NU566 Unit 10 Discussion

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Purdue University Globle 

NU566 NP I – Introduction to Primary Care for the Nurse Practitioner

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NU566 Unit 10 Discussion

Jerome’s presentation is most consistent with a recurrence of depressive symptoms accompanied by anxiety, sleep disturbance, increased alcohol use, and occupational stress. Although the available information does not definitively confirm a diagnosis of Major Depressive Disorder (MDD), his symptoms warrant a comprehensive mental health assessment, screening for depression and suicide risk, evaluation for underlying medical causes, and development of an individualized treatment plan. Early intervention with evidence-based therapies, lifestyle modifications, and close follow-up can significantly improve outcomes while reducing the risk of worsening depression or substance misuse.

Understanding Jerome’s Clinical Presentation

Jerome is a 35-year-old welder who lives with his partner and two young children. He presents to a primary care clinic reporting persistent fatigue, low energy, reduced motivation, and disrupted sleep that have continued for approximately six weeks. Despite feeling overwhelmed by work-related stress, he continues to attend work. To cope with poor sleep, Jerome has increased his alcohol consumption from drinking twice weekly to consuming three bottles of beer every evening.

His medical history includes anxiety, panic attacks, and moderately severe depression, which previously responded well to sertraline therapy. After completing six months of treatment five years ago, he discontinued the medication and remained symptom-free without further clinical follow-up. During the current examination, Jerome appears sad, emotionally withdrawn, and apathetic, although his physical examination is otherwise unremarkable.

These findings raise concern for recurrent depression with associated anxiety symptoms, while his increasing alcohol intake may further worsen mood, sleep quality, and overall functioning.

Initial Clinical Approach to Jerome’s Anxiety and Depression

The first priority is establishing a therapeutic relationship that encourages Jerome to openly discuss his symptoms, emotional well-being, occupational stressors, alcohol use, and family responsibilities. Open-ended questioning and empathetic listening allow the clinician to better understand the severity and duration of symptoms while identifying barriers to previous treatment adherence.

A comprehensive psychiatric history should include:

• Previous depressive and anxiety episodes

• Current stressors at work and home

• Sleep quality and daily functioning

• Alcohol and substance use

• Family history of psychiatric illness

• Previous response to antidepressant therapy

• History of suicidal thoughts or self-harm

Since Jerome successfully responded to sertraline in the past, understanding why he discontinued treatment may help improve long-term medication adherence if pharmacologic therapy becomes necessary.

Current clinical guidelines recommend evaluating both psychological and physical contributors to depressive symptoms rather than assuming depression alone is responsible for fatigue and low motivation.

Assessment and Screening Tools to Support Diagnosis

Accurate diagnosis requires both clinical evaluation and validated screening instruments.

Physical Assessment

A complete physical examination helps identify medical conditions that may mimic depression. Areas requiring attention include:

• General appearance and grooming

• Speech patterns and affect

• Neurological examination

• Thyroid assessment

• Cardiovascular examination

• Nutritional status

Because fatigue is a nonspecific symptom, identifying underlying physical illness remains an essential part of assessment.

Mental Health Screening

Validated screening tools improve early recognition and monitoring of depressive disorders.

Commonly recommended instruments include:

• Patient Health Questionnaire-9 (PHQ-9): Measures depression severity and monitors treatment response.

• Generalized Anxiety Disorder-7 (GAD-7): Screens for anxiety symptoms.

• Quick Inventory of Depressive Symptomatology–Self Report (QIDS-SR): Evaluates depressive symptom severity.

• Alcohol Use Disorders Identification Test (AUDIT-C): Screens for hazardous alcohol consumption.

Positive screening results should always be followed by a structured clinical interview using the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5-TR) diagnostic criteria rather than relying solely on questionnaire scores.

Suicide Risk Assessment

Every patient presenting with depression should undergo suicide risk screening regardless of whether suicidal thoughts are initially reported.

