Running Head: Depression With Psychotic Features - SOAP Note

Running Head Depression With Psychotic Features 1soap Note 48 Year

SOAP Note: 48-year-old Hispanic Female with Depression with Psychotic Features Roxana Orta Florida Atlantic University

Paper For Above instruction

Depression with psychotic features constitutes a severe form of major depressive disorder characterized by the presence of psychotic symptoms such as hallucinations or delusions alongside typical depressive symptoms. This condition demands comprehensive clinical assessment, accurate diagnosis, and a multidisciplinary approach to management due to its potential impact on patients’ functional status and quality of life. The case of Roxana Orta, a 48-year-old Hispanic woman presenting with psychotic symptoms superimposed upon a depressive episode, provides an illustrative example to explore the complexities of diagnosis and treatment strategies for this serious mental health condition.

Introduction

Major depressive disorder (MDD) is a common mental health disorder marked by pervasive low mood, anhedonia, and cognitive and somatic symptoms that impair daily functioning (American Psychiatric Association, 2013). When psychotic features are present during a depressive episode, the clinical picture becomes more complicated, requiring differential diagnosis from other psychotic disorders such as schizophrenia or bipolar disorder with psychotic features. Accurate diagnosis hinges on a thorough psychiatric evaluation, including symptom assessment, family history, and ruling out medical or substance-induced causes (Vieta et al., 2018). The case of Roxana Orta exemplifies core features of depression with psychotic features and highlights the importance of tailored management plans to optimize outcomes.

Clinical Presentation and Diagnostic Assessment

Roxana Orta’s presentation is typical of depression with psychotic symptoms: she exhibits persistent depressive mood, anhedonia, psychomotor agitation, sleep disturbances, significant weight loss, and feelings of hopelessness (American Psychiatric Association, 2013). Notably, she reports command hallucinations and paranoid delusions, such as believing the FBI is after her and her parents intend to poison her, which confirm the psychotic component. Her history includes untreated postpartum depression, family mental health history, and recent stressors like her son leaving for college and her work-related pressures. Her PHQ-9 score of 25 indicates severe depression, corroborated by clinical observations of tearfulness, depressed affect, and impaired social functioning (Gabbay et al., 2015).

Clinically, it is crucial to differentiate depression with psychotic features from primary psychotic disorders. Key diagnostic criteria, as per DSM-5, involve evidence of depressive episodes concurrent with psychotic symptoms, which are not attributable solely to substance use or medical conditions (American Psychiatric Association, 2013). Roxana's negative physical health status, including microcytic anemia and elevated LDL, are secondary concerns but do not directly influence her primary psychiatric diagnosis. The differential diagnosis might include bipolar disorder, particularly if future mood episodes involve manic features, or schizophrenia spectrum disorders, though her mood symptoms predominate (Jäskeläinen et al., 2018).

Pathophysiology and Psychosocial Factors

The pathophysiology of depression with psychotic features involves dysregulation of neurochemical pathways, notably serotonergic, dopaminergic, and glutamatergic systems, contributing to mood and psychotic symptoms (Vieta et al., 2018). Neuroimaging studies suggest alterations in limbic circuits and prefrontal cortical areas that underlie emotional regulation and perception (Jaya et al., 2017). Psychosocial factors in Roxana’s case, including migration stress, social isolation, financial hardship, and family dynamics, exacerbate her vulnerability to psychiatric relapse (Koyanagi & Stickley, 2015). Her social withdrawal, lack of leisure activities, and heavy occupational workload further entrench her isolation, which correlates with psychotic symptom severity (Sönmez et al., 2016). The anxiety related to her family history and recent life changes likely contribute to her current mental state.

Management Strategies

Pharmacological Treatment

First-line treatment for depression with psychotic features combines an antidepressant with an antipsychotic agent, aiming to address both mood and psychotic symptoms (Thompson et al., 2019). Roxana's ongoing medication regimen, including risperidone and citalopram, aligns with evidence suggesting the effectiveness of such combination therapy during acute phases (Grande et al., 2016). However, recent reviews recommend using atypical antipsychotics like olanzapine or quetiapine with selective serotonergic reuptake inhibitors for better tolerability (Thompson et al., 2019). Close monitoring for adverse effects, including metabolic syndrome and extrapyramidal symptoms, is essential (Cipriani et al., 2016). Adjustments to medication based on clinical response should be guided by regular psychiatric evaluations (Vieta et al., 2018).

