Major Depressive Disorder with Anxious Distress Moderate Intensity – Health Assignment Help

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Assignment Task :
DEMOGRAPHIC INFORMATION: 
The patient, Ms. Monique Mendez, was born on January 24, 1985.  She is a 36-year-old female living in Aurora with her mother.  She is currently on leave and in the past she used to work in a retirement home.  She is currently getting the disability benefit and she was not sure whether she is on a short-term benefit, long-term benefit or income replacement benefit.  
 
RELEVANT BACKGROUND INFORMATION:
History of Presenting Illness and Functional Inquiry:  
The patient was assessed on the Doxy.me system.  She reported that many years ago she suffer from depression with low mood, low motivation, low energy, hopelessness, helplessness and ideas of She saw a counselor then she was commenced Zoloft.  She at that time also tried to commit suicide and in her overall history, she tried to harm herself years ago, once before the accident and after the accident she thought of committing suicide on two occasions but stopped.  She said that she is not aware of seeing any psychiatrist but she confirmed that she saw psych counselors.  There was a vague history of hospital admission following her first suicidal attempt but she did not provide me any details about it.  According to her she was on Zoloft in Grade 10 but she was on this medication for less than a year and then she discontinued.  She herself denied any previous admission to mental health services.  She did not report any particular highs and lows in mood.  She did report paranoid features in her profile but did not report any hallucinations.  She was cooperative with the interview and I was able to develop an adequate rapport with her.  She did report that since her accident, her depression has been exacerbated as she tried to harm herself on two occasions but she stopped doing that.  She feels anxious and her functionality is greatly is greatly reduced.  Previously she used to enjoy a number of activities in life but all these activities are now decreased.
 
Past History:  
She saw counselors in the past and was on antidepressant medications in the past and one previous suicide attempt.  She was assessed by a psychologist who determined that she suffers from major depressive disorder and posttraumatic stress disorder.  The patient however reported that since her accident, she gets nightmares and flashbacks.  She avoids those areas where she was hit from behind and she gets numb about thinking of those events.  
The patient was seen by a psychologist and was also seen by a psychiatrist earlier.  She was on CBD and she was also seen by a sleep specialist who diagnosed her suffering from obstructive sleep apnea and delayed sleep phase disorder.
 
Family History:  
The patient reported her parents were divorced.  She is in touch with her father, lives with her mother.  She denies any family history of mental health issues.
 
CLINICAL IMPRESSION:

Major depressive disorder with anxious distress moderate intensity without psychotic features.

Rule out Posttraumatic Stress Disorder.

Rule out borderline personality traits.

 
RECOMMENDATIONS:

She should continue with her current psychotropic medication.

She should follow up with regular psychiatric services.

She should continue with cognitive behavior treatment as well as trauma-focused cognitive behavior therapy.  

She may also benefit from some sessions of DBT.  

Her medication should be monitored and carefully looked into and titrated periodically.

Her medical treatment should continue.  

 
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