent depression. Communication skills are essential to establish rapport and elicit information from Justin and his family. Collaborative care within a multidisciplinary team is crucial to ensure holistic assessment and management. Person-centered care involves tailoring interventions to Justin’s needs and preferences, acknowledging the impact of his recent break-up and decreased interest in sports.
Health promotion and education strategies for Justin involve a multi-faceted approach:
Psychoeducation: Provide Justin and his family with information about depression, its symptoms, and available treatments to enhance understanding and reduce stigma.
Counseling Services: Arrange counseling sessions to facilitate open discussion of thoughts and feelings, allowing Justin to express his emotions in a supportive environment.
Physical Activity: Encourage daily exercise as a means to improve mood and reduce depressive symptoms through the release of endorphins.
Nutritional Monitoring: Instruct Justin’s mother to monitor his nutritional intake, promoting balanced meals that contribute to overall well-being.
Crisis Resources: Provide contact information for the National Suicide Prevention Lifeline and emergency services to ensure immediate help in case of a crisis.
Adolescent depression is a complex mental health issue that requires careful assessment, appropriate interventions, and ongoing support. The case study of Justin underscores the significance of early recognition, accurate diagnosis, and comprehensive care. By addressing the mental health needs of adolescents like Justin, nurses contribute to their overall well-being, promote awareness, and empower them to overcome challenges and improve their quality of life.
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