Alberto, age 55, was brought to the emergency department of a regional medical center by his brother-in-law. Alberto is pacing, demanding, agitated, and speaking vociferously. “I did not wish to come here! My brother-in-law is simply jealous and he is trying to make me appear like I am suffering from some sort of insanity!” Alberto’s treatment is financially subsidized by his brother in law. Alberto will undergo a maximum of 8 sessions at 2 hours each session. The session will start on June 25, 2014.
Presenting Problem
Alberto is a 55-year-old man who was brought to the emergency department of a regional medical center by his brother-in-law. On assessment, the brother-in-law reports that Alberto has become engaged to a 20-year-old waitress to whom he has willed his sizable inheritance including his residence. Alberto loudly praises his fiancée’s sexual abilities and physique. He has been spending huge amount of money on himself and giving his fiancée $500 a week. The brother-in-law informed the physician, “I know it is Alberto’s business what he does with his life, but I am really worried about him. He is beginning to lose weight again. He eats little and never sleeps. I am afraid he is going to collapse!”
Relevant Background History
Five months ago, Alberto was brought to the emergency department unit because of the same problem. Alberto’s brother-in-law said, “He does nothing but sit all day and stare into the room. I cannot convince him to eat or do anything!”
During an interview with Alberto, it was discovered that six months ago, his wife of thirty years had passed away due to massive myocardial infarction. The couple had no kids and had been inseparable. Since his wife’s death, Alberto has visited the cemetery day in and day out, changing the flowers often on the grave. He has not taken away any of her clothes from the chest drawers and closet. Her cosmetic materials still occupy the same space in the powder room. Over the months, Alberto has become increasingly socially isolated. He refuses invitations from friends, preferring instead to make his daily visits to the cemetery. He has lost 20 pounds and his brother-in-law reports that there is very little food in the house. He told his brother-in-law, “I do not wish to live anymore. My life is nothing without Maria.” His brother-in-law became worried and frightened and, with forceful persuasion, was able to convince Alberto he needed to see a doctor. Alberto was admitted to the psychiatric unit. The priority nursing diagnosis for Alberto was risk for suicide. The physician ordered sertraline (Zoloft) 50 mg twice per day for Alberto. After three days of taking the prescribed medication, Alberto told the nurse, “I do not think the medicine is doing me any good. I do not feel better.” Alberto was encouraged to cheer up for he has so much to be grateful for.
After being stabilized on his medication Alberto was discharged from the hospital with directions to continue his sertraline medication as advised by his physician. A week later, his brother-in-law found Alberto in bed and was not able to awaken him. An empty prescription bottle was by his side. He was revived in the emergency department and transferred to the psychiatric unit in a condition of severe depression. The physician determines that ECT may aid Albert. Consent was obtained. About thirty minutes prior to the first treatment, an atropine sulphate 0.4 mg IM was administered. The rationale for this order was to decrease secretions and increase heart rate. When Alberto is in the treatment room, the anaesthesiologist also administered thiopental sodium, (Pentothal) and an IV succinylcholine (Anectine). The objectives of these medications are to induce anaesthesia and relax muscles. Following three ECT’s, Alberto’s mood starts to lift and he said he feels a lot better but he has trouble remembering some things that happened the previous week. Alberto was advised to forget about what happened the previous week and to look forward from that day on.
In the psychiatric unit, Alberto expressed his deep sadness for losing the only person who believed in him, loved him, and cared for him. Alberto claimed that his childhood days were dark and he only found meaning in life when he met his wife. For Alberto, his wife was his only family.
Test Administration
Formulation
Stressful events including the loss of a loved one and previous depressive episode predisposed Alberto to his present condition. Alberto and his wife, Maria, were inseparable. Hence, when Maria passed away, the death brought great trauma to Alberto. Alberto had a relationship with someone young perhaps in his belief that the young lady would not leave him any time soon. His acts of giving his inheritance to the young lady is his way of making sure that the young lady would not leave him so long as he lives. Further, to cope with depression, Alberto uses the young lady for sexual activities. Sex became an outlet of depression for Alberto.
Alberto despises the thought of losing people he loves. When he was a child, Alberto experienced being separated from his parents whom he was close to. His parents passed away from a plane crash and Alberto was left under the care of his uncle who was an alcoholic. Growing up, Alberto learned to turn to alcohol use each time he had problems. When he met his wife, Maria, his life changed completely and he found hope.