Assessment should explore:

• Suicidal ideation

• Intent and planning

• Previous suicide attempts

• Access to lethal means

• Protective factors

• Available social support

Early identification of suicide risk allows timely intervention and improves patient safety.

Possible Physiological Causes of Jerome’s Symptoms

Depression frequently develops secondary to underlying medical illnesses. Before confirming a psychiatric diagnosis, clinicians should exclude physiological contributors that may produce similar symptoms.

Potential medical causes include:

• Hypothyroidism

• Iron deficiency anemia

• Vitamin B12 deficiency

• Vitamin D deficiency

• Diabetes mellitus

• Chronic liver disease

• Chronic kidney disease

• Cardiovascular disease

• Chronic infections

• Neurological disorders

• Obstructive sleep apnea

Medication-induced depression should also be considered, although Jerome currently reports no prescription medications.

Because Jerome recently increased his alcohol intake, alcohol-related sleep disturbance and depressive symptoms should also be evaluated. Chronic alcohol use may both trigger and worsen depression while reducing the effectiveness of antidepressant therapy.

Does Jerome Meet DSM-5 Criteria for Major Depressive Disorder?

According to the DSM-5-TR, Major Depressive Disorder requires five or more depressive symptoms occurring during the same two-week period, with at least one symptom being either depressed mood or markedly diminished interest or pleasure.

Current information indicates Jerome demonstrates:

• Depressed mood

• Fatigue and reduced energy

• Insomnia

These findings alone do not satisfy the minimum DSM-5 diagnostic threshold for Major Depressive Disorder.

However, important symptoms have not yet been fully assessed, including:

• Loss of interest or pleasure

• Appetite or weight changes

• Feelings of worthlessness or excessive guilt

• Poor concentration

• Psychomotor agitation or retardation

• Suicidal ideation

Additional clinical interviewing may reveal sufficient symptoms to meet diagnostic criteria. Therefore, it would be premature to exclude Major Depressive Disorder without completing a comprehensive psychiatric assessment.

Evidence-Based Plan of Care

Management should address both Jerome’s psychological symptoms and potential contributing medical conditions.

Diagnostic Evaluation

Recommended laboratory investigations include:

• Complete blood count (CBC)

• Thyroid-stimulating hormone (TSH)

• Comprehensive metabolic panel (CMP)

• Vitamin B12 level

• Vitamin D level

• Iron studies when indicated

• Blood glucose or HbA1c

• Liver function tests, particularly because of increased alcohol consumption

Additional investigations should be guided by clinical findings.

Pharmacologic Treatment

Because Jerome previously experienced symptom remission with sertraline, restarting the medication may be appropriate after reassessing his current diagnosis and excluding contraindications.

Selective serotonin reuptake inhibitors (SSRIs) remain first-line pharmacologic therapy for moderate depression and many anxiety disorders.

Patients should receive education that:

• Clinical improvement often begins after two to four weeks.

• Maximum benefit may require six to eight weeks.

• Initial side effects often improve with continued treatment.

• Medication should not be discontinued abruptly without medical supervision.

Psychological Therapy

Evidence strongly supports combining medication with psychotherapy for many patients experiencing recurrent depression.

Recommended therapies include:

• Cognitive Behavioral Therapy (CBT)

• Behavioral activation

• Problem-solving therapy

• Interpersonal therapy

Referral to a licensed mental health professional should be offered early during treatment.

Lifestyle and Behavioral Interventions

Lifestyle modifications complement pharmacologic and psychological therapies.

Important recommendations include:

• Reduce or eliminate alcohol consumption.

• Maintain consistent sleep hygiene.

• Engage in regular physical activity.

• Consume a balanced diet.

• Participate in enjoyable activities.

• Strengthen family and social support networks.

• Practice stress-management techniques.

These interventions improve mood, reduce relapse risk, and support long-term recovery.

Follow-Up and Monitoring

Close follow-up is essential during the initial stages of treatment.

Recommended follow-up includes:

• Reassessment within one to two weeks after initiating treatment.

