ASSESSING, DIAGNOSING, AND TREATING ADULTS WITH MOOD DISORDERS

It is important for the PMHNP to have a comprehensive understanding of mood disorders in order to assess and accurately formulate a diagnosis and treatment plan for patients presenting with these disorders. Mood disorders may be diagnosed when a patient’s emotional state meets the diagnostic criteria for severity, functional impact, and length of time. Those with a mood disorder may find that their emotions interfere with work, relationships, or other parts of their lives that impact daily functioning. Mood disorders may also lead to substance abuse or suicidal thoughts or behaviors, and although they are not likely to go away on their own, they can be managed with an effective treatment plan and understanding of how to manage symptoms.(Comprehensive Soap Note Example on Mood Disorders)

In this Assignment you will assess, diagnose, and devise a treatment plan for a patient in a case study who is presenting with a mood disorder.

RESOURCES

Be sure to review the Learning Resources before completing this activity. Click the weekly resources link to access the resources. 

WEEKLY RESOURCES

TO PREPARE

• Review this week’s Learning Resources. Consider the insights they provide about assessing, diagnosing, and treating mood disorders.
• Review the Focused SOAP Note template, which you will use to complete this Assignment. There is also a Focused SOAP Note Exemplar provided as a guide for Assignment expectations.
• Review the video, Case Study: Petunia Park. You will use this case as the basis of this Assignment. In this video, a Walden faculty member is assessing a mock patient. The patient will be represented onscreen as an avatar.
• Consider what history would be necessary to collect from this patient.(Comprehensive Soap Note Example on Mood Disorders)
• Consider what interview questions you would need to ask this patient.
• Consider patient diagnostics missing from the video: Provider Review outside of interview:Temp 98.2  Pulse  90 Respiration 18  B/P  138/88Laboratory Data Available: Urine drug and alcohol screen negative.  CBC within normal ranges, CMP within normal ranges. Lipid panel within normal ranges. Prolactin Level 8; TSH 6.3 (H)(Comprehensive Soap Note Example on Mood Disorders)

THE ASSIGNMENT

Develop a Focused SOAP Note, including your differential diagnosis and critical-thinking process to formulate a primary diagnosis. Incorporate the following into your responses in the template:(Comprehensive Soap Note Example on Mood Disorders)

• Subjective: What details did the patient provide regarding their chief complaint and symptomatology to derive your differential diagnosis? What is the duration and severity of their symptoms? How are their symptoms impacting their functioning in life?
• Objective: What observations did you make during the psychiatric assessment?
• Assessment: Discuss the patient’s mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses with supporting evidence, listed in order from highest to lowest priority. Compare the DSM-5-TR diagnostic criteria for each differential diagnosis and explain what DSM-5 criteria rules out the differential diagnosis to find an accurate diagnosis. Explain the critical-thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.
• Plan: What is your plan for psychotherapy? What is your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters as well as a rationale for this treatment and management plan. Also incorporate one health promotion activity and one patient education strategy.(Comprehensive Soap Note Example on Mood Disorders)
• Reflection notes: Reflect on this case. Discuss what you learned and what you might do differently. Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), social determinates of health, health promotion, and disease prevention that takes into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).(Comprehensive Soap Note Example on Mood Disorders)

BY DAY 7 OF WEEK 4

Submit your Focused SOAP Note.

SUBMISSION INFORMATION

Before submitting your final assignment, you can check your draft for authenticity. To check your draft, access the Turnitin Drafts from the Start Here area. (Comprehensive Soap Note Example on Mood Disorders)

1. To submit your completed assignment, save your Assignment as WK1Assgn+last name+first initial.
2. Then, click on Start Assignment near the top of the page.
3. Next, click on Upload File and select Submit Assignment for review.

Rubric

NRNP_6665_Week4_Assignment_Rubric

NRNP_6665_Week4_Assignment_Rubric

CriteriaRatingsPts

This criterion is linked to a Learning OutcomeCreate documentation in the Focused SOAP Note Template about the patient in the case study. In the Subjective section, provide: • Chief complaint• History of present illness (HPI)• Past psychiatric history• Medication trials and current medications• Psychotherapy or previous psychiatric diagnosis• Pertinent substance use, family psychiatric/substance use, social, and medical history• Allergies• ROS(Comprehensive Soap Note Example on Mood Disorders)

15 to >13.0 pts

Excellent

The response throughly and accurately describes the patient’s subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis.(Comprehensive Soap Note Example on Mood Disorders)

