Pt is a 47 year old female admitted due to suicidal ideation with a plan to overdose on pills. Pt verbalized “I just want to end it all” and not having “the strength or ability to keep going anymore.” Pt verbalized not feeling like she should be a mother anymore as she “can’t handle it.” Prior to admission, pt punched herself in the head and grabbed her hair out of frustration. As per family, this is uncharacteristic of her as she does not typically behave like that. Pt stated that she wanted to kill herself in front of her two young children and feels overwhelming guilty and shameful for this. Pt’s family wanted pt admitted due to the safety of the children, especially the younger one. Pt has chronic self doubt potentially due to her mother’s repeated verbal and emotional abuse throughout her life. Pt stated “I was released from Morristown on Monday and I was still having fleeting suicidal thoughts. I can’t handle every day life. I stress about every stupid little thing. I said I wanted someone to actually kill me so I wouldn’t feel guilty.” Pt describes severe debilitating symptoms of depression such as hopelessness, helplessness, crying spells, panic, not attending to her ADL’s, anhedonia, lack of pleasure/joy, feelings of inadequacy and low self esteem. Pt states that over the past 3 years her depression has taken over her life. When asked if there are any particular precipitants, pt could not identify. Pt mentioned two stressors, but stated that neither of them have contributed to the root cause of her depression. Those two stressors included potentially moving in the future and her son being a cancer survivor (he was diagnosed at 16 months old but is now in remission). At this time, pt displays little ability to care for herself, nor her children. Pt is Aaox3 calm and cooperative. Pt denies any mania, psychosis, self injurious thoughts/behaviors, or homicidal ideation/intent/plan. Pt is still actively suicidal but contracts for safety on the unit. Pt engaged in reciprocal conversation and maintained appropriate eye contact. Pt is extremely tearful throughout interview. Pt’s mood is dysphoric, speech is clear, affect is blunted, thoughts are linear. Pt is dressed in hospital attire, fairly groomed, appears her stated age. Pt’s insight and judgment are poor.
Pt states that she’s been struggling with Major Depressive Disorder, recurrent and severe, for the past 10 years (husband says for over 25 years). Pt has a hx of 1 suicide attempt via overdose on Klonopin 11/2022. Pt denies any hx of self injurious behaviors. Pt has been psychiatrically hospitalized at MMC 5/2024, 11/2023, 10/2023, 11/2022, 10/2022, 2016, 2016, Hackensack 10 years ago. Pt recieved 21 sessions of ECT at MMC 11/2022 but states that it was ineffective. Pt was referred to AHS IOP in Florham Park after her admission from MMC this week. Pt also has a private therapist Tara Reyes LCSW and a prescriber Immaculata Emesue NP for the past two years. Pt has a hx of IOP/PHP at High Focus and Gen Psych. Pt is currently prescribed Wellbutrin 150mg, Effexor 225mg, Klonopin 1mg BID, Trazodone 50mg, and Abilify 30mg. Pt states that her current medication regiment is ineffective and does not provide relief. Pt states that she has a long hx of medication resistance with past medication trials of Lithium, Latuda, Vraylar, Lamictal, Gabapentin, Inderal, Buspar, Hyroxyzine, Zyprexa, every SSRI, etc. Pt was UDS + for Benzo (prescribed Klonopin) and BAL negative on admission. Pt denies the use of cannabis, tobacco, nicotine, alcohol, or illicit substances. No hx of SUD. Pt has no hx of violence or legal issues.
Pt grew up with 1 sister. Pt states that when she was around 14 years old her father left her mother and they got divorced. Pt states that she was crying and holding onto his legs begging him not to leave. Pt states that at this time, she has a fair relationship with her father. Pt states that she cut off her mother due to severe emotional abuse. Pt endured emotional abuse and neglect growing up from her parents. Pt’s sister has a hx of anxiety and pt’s mother has a hx of depression. Pt obtained her Associates Degree in Fashion Marketing. Pt is currently unemployed. Pt last worked as a teacher’s aid in over 1 year ago. Pt has prior work hx in retail and education. Pt states that she is working on obtaining Disability. Pt states that her husband is supporting the family financially at this time. Pt has been married to her husband for 25 years. He works in sales. Pt and her husband have a 14 year old son and a 5 year old daughter. Pt resides in a house inwith her husband and two kids. Pt signed an ROI for her husband to be involved in her treatment and discharge planning. Pt states that she has a good support system between her husband, friends, and congregation.
Records from Morristown Memorial Hospital reviewed.
Patient seen along with social worker.
Identification Data: Patient is a 47 years old date of birth January 22nd, 1977, married for 25 years, unemployed female mother of two children 14-year-old son who had been diagnosed with neuroblastoma and a 5-year-old daughter. She lives in a house in with the husband and two kids.
She has a history of multiple psychiatric hospitalizations. Diagnosed major depressive disorder severe recurrent.
Reason for admission: The patient was discharged from Morristown Memorial Hospital two days ago and was referred to their IOP. She went to Morristown ED requesting rehospitalization stating that she was still suicidal. She was then referred to . She stated she had a plan to overdose on pills. Made statements that “I just want to end it all” she felt she could not be a mother anymore. She cannot handle it. Prior to admission she had been punching self in the head and grabbed her hair out of frustration.
