Major Depressive Disorder: Treatment Plan and Screening Instruments

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1 Describe the presenting problems.
The main presenting problem is the presence of an exceedingly depressed mood, which was evident when Kel stated that she feels sad, hopeless and that nothing will change in the future, and her loss of pleasure over the things she was previously excited about, such as when she did not dream of traveling via a cruise ship. The other remarkable symptoms include feelings of worthlessness, significant weight loss without conscious effort, constant fatigue despite having ample sleep and relaxation, reduced movement, disorganized thinking, and indecisiveness.
2 Generate a primary and differential diagnosis using the DSM5 and ICD 10 codes.
The primary diagnosis is major depressive disorder, with an ICD-10 code of F32.9. The differential diagnosis is bipolar disorder, with an ICD-10 code of F31.9 (Durand et al., 2018; ICD10 Data, 2021). Durand et al. (2018) enumerate the criteria to diagnose depression based on the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) with the prominence of at least five of the symptoms for two weeks, and one of these must be a distinct mood depression or the loss of gratification. Other symptoms that qualify the disorder include an almost daily and constant feeling of depressed mood, distinct reduction in gratification, marked weight loss or gain without a conscious effort to lose or gain weight, feeling of fatigue for almost every day, feeling of irrelevance or insignificance, difficulty in concentrating or lack of certainty when making decisions, and recurrent suicidal ideations, as manifested by planning or attempting, without a particular reason.
Conversely, bipolar disorder can be classified into bipolar I, with manic-depressive episodes, bipolar II, less severe manic and depressive episodes, and cyclothymic disorder, which presents with alternate feelings of depression and hypomania. In the patient, the most prominent feature that fulfills the criteria of bipolar disorder is the presence of a major depressive episode. Thus, its criteria are similar to major depressive disorder (Durand et al., 2018; Center for Behavioral Health Statistics and Quality, 2016).
3 Formulate and prioritize a treatment plan
The patient’s treatment plan will be divided into three, including pharmacologic treatment, non-pharmacologic treatment or psychiatric therapy, and patient education.
For the pharmacologic treatment, the patient shall be given a selective serotonin reuptake inhibitor (SSRI). It is the most commonly used first-line treatment drug for the disorder established under the National Institute for Health and Care Excellence (NICE) guidelines (Prescott & White, 2017). It diminishes depressive episodes by preventing the reuptake of serotonin. Hence, increasing its activity, stabilizing the mood of the patient. In addition, it has fewer adverse effects than other antidepressants such as tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs). This is secondary to its fewer impact on other neurotransmitters like norepinephrine and dopamine and some receptors, such as cholinergic, anticholinergic, and histaminergic receptors (Chu & Wadhwa, 2021).
Pharmacotherapy shall be combined with cognitive-behavioral therapy (CBT), which allows the individual to control her emotional changes. The therapist shall assist the patient in diminishing her negative ideations, allowing her to properly manage her symptoms, especially during periods of extreme emotional negativities (Mayo Clinic Staff, 2019).
The patient must be educated on the common side effects of SSRIs. These include weight gain or weight loss, heightened anxiety, difficulty sleeping, and dr...