13 to >11.0 pts

Good

The response accurately describes the patient’s subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis.(Comprehensive Soap Note Example on Mood Disorders)

11 to >10.0 pts

Fair

The response describes the patient’s subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis but is somewhat vague or contains minor innacuracies.(Comprehensive Soap Note Example on Mood Disorders)

10 to >0 pts

Poor

The response provides an incomplete or inaccurate description of the patient’s subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis. Or the subjective documentation is missing.(Comprehensive Soap Note Example on Mood Disorders)

15 pts

This criterion is linked to a Learning OutcomeIn the Objective section, provide:• Review of Systems (ROS) documentation and relate if pertinent to the chief complaint, HPI, and history• Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses(Comprehensive Soap Note Example on Mood Disorders)

15 to >13.0 pts

Excellent

The response thoroughly and accurately documents the patient’s ROS for pertinent systems. Diagnostic tests and their results are thoroughly and accurately documented.

13 to >11.0 pts

Good

The response accurately documents the patient’s ROS for pertinent systems. Diagnostic tests and their results are accurately documented.

11 to >10.0 pts

Fair

Documentation of the patient’s ROS is somewhat vague or contains minor innacuracies. Diagnostic tests and their results are documented but contain minor inaccuracies.(Comprehensive Soap Note Example on Mood Disorders)

10 to >0 pts

Poor

The response provides incomplete or inaccurate documentation of the patient’s ROS. Systems may have been unnecessarily reviewed. Or the objective documentation is missing.(Comprehensive Soap Note Example on Mood Disorders)

15 pts

This criterion is linked to a Learning OutcomeIn the Assessment section, provide:• Results of the mental status examination, presented in paragraph form• At least three differentials with supporting evidence. List them from top priority to least priority. Compare the DSM-5 diagnostic criteria for each differential diagnosis and explain what DSM-5 criteria rules out the differential diagnosis to find an accurate diagnosis. Explain the critical-thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.

20 to >17.0 pts

Excellent

The response thoroughly and accurately documents the results of the mental status exam. Response lists at least three distinctly different and detailed possible disorders in order of priority for a differential diagnosis of the patient in the assigned case study, and it provides a thorough, accurate, and detailed justification for each of the disorders selected.(Comprehensive Soap Note Example on Mood Disorders)

17 to >15.0 pts

Good

The response accurately documents the results of the mental status exam. Response lists at least three distinctly different and detailed possible disorders in order of priority for a differential diagnosis of the patient in the assigned case study, and it provides an accurate justification for each of the disorders selected.(Comprehensive Soap Note Example on Mood Disorders)

15 to >13.0 pts

Fair

The response documents the results of the mental status exam with some vagueness or innacuracy. Response lists at least three different possible disorders for a differential diagnosis of the patient and provides a justification for each, but may contain some vagueness or innacuracy.(Comprehensive Soap Note Example on Mood Disorders)

13 to >0 pts

Poor

The response provides an incomplete or inaccurate description of the results of the mental status exam and explanation of the differential diagnoses. Or the assessment documentation is missing.(Comprehensive Soap Note Example on Mood Disorders)

20 pts

This criterion is linked to a Learning OutcomeIn the Plan section, provide:• Your plan for psychotherapy• Your plan for treatment and management, including alternative therapies. Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters as well as a rationale for this treatment and management plan. • Incorporate one health promotion activity and one patient education strategy.(Comprehensive Soap Note Example on Mood Disorders)

25 to >22.0 pts

Excellent

The response provides an evidence-based, detailed, and appropriate plan for psychotherapy for the patient. The response provides an evidence-based, detailed, and appropriate plan for treatment and management, including pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters. A strong rationale for the plan is provided that demonstrates critical thinking and content understanding. … The response includes at least one evidence-based health promotion activity and one evidence-based patient education strategy.(Comprehensive Soap Note Example on Mood Disorders)

22 to >19.0 pts

Good

The response provides an evidence-based and appropriate plan for psychotherapy for the patient. The response provides an evidence-based and appropriate plan for treatment and management, including pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters. An adequate rationale for the plan is provided. … The response includes at least one health promotion activity and one patient education strategy.(Comprehensive Soap Note Example on Mood Disorders)

