Video Presentation: Anxiety and Depression in a 32-year-old Male
Chief complaint: Patient presents complaining of anxiety, depressed mood, reduced energy and difficulty sleeping.
Histories of present illness: He reports his symptoms began six months ago, when his job was lost due to the COVID-19 epidemic. The patient has struggled with guilt, hopelessness and worthlessness. Additionally, the patient reports an increase in anxiety symptoms including racing thoughts and excessive worry. His ability to fall asleep has made it difficult for him to resume the things he enjoyed. He denies having any thoughts of suicide or murder.
Annotated Past Psychiatric History – The patient had a history with anxiety and depression. He was also previously prescribed sertraline. The medication was no longer helping the patient after only a few weeks. He has not reported any history of suicide attempts or hospitalizations.
Drug and Alcohol History: Substance Use History is the patient’s denial of any drug or alcohol abuse.
Medical history: This patient is suffering from hypertension. However, he has managed to control it with the help of lisinopril. Other medical conditions are not present.
Social History: He is married, and has 2 children. The pandemic has left him unemployed. He denied any financial or legal difficulties and denies having had them.
Family history: A patient describes a family history that includes a mother and sister who suffered from anxiety disorders and depression.
Mental Status Test: He appears nervous and unfocused. He participates in interviews and is cooperative. He is moody and has a restricted affect. His thinking processes are organized and logical. It is not possible to see evidence of schizophrenia or suicidal/homicidal thoughts. He is able to think clearly and has good judgment.
Diagnostic criteria: A patient is diagnosed with major depressive disorder or generalized anxiety disorder.
Differing Diagnoses ruled Out: There are other possible differential diagnoses that can be considered but ruled out, including adjustment disorder with depression, post-traumatic stress disorder and bipolar disorder.
Treatment plan: Patient was referred to psychotherapy and started on a selective serotone reuptake inhibitor (SSRI). Follow-up appointments were scheduled to monitor the patient’s response to treatment and to adjust the treatment plan if necessary. It was recommended that the patient avoid drugs and alcohol, and engage in physical activity as well as self-care.