She made statements in front of her children that she wanted to kill herself.
DCP and P have never been involved.
As per reports from Morristown Memorial Hospital the patient wants only medications to fix her symptoms and does not want to make any efforts in terms of therapy stating “I cannot do it”. It was reported that the patient may have “a character pathology “along with depression.
History of Present Illness: The patient reported she has been struggling with severe depression for the past 10 years. Has been reported that it was over 25 years. History of one suicide attempt via overdose on Klonopin on 11/2022.
The patient states that one of the psychiatrist at Morristown told her that she was “treatment resistant”.
Reports feeling hopeless, helpless, no pleasure in any activity, severe anhedonia, no hobbies.
Psychiatric History:
Pt has a hx of 1 suicide attempt via overdose on Klonopin 11/2022. Pt denies any hx of self injurious behaviors. Pt has been psychiatrically hospitalized at MMC 5/2024, 11/2023, 10/2023, 11/2022, 10/2022, 2016, 2016, Hackensack 10 years ago. Pt recieved 21 sessions of ECT at MMC 11/2022 but states that it was ineffective. Pt was referred to AHS IOP in Florham Park after her admission from MMC this week. Pt also has a private therapist Tara Reyes LCSW and a prescriber Immaculata Emesue NP for the past two years. Pt has a hx of IOP/PHP at High Focus and Gen Psych. Pt is currently prescribed Wellbutrin 150mg, Effexor 225mg, Klonopin 1mg BID, Trazodone 50mg, and Abilify 30mg. Pt states that her current medication regiment is ineffective and does not provide relief. Pt states that she has a long hx of medication resistance with past medication trials of Lithium, Latuda, Vraylar, Lamictal, Gabapentin, Inderal, Buspar, Hyroxyzine, Zyprexa, every SSRI, etc. . Pt has no hx of violence . States she was seen by Dr.Niazi at Morristown Memorial Hospital.
Denied any history of manic episodes.
Denied any history of an eating disorder.
Denies any history of psychosis.
Eating well. Sleeping well.
Alcohol/Substance Abuse/Tobacco History:
The patient denies use of any illicit substances. Denies use of cannabis or tobacco. UDS was positive for benzodiazepines secondary to being prescribed Klonopin. BAL negative on admission.
Medical History: Denies any medical issues at this time. Was seen by the medical consult. History of some form of nasal surgery in childhood.
Review of Systems:
Patient denies fever, chills, or night sweats
Patient denies weight gain or weight loss
Patient denies blurry or double vision
Patient denies issues with ears, nose, or throat
Patient denies cough or trouble swallowing
Patient denies chest pain or shortness of breath
Patient denies nausea, vomiting, diarrhea, or constipation
Patient denies blood in stool or urine
Patient denies itchiness or rashes
Patient denies numbness or tingling
Allergies: No known allergies.
Family History: The patient reports her mother had depression but not treated. She does not have good relation with her. Her sister has anxiety. The parents divorced when the patient was pre teen. That was traumatic time for her.
Psychosocial History: The patient’s support network include her husband her congregation and friends.
She states she has applied for disability.
Employment/Education History: She has an associate’s degree in fashion marketing. Not working
Legal History: Denied.
Mental Status Examination:
Appearance: Casually attired female height 5 ft 1 in, weight 145 lb 8 oz and BMI 27.49
Behavior: Cried most of the session. Focused on medications. Wants to be on the ” right medication”. At the same time states that no medication works for her. Good eye contact. Was able to describe her symptoms and her medication history. Asserts that she was having suicidal thoughts but denies any current intent or plan.
Orientation: X3.
Sensorium: Clear.
Affect: Depressed anxious.
Mood: Depressed.
Speech: Productive, spontaneous goal directed. Normal tones.
Thought Content: No evidence of delusions. Reports feeling hopeless helpless guilt.
Perceptual Disturbance: Denied.
Thought Process: Organized.
Cognition: Intact.
Insight: Limited.
Judgement: Poor.
She stated she wanted only one answer , “what is the reason for my depression”. She has been in multiple hospitals states she does not know the reason.
She was given education on major depressive disorder including genetic causes, environmental causes and biological causes. She appears to comprehend.
Admitting Diagnosis: Major depressive disorder severe recurrent without psychotic features F 33.2.
Assessment:
Inpatient treatment is expected to improve the patient’s condition. Inpatient level of care is necessary due to the patient’s severe depressive episodes, refractory to most interventions, suicidal ideations. She needs the current hospital level of care for stabilization and for safety.
Current Medications: The patient will continue on Abilify 30 mg daily.
Continue on Wellbutrin XL 150 mg daily. She states she was on 450 mg but experienced anxiety.
Continue the Klonopin 1 mg twice daily. She denies abusing Klonopin.
Continue trazodone 50 mg at bedtime.
She wishes to discontinue Effexor stating “it was not working”.
She agrees for a trial with Cymbalta 30 mg daily.
Medication education given.
She was given a thorough education as to the treatment of a major depression includes being involved in therapy, CBT counseling. Support groups, IOP setting, besides medications. The patient at this time appears to be only medication focused.
She was very comfortable in the hospital setting.
Perhaps a referral for E ketamine therapy could be considered.