19 to >17.0 pts

Fair

The response provides a somewhat vague or inaccurate plan for psychotherapy for the patient. The response provides a somewhat vague or inaccurate plan for treatment and management, including pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters. The rationale for the plan is weak or general. … The response includes one health promotion activity and one patient education strategy, but it may contain some vagueness or innacuracy.(Comprehensive Soap Note Example on Mood Disorders)

17 to >0 pts

Poor

The response provides an incomplete or inaccurate plan for psychotherapy for the patient. The response provides an incomplete or inaccurate plan for treatment and management, including pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters. The rationale for the plan is inaccurate or missing. … The health promotion and patient education strategies are incomplete or missing.(Comprehensive Soap Note Example on Mood Disorders)

25 pts

This criterion is linked to a Learning Outcome• Reflect on this case. Discuss what you learned and what you might do differently. Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), social determinates of health, health promotion, and disease prevention that takes into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).(Comprehensive Soap Note Example on Mood Disorders)

5 to >4.0 pts

Excellent

Reflections are thorough, thoughtful, and demonstrate critical thinking.

4 to >3.5 pts

Good

Reflections demonstrate critical thinking.

3.5 to >3.0 pts

Fair

Reflections are somewhat general or do not demonstrate critical thinking.

3 to >0 pts

Poor

Reflections are incomplete, inaccurate, or missing.

5 pts

This criterion is linked to a Learning OutcomeProvide at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines that relate to this case to support your diagnostics and differential diagnoses. Be sure they are current (no more than 5 years old).(Comprehensive Soap Note Example on Mood Disorders)

10 to >8.0 pts

Excellent

The response provides at least three current, evidence-based resources from the literature to support the assessment and diagnosis of the patient in the assigned case study. The resources reflect the latest clinical guidelines and provide strong justification for decision making.(Comprehensive Soap Note Example on Mood Disorders)

8 to >7.0 pts

Good

The response provides at least three current, evidence-based resources from the literature that appropriately support the assessment and diagnosis of the patient in the assigned case study.(Comprehensive Soap Note Example on Mood Disorders)

7 to >6.0 pts

Fair

Three evidence-based resources are provided to support the assessment and diagnosis of the patient in the assigned case study, but they may only provide vague or weak justification.

6 to >0 pts

Poor

Two or fewer resources are provided to support the assessment and diagnosis decisions. The resources may not be current or evidence based.

10 pts

This criterion is linked to a Learning OutcomeWritten Expression and Formatting – The paper follows correct APA format for parenthetical/in-text citations and reference list.(Comprehensive Soap Note Example on Mood Disorders)

5 to >4.0 pts

Excellent

Uses correct APA format with no errors

4 to >3.5 pts

Good

Contains a few (one or two) APA format errors

3.5 to >3.0 pts

Fair

Contains several (three or four) APA format errors

3 to >0 pts

Poor

Contains many (five or more) APA format errors

5 pts

This criterion is linked to a Learning OutcomeWritten Expression and Formatting – English Writing Standards: Correct grammar, mechanics, and punctuation

5 to >4.0 pts

Excellent

Uses correct grammar, spelling, and punctuation with no errors

4 to >3.5 pts

Good

Contains a few (one or two) grammar, spelling, and punctuation errors

3.5 to >3.0 pts

Fair

Contains several (three or four) grammar, spelling, and punctuation errors

3 to >0 pts

Poor

Contains many (five or more) grammar, spelling, and punctuation errors that interfere with the reader’s understanding

5 pts

Total Points: 100

PreviousNext

Comprehensive Soap Note Example on Mood Disorders

Subjective:

CC (chief complaint): “I really feel like the medication squashes who I am.”

HPI: Ms. PP is a 27-year-old female present for mental health assessment. Ms. PP has a history of taking and stopping medications. She believes she does not need them. She reports episodes of depression and increased energy. There was a period in which Ms. PP did not sleep for a week and was reported to the police for dancing in the field with her guitar and in a nightgown. She does not remember much of the instance and accused the mother of making up the story. Ms. PP reports having four to five episodes of depression in a year which keeps her from going to work. She reports episodes of low energy, no interest in her creativity, and no motivation. “Sometimes I just don’t want to get out of bed.” The client reports feeling worthless and her creativity (passion) slipping away. Such instances follow long periods of activity, particularly painting, writing, and music. She loves episodes in which she is active and does not take medication at such times because she feels “squashed.” Ms. PP reports high energy when active, sleeping less, accomplishing various activities, talking too much, and appearing scattered. During the active episodes, which last about a week, Ms. PP engages in sex with multiple partners. She also reports having experienced instances of sleeplessness and audio and visual hallucinations a month ago. Ms. PP’s appetite decreases when she is creative and increases when resting or crashing. On average, she sleeps for five or six hours. However, she sleeps three hours a week when creative and 12-16 hours daily when crashed.(Comprehensive Soap Note Example on Mood Disorders)

Past Psychiatric History:

General Statement: PP entered mental health treatment as a teenager following 4 or 5 days of no sleep.