Maria loved Alberto dearly. She was the light in Alberto’s darkest paths. She guided him and taught him to overcome his struggles to protect the people he love. She always assured him that she would always be around. Hence, when Maria died, Alberto felt greatly devastated that all memories of his childhood and the death of Maria brought him severe depression.
Discussion of Evidence Based Theories
The main disturbance in depression is more on cognitive instead of affective. The fundamental reason behind this is that the depressive affect is observed as cognitive misrepresentations that experts believe as the grounds for depression. This includes false expectations of oneself, false expectations of the environment, and false expectation of the future. These distortions arise out of impairment in cognitive development, and the person feels worthless, inadequate, and rejected by people around him. The client’s outlook for the days ahead is filled with hopelessness and pessimism.
In 1989, the National Institute of Mental Health studied different forms of psychosocial therapies and found that among all types of psychotherapy, the most promising is the interpersonal therapy (Long, 1998). This form of therapy focuses on the treatment of social dysfunction.
Rosello et al (2007) claims that research studies in the past consistently show that cognitive behaviour therapy is effective in treating mental disorders including anxiety, depression, or oppositional defiant disorders. Further, Rosello et al (2007) suggests that cognitive behaviour therapy is grounded on the interrelationship of actions, feelings, and thoughts.
In another study conducted by Arean et al, (2010), the group determined the effectiveness of problem-solving therapy in patients with depression. Adults age 60 participated in the system. Each of these adults has major depression. The participants engaged in a twelve-week sessions and it was found that problem solving therapy is effective in reducing depressive symptoms (Arean et al, 2010).
Diagnosis
Initially, the client presented with a risk for suicide relative to depressed mood. He has dysfunctional grieving due to real loss, bereavement overload, denial of loss, and inability to carry out activities of daily living. He feels powerless and his self-esteem has been affected. He also has disturbed sleep pattern and self-care deficit. Because the client has not been eating, he also has imbalanced nutrition. Alberto’s sexual activities make him at risk for injury. Alberto is diagnosed to have bipolar mania which is a form of manic depression.
The exact origin of depressive disorder is said to be due to the chemical imbalance in the brain, although the cause of the imbalance also remains unclear. Theories that take into account the combination of environmental triggers and hereditary factors seem to hold the greatest credibility. Alberto also experiences delusion of persecution. He is disoriented and full of delusional thoughts.
Intervention Plan
The goals of the intervention plan were as follows: The client would not be at risk for injury; the client would no longer show signs or symptoms of lack of nutrition. The client had extreme hyperactivity as evidenced by his increased agitation as well as lack of control over purposeless and possible injurious movements. Among the intervention plan for Alberto was to reduce environmental stimuli. Alberto was given a private room that has simple décor or on a quiet room if possible. The lighting and noise was kept at a low level. This is because Alberto was exceedingly distractible and whenever there were stimuli around; his responses appeared to be exaggerated. Hazardous objects and toxic substances including smoking were eliminated. This is because, with Alberto’s current condition, his rationality was not functioning well and he might harm self inadvertently. The client was closely monitored for his hyperactivity and agitations. This provided support to the client and gave him the feeling of security he needed. Physical activities were provided to help Alberto relieve his pent up tension.
Intervention Delivery
- Initially, the client was interviewed about his relationship with his wife and the people around him. The client shared his strong connection with his wife.
- The client was also asked about his suicidal thoughts, his plans of committing, and means of doing it. The client mentioned that he feels so alone that he just wants to disappear. He wishes to end his life so he can be with his wife again. He has thoughts of committing suicide through drug overdose because he feels that the procedure is painless.
- The environment was made safe and secure for the client and a short-term agreement was formulated. The client cooperated and felt happy about the agreement.
- The client is also under close observation and supervision and he is encouraged to become open about his feelings.
- During the session, the client’s grief process was also evaluated. It was discovered that the client is in denial about his wife’s death.
- More emphasis was placed on client’s strengths and failures were not so much given attention.
- The client was also given supervision in terms of behaviours that require changes.
- Assertiveness as well as effective communication was also taught to the client.
- Other interventions were provided such as the following:
- Problem-solving therapy for mild executive dysfunction (PST-ED)
PST-ED is a 12-week outpatient intervention for clients who are ambulatory such as in the case of Alberto. Alberto went through the 7 problem-solving phases which helped him in identifying the problems and in seeking the best likely solution. Alberto acknowledged the effectiveness of the problem-solving phases and implemented them to all other problems which encountered after his session periods.