• Monitoring medication adherence and adverse effects.

• Repeat PHQ-9 or GAD-7 assessments to measure treatment response.

• Ongoing suicide risk evaluation.

• Follow-up every two to four weeks until symptoms stabilize.

Patients should also receive clear instructions to seek immediate medical attention if suicidal thoughts develop or depressive symptoms rapidly worsen.

Key Clinical Points

• Jerome’s symptoms are highly suggestive of recurrent depression with anxiety, although additional assessment is necessary before confirming Major Depressive Disorder.

• Standardized screening tools such as the PHQ-9, GAD-7, and AUDIT-C improve diagnostic accuracy and treatment monitoring.

• Medical conditions including thyroid disease, anemia, vitamin deficiencies, diabetes, and chronic illness should be excluded before establishing a primary psychiatric diagnosis.

• Increased alcohol consumption may both contribute to and worsen depressive symptoms.

• A combination of psychotherapy, lifestyle modification, and antidepressant medication provides the strongest evidence for improving outcomes in recurrent depression.

• Regular follow-up and suicide risk assessment remain essential components of evidence-based care.

Frequently Asked Questions

What is the most likely diagnosis for Jerome?

Jerome most likely has recurrent depressive symptoms accompanied by anxiety and increased alcohol use. However, additional clinical assessment is required to determine whether he meets the full DSM-5-TR criteria for Major Depressive Disorder.

Which screening tool is recommended for depression in primary care?

The Patient Health Questionnaire-9 (PHQ-9) is one of the most widely recommended screening tools because it measures symptom severity, supports diagnosis, and helps monitor treatment progress.

Why should alcohol use be assessed in patients with depression?

Alcohol can worsen depressive symptoms, impair sleep, reduce antidepressant effectiveness, and increase suicide risk. Screening for alcohol misuse is therefore an important part of comprehensive mental health assessment.

Should laboratory tests be performed before diagnosing depression?

Yes. Laboratory investigations help identify medical conditions such as hypothyroidism, anemia, vitamin deficiencies, diabetes, and liver disease that may present with symptoms similar to depression.

Why is suicide risk assessment necessary even if the patient denies suicidal thoughts?

Suicide risk assessment is considered standard practice because some individuals may initially withhold suicidal thoughts. Routine assessment improves patient safety and ensures timely intervention when risk factors are identified.

Depression commonly presents with persistent fatigue, low mood, loss of motivation, and sleep disturbances. Evidence-based management begins with a comprehensive biopsychosocial assessment, validated screening tools, evaluation for medical causes, suicide risk assessment, and individualized treatment using psychotherapy, lifestyle interventions, and antidepressant medication when clinically indicated. Regular follow-up improves symptom monitoring, medication adherence, and long-term recovery.

References

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.; DSM-5-TR). American Psychiatric Association Publishing. https://doi.org/10.1176/appi.books.9780890425787

Aziz, R., Dunphy, L., & Bulfin, S. (2019). Mood disorders. In L. Dunphy, J. Winland-Brown, B. O. Porter, & D. J. Thomas (Eds.), Primary care: The art and science of advanced practice nursing—An interprofessional approach (5th ed., pp. 1100–1128). F.A. Davis.

Cook, M., & Wolz, A. (2018). Depression. In J. C. Cash & C. A. Glass (Eds.), Family practice guidelines (5th ed.). Springer Publishing. https://www.springerpub.com/family-practice-guidelines-9780826179463.html

NU556 Unit 10 Discussion

Maurer, D. M., Raymond, T. J., & Davis, B. N. (2018). Depression: Screening and diagnosis. American Family Physician, 98(8), 508–515. https://www.aafp.org/pubs/afp/issues/2018/1015/p508.html

U.S. Preventive Services Task Force. (2023). Screening for depression and suicide risk in adults: US Preventive Services Task Force recommendation statement. JAMA, 329(23), 2057–2067. https://jamanetwork.com/journals/jama/fullarticle/2806228