Hospitalizations: Hospitalized four times.  

Medication trials: Tried Zoloft, risperidone, Seroquel, Klonopin, and other unknown medications. The client associated risperidone and Seroquel with weight gain. The client associated with Klonopin slowing him down.

Psychotherapy or Previous Psychiatric Diagnosis: The client has a history of depression, anxiety, and bipolar.

Substance Use History: The client uses nicotine and last drank alcohol at age 19. She tried marijuana once. Denies using cocaine, sedative or opiate medications, synthetic, or hallucinogenic.

Family Psychiatric/Substance Use History: Mother had bipolar. Mother tried suicide Father was imprisoned for drugs. Has not interacted with her father in ten or eight years.

Social History: Raised by mother and elder brother. She has never been married and lives with her boyfriend. No children. No significant legal issues or DUI. Works part times at a bookstore. The client is in Vo-tech school studying cosmetology. She likes painting and writing her life story. Had a difficult childhood.(Comprehensive Soap Note Example on Mood Disorders)

Medical History: Has hypothyroidism and polycystic ovaries.

Current Medications:  Birth control pill for polycystic ovaries.

Allergies: NKFDA.

Reproductive Hx: Experiences regular menses. No pregnant. Sexually active.

ROS:

GENERAL: Experiences episodes of fatigue. No weight loss/gain or fever.

HEENT: No visual loss, hearing loss, nasal congestion, or sore throat.

SKIN: No rashes or itching.

CARDIOVASCULAR: No chest pain, palpitations, or discomfort.

RESPIRATORY: No breathing difficulties or cough.

GASTROINTESTINAL: No nausea or vomiting. No anorexia. No abdominal pain.

GENITOURINARY: No hematuria or dysuria.

NEUROLOGICAL: No headache or dizziness. No seizures, numbness, paralysis, or tingling.

MUSCULOSKELETAL: No muscle pain or stiffness.

HEMATOLOGIC: No anemia.

LYMPHATICS: No enlarged nodes or history of splenectomy.

ENDOCRINOLOGIC: No polyphagia, polydipsia, or polyuria.

Physical Exam:

Completed by PCP.

Vital Signs: T- 98.2 R 18 P 92 BP 138/88

Laboratory Data: Negative for urine drug and alcohol screen. CBC, CMP, and Lipid panel within normal ranges. Prolactin Level 8 and TSH 6.3 (H).

Diagnostic Results: Bipolar Inventory of Symptoms Scale (BISS) is an effective assessment tool for bipolar disorder that encompasses all the symptoms (Harrington, 2019). BISS is reliable and valid for assessing bipolar disorder. Bech–Rafaelsen Mania Scale (MAS) is an effective tool for assessing the severity of mania. MAS has high internal and interrater reliability and high sensitivity to treating manic symptoms (Allen et al., 2019).(Comprehensive Soap Note Example on Mood Disorders)

Assessment

Mental Status Examination: Ms. PP is well-kempt, alert, and oriented*4. She is cooperative and conversant. She makes direct eye contact. Affect in full range with mixed mania. Abnormal psychomotor activity was noted during the exam. Speech is clear and coherent, with a wide vocabulary. The thought process is linear and logical. Insight and judgment were good. Her thought process is tangential and logical, and she has a good insight into the situation. No difficulty with attention or concentration. No current suicide ideation. No evidence of risk to self or others.