- Cognitive Behavioural Therapy
Alberto worked with a counsellor in identifying restricting or unhelpful patterns of behaviour and thinking which made him depress or kept him from getting better as soon as he started feeling depressed. Over the course of his treatment, Alberto identified the negative patterns of his behaviours and replaced them with behaviours and thoughts that were more realistic, helpful, and positive. Through this, Alberto was able to successful improve his coping skills and his moods. Alberto was helped in making changes in the behaviour and thinking including self-critical, self-focused, and avoidant behaviour or low-energy which was associated with the depression. Alberto started to think in a more life-enhancing manner, and resumed activities which he enjoyed before such as fishing, as well as other activities which gave him a feeling of fulfilment.
- Behaviour Therapy
Behaviour Therapy is also known as behavioural activation and is also part of cognitive behaviour therapy but attempts to change the behaviour the person and not just their attitudes or thoughts. The main purpose of doing behaviour therapy to Alberto was to increase the level of pleasure and activity that the individual used to experience before.
- Psychodynamic Psychotherapy
The main purpose of this intervention plan is to focus on the unconscious patterns of feelings and thoughts in the mind of Alberto and the unconscious patterns in his relationships. In this session, we delved deeper into the issues that created Alberto’s depression. It was found out that Alberto had experienced being separated from his parents whom he was close to. His parents passed away from a plane crash and Alberto was left under the care of his uncle who was an alcoholic. Growing up, Alberto learned to turn to alcohol use each time he had problems. When he met his wife, Maria, his life changed completely and he found hope.
Evaluation and Reflection
Following the sessions and close supervision of medications, the client exhibited positive changes.
- No more evidence of physical injury was observed in Alberto’s behavior.
- Alberto no longer experiences physical agitation.
- There was no evidence of hallucinations or delusions.
- Alberto ate a well-balanced diet.
- The client’s weight had stabilized.
- Alberto was able to accept responsibility for his own behaviours. He no longer manipulated others to send gratification to his personal needs.
- Alberto was able to interact well with other people.
- Alberto was able to eat his complete meals.
- Alberto managed to socially interact with others without having to feel depressed. He responded to others with a smile.
- At times, Alberto still stared at blank space but constant reminder and talking to him helped alleviate the loneliness he feels.
- Albert was able to verbalize accurate interpretation of his surroundings.
- Alberto was able to verbalize that hallucinatory activity has stopped and shows no outward behavior that indicates hallucinations.
- Alberto was also able to fall asleep within 30 minutes of retiring. He is able to sleep for six to eight hours per night without having to take any medications.
- The cognitive behaviour therapy had been effective in reducing the impacts of depression in Albert’s case.
- Through Behaviour therapy, Alberto learned to become more involved and active in doing rewarding activities. By participating in activities, Alberto learned to substitute patterns of inactivity, avoidance, and withdrawal, which cause worsening of depression, with experiences that were more rewarding and greatly reduced depression.
DASS42 pre and post measure (8 sessions)
References
Arean, P., Raue, P., Mackin, R., Kanellopoulos, D., McCulloch, C., & Alexopoulos, G. (2010). Problem-solving therapy and supportive therapy in older adults with major depression and executive dysfunction. American Journal Of Psychiatry, 167(11), 1391--1398.
Long, P. (1998). Major Depressive Disorder: Treatment. Mentalhealth.com. Retrieved 20 June 2014, from http://www.mentalhealth.com/rx/p23-md01.html
Rossello, J., Bernal, G., Munoz, R., Aguilar-Gaxiola, S., & Guzman, J. (2007). Treatment manual for cognitive behavioral therapy for depression. Retrieved From.
Frank, E., Prien, R., Jarrett, R., Keller, M., Kupfer, D., & Lavori, P. et al. (1991). Conceptualization and rationale for consensus definitions of terms in major depressive disorder: remission, recovery, relapse, and recurrence. Archives Of General Psychiatry, 48(9), 851--855.
Hasin, D., Goodwin, R., Stinson, F., & Grant, B. (2005). Epidemiology of major depressive disorder: results from the National Epidemiologic Survey on Alcoholism and Related Conditions. Archives Of General Psychiatry, 62(10), 1097--1106.
Kessler, R., Nelson, C., McGonagle, K., Liu, J., & others,. (1996). Comorbidity of DSM-III—R major depressive disorder in the general population: Results from the US National Comorbidity Survey. The British Journal Of Psychiatry.
