1.   The mental state examination, when it is to be used and why it is a useful tool (max 100 words) 5 marks

The mental state examination performed on John is mental status assessment. It is utilized to study the cognitive and behavioural functioning of a patient. The tool enables the description of judgment appearance of a patient as well as attentiveness, speech and motor activity, thought, perception, affect and mood, attitude, memory, language, and abstract reasoning. In turn, the mental status assessment helps psychiatrists to understand the actual features of the mental derangement ihelpsn a patient and make accurate judgement of the prognosis of the situation. Although the instrument might be threatening to a patient, it reveals the accurate and sensitive facts about the patient’s history.

2.      John’s appearance and behaviour during the initial assessment with the psychiatrist (100 words) 3 marks

Martin (1990) stated that the appearance and general behaviour is what an examiner relies on to get the general impression of a patient. During the assessment, John appears much older that his actual age (62 years) but was properly dressed. He often rubs his hands against each other, and places against his face when talking about sad events in his life. This happens more frequently when John speaks of Jean and Tom (Hart, 2016). Again, he avoids eye-contact and only looks up when psychiatrist asks more sensitive questions about his life. John remains cooperative and calm throughout the initial assessment.

3.       Differentiate between mood and affect, and then describe both as they relate to John (max 50 -100 words) 3 marks

Affect refers to the immediate emotions of a patient as observed by the examiner while mood are emotions of a patient that describe his or her personality (Martin, 1990). John is generally sad and miserable. The loss of his job, inability to get one, being left by the wife, and the son not talking to him all make him very sad. The sadness is apparent from his look and how he speaks about himself and life events. Onto his mood, psychiatrist concludes that John was depressed. This is based on the overall evaluation of how the patient described himself. The outcome also confirms the statement by Bowen, Peters, Marwaha, Baetz, and Balbuena (2017) that depressed individuals’ moods tend to be biased and inclined to the negative.

4.  ,John’s speech (max 50 -100 words) 3 marks

John’s speech is slow and soft (Hart, 2016) but may be reasonable enough for the concerned context. Wang, Zhang, and Liu et al. (2019) indicated that a depressed person has slow, disfluent and monotonous voice. This may, however, be difficult to prove with certainty in John’s case because of the lack of knowledge of how he sounded when healthy. Even then, John’s speech sounds laboured as he pauses or stops at times. Also, given that he held a job position earlier on, he must have been more fluent in his speech during the session. John’s speech also has a direct link to his negative mood.

5.      What signs or symptoms associated with depression can you identify in the interview with John? (max 100 - 150 words) 5 marks

According to Kennedy (2008), the primary depression symptoms include depressed mood and lack of interest in almost all activities. John admits to feeling depressed since he lost his job and also states that he did not find pleasure in anything. For instance, he says he cannot read a book or newspaper and is unable to watch television. John says he would switch on the television but was incapable of concentrating on it (Hart, 2016). He has also lost interest in life and believes killing himself would be the solution to his problems. Additional symptoms of depression are sleep disturbances, anxiety, sexual dysfunction, fatigue, and guilt (Kennedy, 2008). John tells the psychiatrist that he constantly felt tired but would turn and toss in bed, unable to get proper sleep (Hart, 2016). While explaining his belief that he caused Jean to leave him, John also states that he was unable to provide for her financially, emotionally, and sexually.

6.      What physical investigations (blood tests, medical imaging etc.) might the psychiatrist request at the end of the brief consult with John, and why are these important in the context of symptoms consistent with depression? (max 100 words) 3 marks

Body temperature and medical imaging are necessary. Depression interferes with circadian rhythms which includes sleep, cognitive function, body temperature, etc. (Song et al., 2018). Therefore, if a patient has higher body temperature during the day and it rises at night, this could indicate that the patient’s thermoregulatory cooling systems are dysfunctional. On the other hand, glucose is the first component of medical imaging. Song et al. (2018) argued that loss of appetite, a symptom of depression, interferes with glucose level in the body due to the reduced amount of ingested food. Functional Magnetic resonance imaging should reveal defects in glucose metabolism in the patient’s brain.

7.      Describe John’s thought form and content. Ensure that you assess his perception as well (maximum 50-100 words) 5 marks

A number of the brain triggers and alterations resulting from depression are likely to interfere with the patient’s thinking skills (Martin, 1990). Depression sucked joy out of John making him to see life as less meaningful. He thinks that he has lost everything, is incapable of sorting anything, and has no way of recovering things that brought joy and meaning to his life. John thinks no one cares about him, and that when he dies nobody will miss him (Hart, 2016). He prevents himself from seeing that Jean still cares and visits him, and that she even called the ambulance on the day John attempted suicide.   