Differential Diagnoses:

1. Moderate Bipolar I Disorder, with manic episode, 296.42 (F31.12) – To be diagnosed with Bipolar I Disorder (BP-I), an individual must present with a manic episode preceded or followed by a major depressive disorder (MDD) or hypomanic episodes. A manic episode is characterized by a characteristic period of elevated and abnormal mood and goal-directed energy/activity and symptoms such as grandiosity/inflated self-esteem, limited sleep, talkativeness, racing thoughts, distractibility, psychomotor agitation, and involvement in risky activities that last a week (American Psychiatric Association [APA], 2019). Symptoms of a hypomania episode are similar to a manic episode and are observable by others hypomanic, lasting about four days. These symptoms interfere with social and occupational impairments and can lead to hospitalization. This is the primary diagnosis.(Comprehensive Soap Note Example on Mood Disorders)
2. Bipolar II Disorder, 296.89 (F31.81) – The diagnostic criteria for Bipolar II Disorder (BP-II) include past or present hypomania and MDD episodes in four consecutive days. BP-II symptoms include distinct periods of persistently elevated and abnormal moods, such as a change in normal behavior, grandiosity, limited sleep, talkativeness, flight of ideas, distractibility, and high goal-directed activity, which affect functioning. This is a secondary diagnosis(Comprehensive Soap Note Example on Mood Disorders).
3. Major Depressive Episode, 296.22 (F32.1) – The diagnostic criterion for Major Depressive Episode (MDD) includes two weeks of diminished pleasure or depressed mood. Individuals show symptoms such as depressed mood, diminished pleasure in activities, insomnia, weight loss, psychomotor agitation, hypersomnia, worthlessness, inability to think or concentrate, thoughts of death, and fatigue (APA, 2019). This is a secondary diagnosis.(Comprehensive Soap Note Example on Mood Disorders)

Reflection

The client’s symptoms meet the diagnosis criterion for BP-I disorder. The client reports episodes of depression and increased energy, which lasts about one week. During high-energy episodes, she engages in potentially harmful activities such as multiple sex experiences, sleeps only three hours during the week, experiences racing thoughts, talks much, and appears scattered. She also experiences auditory and visual hallucinations when her mood is elevated. However, when depressed, she feels worthless and fatigued and does not go to work. Therefore, I agree with the preceptor’s diagnosis of BP-I as the primary diagnosis. However, additional evaluation using MAS and BISS would provide more data for a definitive diagnosis. The client’s history of nicotine abuse, family history of bipolar disorder, and difficult childhood could be predisposing factors to her condition. Moreover, the client is diagnosed with polycystic ovaries, which are associated with bipolar disorder.(Comprehensive Soap Note Example on Mood Disorders)

Case Formulation and Treatment Plan

Start Lithobid 900 mg/day PO divided q12. Lithobid is considered the gold standard for bipolar disorder and is FDA-approved. Effective in preventing relapse, and managing acute episodes (mania, hypomania, and depression), leading to good quality of life, community participation, and preventing morbidities (Volkmann et al., 2020).

Refer the client for cognitive behavioral therapy (CBT). CBT reduces relapse rates, manages depressive symptoms, reduces mania severity, and improves cognitive function (Chiang et al., 2017). CBT will help the client identify triggers of BP, negative attitudes, and behavior and substitute them with positive ones. (Comprehensive Soap Note Example on Mood Disorders)

Recommend the National Alliance for mental illness (NAMI) local chapter. NAMI support bipolar individuals and their families, helping them find community resources. NAMI HelpLine at 1-800-950-NAMI (6264) for information on bipolar disorder. Follow up with the client after four weeks. (Comprehensive Soap Note Example on Mood Disorders)

References

American Psychiatric Association. (2019). Diagnostic and statistical manual of mental disorders (7^th ed.). American Psychiatric Publishing, Inc.   

Allen, D. N., & Becker, M. L. (2019). Diagnostic and symptom interviews for adults. In Handbook of psychological assessment (pp. 355-393). Academic Press.

Kinrys, G., Bowden, C. L., Nierenberg, A. A., Hearing, C. M., Gold, A. K., Rabideau, D. J., … & Reilly-Harrington, N. A. (2019). Comorbid anxiety in bipolar CHOICE: Insights from the bipolar inventory of symptoms scale. Journal of affective disorders, 246, 126-131. https://doi.org/10.1016/j.jad.2018.12.039

Chiang, K. J., Tsai, J. C., Liu, D., Lin, C. H., Chiu, H. L., & Chou, K. R. (2017). Efficacy of cognitive-behavioral therapy in patients with bipolar disorder: A meta-analysis of randomized controlled trials. PloS one, 12(5), e0176849. https://doi.org/10.1371%2Fjournal.pone.0176849

Volkmann, C., Bschor, T., & Köhler, S. (2020). Lithium treatment over the lifespan in bipolar disorders. Frontiers in Psychiatry, 11, 377. https://doi.org/10.3389/fpsyt.2020.00377