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I have choses to make the primary diagnosis Generalized Anxiety Disorder (GAD) ICD-10 code 300.02 (F41.1).  According to the (American Psychiatric Association [APA], 2013), for this diagnosis the client must have symptoms for greater than 6months with three or more of the six associated symptoms.  The symptoms that the client has that meets these criteria are difficulty falling asleep, easily fatigued, difficulty concentrating (APA, 2013).

 I chose to make this the primary because when the practitioner questioned why depressed now, the client’s response was the imminent death of his father, his prostate cancer this year, and the face that he was having to face the end-of-life-issues. To me this still sounds like worry. Worry can feel overwhelming, cause exhaustion and withdrawal (Wheeler, 2014).  

The differential diagnosis would be Major Depressive Disorder (MDD) with anxious distress. The client does not express hopelessness, worthlessness, but does express fatigue and retardation on movement, concentration, diminished pleasure and sleep problems, all which would qualify the client for the diagnosis (APA, 2013).  In order to accurately know if MDD should be the primary diagnosis, I would want to see the results of a depression rating scale such as the Geriatric Depression Scale, the Hamilton Scale, or the Beck Depression Inventory which all have shown validity and reliability (Wheeler, 2014).

 I would also want to know how long they tried the medications they attempted in the past and why they stopped the, what dosage they went up to.  The medications mentioned that have been used would be the first line treatment for both GAD and MDD.  I would also want to know if the Lorazepam is helping or not when deciding the diagnosis.

I would start Sertraline again, according to (Stahl, 2014), this is a first line treatment for multiple anxiety disorders and MDD. I would begin at 50mg daily and would be able to taper up as needed to 200mg. This medication is not one that is linked with weight gain or sedation (Stahl, 2014).  One option that has not been tried in the past that also works for both GAD and MDD is desvenlafaxine (Pristiq), this also would be started at 50mg daily and could taper up to 100mg daily if needed. I would also want to encourage continued psychotherapy.  Due to the clients current symptoms, as well as the impending loss of his father, interpersonal therapy or supportive therapy would be my personal choice over cognitive behavioral because I feel that CBT focuses a lot on specific problem solving and there is not a solution to the client’s current problems, only learning to cope and accept.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders. Retrieved from https://dsm-psychiatryonline-org.ezp.waldenulibrary.org/doi/full/10.1176/appi.books.9780890425596.dsm05

Stahl, S. M. (2014). The prescriber’s guide (5th ed.). Retrieved from https://stahlonline-cambridge-org.ezp.waldenulibrary.org/prescribers_drug.jsf?page=9781316618134c114.html.dosing&name=SERTRALINE&title=Dosing%20and%20Use

Wheeler, K. (2014). Psychotherapy for the advanced practice psychiatric nurse: A how to guide for evidence-based practice (2nd ed.). New York, NY: Springer