Discussion: Applying Differential Diagnosis to Depressive and Bipolar Disorders: The Case of Sam

What is it truly like to have a mental illness? By considering clients’ lived experiences, a social worker becomes more empathetic and therefore better equipped to treat them. In this Discussion, you analyze a case study focused on a depressive disorder or bipolar disorder using the steps of differential diagnosis. You also describe lived experiences of depression.

To prepare: View the TED Talk “Depression, the Secret We Share” (TED Conferences, LLC, 2013) and compare the description of Andrew Solomon’s symptoms to the criteria for depressive disorders in the DSM-5. Next review the steps in diagnosis detailed in the Morrison (2014) reading, and then read “The Case of Sam,” considering Sam against the various DSM-5 criteria for depressive disorders and bipolar disorders.

By Day 3

Post a 300- to 500-word response in which you address the following:

• Provide the full DSM-5 diagnosis for Sam. For any diagnosis that you choose, be sure to concisely explain how Sam fits that diagnostic criteria. Remember, a full diagnosis should include the name of the disorder, ICD-10-CM code, specifiers, severity, medical needs, and the Z codes (other conditions that may be a focus of clinical attention). Keep in mind a diagnosis covers the most recent 12 months.
• Explain the diagnosis by matching the symptoms identified in the case to the specific criteria for the diagnosis.

The Case of Sam

Sam is a 62-year-old, widowed, African American male. He is unemployed, receives
Social Security benefits, and lives on his own in an apartment. Sam has minimal peer
relationships, choosing not to socialize with anyone except his daughter, with whom he
is very close. Sam raised his daughter as a single father after his wife passed away.
Melissa is 28 years old and works as an emergency medical technician (EMT). When
Sam was 7 years old, he was placed in foster care and has had very limited contact with
his extended family.
Prior to September 11, 2001, Sam had a steady employment history in food services
and retail. He had no psychiatric history before that time. Sam reported his religious
background is Catholic, but he is not affiliated with a congregation or church.
Sam became depressed and psychotic sometime after 9/11 and had to be taken to an
emergency room. He was hospitalized at that time for several weeks. His mental status
exam (MSE) and diagnostic interview showed no history of alcohol or substance abuse
issues, and he had no criminal background or current legal issues. Sam was released to
outpatient care but was deemed unable to return to work. At that time, he had a
diagnosis of major depression with psychotic features; he also has a history of high
blood pressure and migraines. After several additional multiple psychiatric
hospitalizations, he was gradually stabilized.
Sam has been seeing a psychiatrist once a month for over a decade for medication
management and is currently prescribed Depakote®, Abilify, and Wellbutrin®. Sam has
a positive history of medication and treatment compliance. He was treated by a social
worker at an outpatient program for about 2 years after his hospitalizations for his
psychosis and depression. He gradually stopped attending sessions with the social
worker after his symptoms stabilized, and his termination from the outpatient program
was deemed appropriate; he continued to see the psychiatrist monthly for medication
management.
After about 10 years of seeing only the psychiatrist, Sam scheduled a meeting with this
social worker for increased feelings of depression. These feelings were brought on after
his daughter moved out of the apartment they had shared for many years to live with
her boyfriend. He reported difficulty adjusting to living alone and said he often feels
lonely and anxious. He reported during sessions with his social worker that he speaks to
his daughter frequently, and although she only lives 10 blocks away, he misses her
terribly.
Our sessions for the last 3 months have focused on his mixed feelings around his
daughter’s new life with her boyfriend. He said he is happy that she is happy but misses
her very much. I emphasized his strengths and helped him reframe his situation by
focusing on the positive changes in her life as well as his own life. Our goals were to
help him reduce his symptoms of anxiety and begin searching for new opportunities for
socialization outside of his daughter.
During our last two sessions, I became concerned because Sam, who was normally
articulate, had been appearing confused and slightly disorganized. I asked him if he had
a recent medication change and if he had been compliant with his current medications,
but he denied noncompliance or any recent medication adjustment.
I asked Sam if he was experiencing any physical health problems. He denied any
ongoing problems but mentioned that he had collapsed on the street recently. He
reported that he had been hospitalized and had undergone a number of tests, which he
thinks were all negative. He said he still feels “foggy” at times, and sometimes time
seems to be “missing.”
I reviewed his medications with him. As he went down the list, he reported taking
Cogentin® and Ativan®, which according to his chart history had been discontinued
months ago. When I asked Sam where he obtained these medications, he stated, “I got
them out of the bag.” Sam reported he has a bag at home in which he puts all leftover
and discontinued medications. He could not explain why he was taking discontinued
medication or for how long. Sam stated, “I thought I was supposed to take it.”
I called his daughter, and she verified he had recently been hospitalized and that the
MRI, CT scan, and EEG tests were negative. I requested that Melissa go to her father’s
apartment to look for the bag of medications he mentioned, because it seemed likely
that her father was taking discontinued medications. I then scheduled a meeting with
Sam and his daughter for later that week. During that session, Melissa reported that she
found multiple vials of old medication on the kitchen counter mixed in with her father’s
current medications. Melissa reported that she collected and disposed of all the old
medications. I recommended obtaining a daily medication planner. Although the hospital
tests were negative, I recommended scheduling an appointment with a neurologist, and
both agreed.
Sam saw a neurologist who reported that his test results were negative but did not rule
out the possibility of a seizure disorder. The neurologist recommended a follow-up
appointment in 3 months. He also contacted Sam’s psychiatrist and recommended that
the Wellbutrin be discontinued because it is known to have the potential to cause
seizures and that Sam should start on another antidepressant. Sam began to focus and
become more cognitively alert after the discontinued medications were disposed of and
the Wellbutrin was discontinued.
I scheduled another family session for Sam to discuss his feelings regarding Melissa
moving out. Sam was tearful when he told Melissa he missed her and her dog Sonny.
He also told her he was concerned he would not be financially able to remain in the
apartment. Melissa reported working long and odd hours but did call her father often
and invited him over to her apartment. She further reported that he often declined her
invitations. Sam reported he declined because he did not want to intrude on her life or
her boyfriend. Melissa assured her father that both she and her boyfriend wanted him to
visit and be part of their lives. I asked Sam if Melissa’s dog had been company for him,
and he replied, “Yes, and I miss him.” I asked Melissa if it would be possible for Sonny
to spend some time with her father. Melissa reported her long work hours were making
it difficult to take care of Sonny and asked her father if he would like Sonny to live with
him. Sam replied, “I would like that.”
I discussed with Sam how he spends his time, which normally consists of reading a
newspaper, watching television, or listening to talk radio. I suggested Sam increase his
socialization and recommended a social club for older adults that is near his home. Sam
said he would consider this idea. I asked Sam to discuss his financial concern that he
may not be able to remain in his apartment. Sam stated that Melissa had been
contributing to the household expenses but stopped when she moved out. He stated he
had been too embarrassed and ashamed to discuss this with Melissa and had been
keeping this to himself. Although Sam is on a fixed income, he is currently able to meet
his expenses. However, he is concerned about his rent, which is his largest expense.
I explored state and federal rent assistance programs for seniors and the disabled. I
found a program through which tenants who qualify can have their rent frozen at their
current level and be exempt from future rent increases. Sam met the program
requirement of being at least 62 years of age, currently living in a rent-controlled
apartment, and having a household income that was within the specified guidelines. I
obtained the required forms and personal documentation from Sam and completed the
application, sending it to the appropriate agency.