8   John’s suicidal thinking is cause for concern. Which risk factors does he present with currently? (maximum 50-100 words) 3 marks

The constant feeling of sadness and hopelessness are risk factors that may push John into attempting suicide again. John spends all his waking time feeling sorry for himself and remembering how he lost his job, faced financial difficulties, and separated from his family (Hart, 2016). He also feels humiliated by the fact that he cannot get the jobs he seeks and that no one wants him. Even worse, John is not happy to have survived his attempted suicide and is ready to try it again by electrocuting himself. Generally, the main source of the risks is John’s mindset, thoughts and perceptions.

9.  Other than his risk for suicide, which other risks does John present with?  Please consider his physical health in addition to other possible risks. (max 150-250 words) 5 marks

Depression is a psychological issue which may worsen John’s condition due to his lifestyle changes and non-adherence to medication. Depression happening alongside constant emotional stress can deregulate the immune system through interference with adrenal hormones, neurohormones, and neurotransmitters (Lee, Sung, Kim, Lee, Park, and Shim, 2015). People with depression experience appetite alterations, and loss of appetite like in John’s case may result in weight loss. If he becomes underweight, the outcome may be bad for his heart and may result in fatigue. Additionally, depression has a role in the emergence of age-related illnesses such as diabetes, heart disease, obesity and cancer (Lee et al., 2015). What happens is that depression impairs an individual’s ability to come up with proper lifestyle decisions.

Sedentary lifestyles and poor diet may result in heart disease. Emotional stress is also a risk factor of cancer, especially the chronic/severe depression (Lee et al., 2015). Stressful life events such as losing a job or staying away from family members (Jean and Tom) that John was used can, therefore, increase his cancer risk. Additionally, depression affects the incidence of functional gastrointestinal disorders like irritable bowel syndrome (Shah, Rezaie, Riddle, & Pimentel, 2014). Shah and colleagues stated that irritable bowel syndrome (IBS) relates closely to psychological disorders. The authors stated that IBS symptoms such as fatigue, pelvic inflammation, and joint pains are psychological in nature.

1    John is diagnosed with major depressive disorder. What interventions/treatment and care pathways/options would be appropriate for his care? Provide rationales for your plans. (max 300-350 words) 10 marks

Depression management requires comprehensive evaluation, accurate diagnosis, and formulation of the procedures to follow during treatment. The setting, medications, appropriate psychological measures to use have to be determined for effective treatment (Gautam, Jain, Gautam, Vahia, & Grover, 2017). Given that John presents with suicidal behaviour, the clinical setting is the safest place for his treatment. Moreover, he will not get the necessary social support for his treatment away from the hospital. The psychiatrist in charge should also develop a positive therapeutic alliance with John to increase chances of positive outcome. Again, the psychiatrist will have to work on the initial signs of relapse.  Gautam et al. (2017) grouped depression treatment into antidepressants, psychological interventions and electroconvulsive therapy. Light therapy, stimulation of vagal nerve or deep brain and transcranial, and other options that involve deprivation of sleep.

Mayo Clinic (2018) explained that psychotherapy and medications are often suitable for many patients with major depression disorder, and that there are several types of antidepressants. Examples of antidepressants include selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine inhibitors (SNRIs), atypical antidepressants, tricyclic antidepressants, and monoamine oxidase inhibitors (MAOIs). Mayo Clinic (2018) asserted that although antidepressants are generally safe, they should contain strictest warning on prescriptions. If antidepressants are used on John, however, the psychiatrist should know that suicidal thoughts may be elevated during the initial weeks and in case the dose changes happen. Therefore, John has to be closely watched to identify any unusual behaviours.

On the good side, the antidepressants should improve mood and reduce suicidal tendencies in the long run. Psychotherapy, on the other hand, refers to depression treatment through talking with a mental health expert about the situation and associated issues (Mayo Clinic, 2018). Cognitive behavioural therapy and interpersonal therapy are examples of psychotherapy. The therapies enable a patient to adjust to a difficult situation, get rid of the negative beliefs, establish positive interaction with others, cope with emotions, and regain control over personal life by eliminating hopelessness.