NRNP 6635 Week 11 Integrated Psychiatric Evaluation Example

Integrated Psychiatric Evaluation: A Man in His Fifties With Recurrent Depression, Evening Drinking, and Insomnia, Every Finding Tagged to the Impression

Student Name

College of Nursing, Walden University

NRNP 6635: Psychopathology and Diagnostic Reasoning

Instructor Name

Month Day, Year

Integrated Psychiatric Evaluation: A Man in His Fifties With Recurrent Depression, Evening Drinking, and Insomnia, Every Finding Tagged to the Impression

Identifying Information and Reason for Referral

Composite patient: a man in his fifties, outpatient mental health clinic, referred by his primary care clinician. Reason for referral, in his words: "I've been down like this before, and this time the wine isn't helping me sleep anymore."

History of Present Illness

Low mood most days for about 3 months [H1]. Lost interest in woodworking, which he has done every weekend for 20 years [H2]. Early waking at 03:30 most nights, and difficulty falling asleep on nights without alcohol [H3]. Weight down 8 pounds without trying [H4]. Poor concentration at his job as a municipal water treatment operator, with one near-miss on a chemical dosing log [H5]. Guilt about "letting my family down" [H6]. No thoughts of suicide; passive thoughts denied on direct questioning [H7]. PHQ-9 17 [H8] (Kroenke et al., 2001). Triggered, in his view, by his father's death in the spring and a reorganization at work.

Past Psychiatric History

Two prior depressive episodes, at 38 and 46, each lasting about 6 months, the second treated with an antidepressant with good response for a year [P1]. No hospitalizations, no suicide attempts [P2]. On careful questioning, and with his wife's confirmation, no period of decreased need for sleep with elevated mood or increased energy [P3].

Substance Use

Three to four glasses of wine most evenings for the past 2 years, increased from two since his father's death [S1]. AUDIT 12 [S2] (Saunders et al., 1993). Drinks more on weekends than intended; wife has asked him to cut down; no withdrawal symptoms, no morning drinking, no failed attempts to stop, no work absences from drinking [S3]. He stopped for 5 weeks last Lent; his low mood during his second episode persisted through that period, by his and his wife's account [S4]. No tobacco, cannabis, or other drugs [S5].

Medical, Family, and Social History

Hypertension, treated; no other illnesses [M1]. TSH normal this month [M2]. No medications affecting mood or sleep [M3]. Family: father with depression, treated late in life; no bipolar disorder or suicide known [F1]. Married 28 years, two adult children, lives with his wife; works rotating shifts, currently days [SO1].

Mental Status Examination

Appearance: casually dressed, clean, looks tired [E1]. Behavior: slow to answer, sighs frequently, eye contact intermittent [E2]. Speech: soft, slowed, normal articulation [E3]. Mood, in his words: "heavy" [E4]. Affect: restricted, tearful when discussing his father [E5]. Thought process: linear [E6]. Thought content: guilt themes; no suicidal or homicidal ideation; no delusions [E7]. Perception: no hallucinations [E8]. Cognition: alert, oriented, attention intact on serial subtraction [E9]. Insight: good; he links his drinking to his sleep [E10]. Judgment: intact; he reported the dosing near-miss to his supervisor [E11].

Diagnostic Impression, Built From Pointers

1. Major depressive disorder, recurrent episode, moderate (F33.1) (American Psychiatric Association, 2022). Supported by depressed mood [H1, E4], loss of interest [H2], insomnia [H3], weight loss [H4], poor concentration [H5, E9 with slowed responses], guilt [H6, E7], psychomotor slowing observed [E2, E3], duration of 3 months, and two prior episodes [P1]. Moderate, not severe, because he continues to work and has no suicidal thoughts [H7] or psychotic features [E7, E8].

2. Alcohol use disorder, mild (F10.10). Supported by weekend drinking beyond what he plans and by carrying on although his wife has objected [S3], meeting at least two criteria but not four, with an AUDIT of 12 [S2]. No withdrawal [S3].

3. Insomnia disorder (F51.01), considered and not diagnosed separately at this time: his sleep complaints [H3] are fully accounted for by the depressive episode and alcohol use, and DSM-5-TR asks whether the insomnia is adequately explained by a coexisting mental disorder; recorded for reassessment if insomnia persists after the depression remits and drinking stops.

Differentials With Reasons

Bipolar II disorder: set aside, no hypomanic episode by patient and collateral [P3]. Alcohol-induced depressive disorder: set aside, because a prior depressive episode persisted through 5 weeks of abstinence [S4] and he had episodes before the current drinking pattern [P1, S1]. Depressive disorder due to another medical condition: set aside, TSH normal [M2], no relevant medications [M3].

Interaction, Explained Last

The three conditions feed each other: depression disturbs his sleep, he drinks to sleep, alcohol fragments sleep in the early morning and worsens mood the next day, and poor sleep and low mood lower his resistance to the next evening's drinking. His two earlier depressive episodes occurred without this drinking pattern [P1, S1], which is why depression is listed first and treated as independent. The practice guideline recommends that the evaluation establish such relationships among conditions to guide treatment (American Psychiatric Association, 2015); here, treatment addresses the depression and the drinking at the same time, since treating either alone would leave the loop intact.

References

American Psychiatric Association. (2015). The American Psychiatric Association practice guidelines for the psychiatric evaluation of adults (3rd ed.). https://doi.org/10.1176/appi.books.9780890426760

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

Kroenke, K., Spitzer, R. L., & Williams, J. B. W. (2001). The PHQ-9: Validity of a brief depression severity measure. Journal of General Internal Medicine, 16(9), 606-613. https://doi.org/10.1046/j.1525-1497.2001.016009606.x

Saunders, J. B., Aasland, O. G., Babor, T. F., de la Fuente, J. R., & Grant, M. (1993). Development of the Alcohol Use Disorders Identification Test (AUDIT): WHO collaborative project on early detection of persons with harmful alcohol consumption-II. Addiction, 88(6), 791-804. https://doi.org/10.1111/j.1360-0443.1993.tb02093.x