Psychoeducation and Psychotherapy

Patient and family psychoeducation are critical components, focusing on medication adherence, understanding symptoms, and recognizing early warning signs of relapse (Moritz et al., 2015). Cognitive-behavioral therapy (CBT) can help Roxana challenge delusional thoughts, develop insight, and enhance coping mechanisms, especially addressing feelings of guilt and hopelessness (Jaya et al., 2017). Moreover, psychoeducation about sleep hygiene and relaxation techniques may ameliorate insomnia, which is closely related to psychotic symptom exacerbation (Koyanagi & Stickley, 2015).

Addressing Social and Environmental Factors

Social interventions, including support groups and community engagement, can mitigate feelings of loneliness and social withdrawal. In Roxana’s case, establishing a social network might reduce psychotic symptom severity and improve her overall functioning (Sönmez et al., 2016). Cognitive remediation and occupational therapy may aid in restoring her work capacity and enhancing quality of life. Additionally, addressing her economic stressors through social work referrals could alleviate some stressors that may trigger relapse (Grande et al., 2016).

Safety and Monitoring

Given her recent suicidal ideation and psychotic symptoms, constant safety assessment is mandatory. Implementation of safety protocols, hospitalization if necessary, and involvement of her family for support are critical (Gabbay et al., 2015). Regular psychiatric follow-ups are necessary to evaluate treatment efficacy and modify interventions as needed. Screenings for comorbidities like substance abuse or medical illnesses are also important, considering their potential to complicate the clinical course (Vieta et al., 2018).

Prognosis and Long-term Care

The prognosis of depression with psychotic features varies depending on early intervention and treatment adherence. Patients with prompt, appropriate management often respond well, but relapse risk remains high, especially in the presence of psychosocial stressors (Jäskeläinen et al., 2018). Long-term management involves maintenance therapy, psychoeducation, and supportive therapies to prevent recurrence. For Roxana, ongoing psychiatric care, social support, and stress management strategies will be crucial to improve her prognosis and quality of life.

Conclusion

Roxana Orta’s case underscores the importance of a comprehensive clinical evaluation, integrating biological, psychological, and social factors in diagnosing and managing depression with psychotic features. Effective treatment relies on a combination of pharmacotherapy, psychoeducation, psychotherapy, and social interventions. Recognizing the multifaceted nature of her condition and intervening early can enhance her functional capacity and reduce the risk of relapse. Continued research and tailored approaches are essential for improving outcomes in patients with such complex presentations.

References

  • American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Washington, DC: American Psychiatric Publishing.
  • Cipriani, A., Zhou, X., Del Giovane, C., Hetrick, S. E., Qin, B., Whittington, C., & Cuijpers, P. (2016). Comparative efficacy and tolerability of antidepressants for major depressive disorder in children and adolescents: a network meta-analysis. The Lancet, 388(10047), 881-890.
  • Gabbay, V., Johnson, A. R., Alonso, C. M., Evans, L. K., Babb, J. S., & Klein, R. (2015). Anhedonia, but not irritability, is associated with illness severity outcomes in adolescent major depression. Journal of Child and Adolescent Psychopharmacology, 25(3), 271-278.
  • Grande, I., Berk, M., Birmaher, B., & Vieta, E. (2016). Bipolar disorder. The Lancet, 387(10027), 1561-1572.
  • Jäskeläinen, E., Juola, T., Korpela, H., Lehtiniemi, H., Nietola, M., Korkeila, J., & Miettunen, J. (2018). Epidemiology of psychotic depression–systematic review and meta-analysis. Psychological Medicine, 48(6), 835-846.
  • Jaya, E. S., Hillmann, T. E., Reininger, K. M., Gollwitzer, A., & Lincoln, T. M. (2017). Loneliness and psychotic symptoms: The mediating role of depression. Cognitive Therapy and Research, 41(1), 125-137.
  • Koyanagi, A., & Stickley, A. (2015). The association between sleep problems and psychotic symptoms in the general population: a global perspective. Sleep, 38(12), 1965-1972.
  • Moritz, S., Cludius, B., Hottenrott, B., Schneider, B. C., Saathoff, K., Külz, A. K., & Gallinat, J. (2015). Mindfulness and relaxation treatment reduces depressive symptoms in individuals with psychosis. European Psychiatry, 30(6), 620-625.
  • Sönmez, N., Rössberg, J. I., Evensen, J., Barder, H. E., Haahr, U., Tvenne, H., & Melle, I. (2016). Depressive symptoms in first-episode psychosis: a 10-year follow-up study. Early Intervention in Psychiatry, 10(3), 237-244.
  • Vieta, E., Berk, M., Schulze, T. G., Carvalho, A. F., Suppes, T., Calabrese, J. R., & Grande, I. (2018). Bipolar disorders. Nature Reviews Disease Primers, 4, 18008.

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