Diagnosis
Jane is suffering from major depressive disorder (MDD) or simply depression. This diagnosis is made using the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Symptoms of depression include weight loss or gain, sleeplessness, loss of interest in different activities, restlessness and being agitated, feeling sluggish and having physical or mental slow down, tiredness or lack of energy, feeling worthless, suicidal thoughts, and trouble concentrating. According to DSM-5, for a patient to be diagnosed with MDD, he or she should have five or more of these symptoms within 2 weeks (Tolentino & Schmidt, 2018). However, one of the primary symptoms should be either loss of interest or pleasure (anhedonia) or depressed mood. In this case, Jane is showing anhedonia, as she says that she has barely left the house for one month since the death of her husband, Jake. She is also showing signs of exhaustion, sleeplessness due to nightmares, loss of appetite as she is barely eating, and is in a depressed mood. Therefore, based on the DSM-5 criterion, Jane is diagnosed with MDD because she meets all the conditions laid out for someone suffering from this condition.
My Biggest Concern
The biggest concern for Jane is her four-month pregnancy. According to Qu et al. (2017), psychological stress is positively associated with an increased risk of miscarriage. In this case, Jane is 16 weeks pregnant, which makes her a prime candidate for miscarriage due to her psychological condition. Qu et al. (2017) state that some of the psychological issues that could lead to miscarriage include emotional trauma, lack of money, marital disharmony, pressure from work, and social problems, among other emotionally strenuous occurrences. Jane is suffering from emotional trauma after the death of her husband a month ago. Additionally, her depression could be exacerbated by the fact that she is pregnant through the peripartum onset. Therefore, her MDD should be addressed first to ensure that all other issues fall in place. If her condition is managed well, her pregnancy would no longer be at risk, and her 18-month-old son, James, would not be exposed to the dangers associated with being taken care of by a depressed person. In other words, everything else around Jane depends on her mental well-being, which explains why the condition should be addressed first.
Pharmacological and Non-pharmacological Interventions
The choice of pharmacological and non-pharmacological interventions that could be suggested for Jane depends on her state of being pregnant for four months. The common pharmacological intervention for depression during pregnancy would be antidepressants such as monoamine oxidase inhibitors (MAOIs), serotonin and norepinephrine reuptake inhibitors (SNRIs), tricyclic antidepressants (TCAs), and Selective serotonin reuptake inhibitors (SSRIs) (Epstein, Moore, & Bobo, 2014). In most cases, patients are started on SSRIs because they are considered safer, and they have lesser side effects as compared to the others. Examples of these drugs include citalopram, Prozac, Zoloft, and Lexapro (Mayo Clinic, 2018). If SSRIs do not work, SNRIs are recommended, and they include duloxetine, Fetzima, Pristiq, and Effexor XR, among others. In cases where SSRIs and SNRIs have not worked, TCAs could be prescribed. However, despite being very effective, this class of antidepressants has more severe side effects as compared to other drugs. MAOIs would not be prescribed to Jane as the drugs have serious side effects, and given her pregnancy, it would be unsafe for her to take these antidepressants. These drugs would help Jane maintain euthymia during her pregnancy, thus reducing the risk of miscarriage.
The available non-pharmacological interventions for Jane include psychotherapy and phototherapy. According to Epstein et al. (2014), the common types of psychotherapy are interpersonal therapy and cognitive-behavioral therapy (CBT). Interpersonal therapy involves improving coping skills and social interactions. In a study carried out by Epstein et al. (2014), it was established that pregnant women undergoing interpersonal therapy for depression showed improved results as compared to the control group that did not receive any form of intervention.
On the other hand, CBT focuses on helping patients to adjust their self-detrimental thought processes. However, in most cases, CBT is preferred in the management of postpartum depression. Nevertheless, the study by Epstein et al. (2014) showed that using CBT to manage perinatal depression showed greater improvements in depressive symptoms as compared to standard care. Phototherapy or immunotherapy involves exposing patients to bright light for at least one hour a day for about 5 weeks as a way of managing depression. Other therapies include alternative medicine treatments such as acupuncture and massage. Repetitive transcranial magnetic stimulation (rTMS) could also be used in Jane’s case. According to Epstein et al. (2014), a study conducted on the effectiveness of rTMS treatment in the management of depression in pregnant women showed that this technique reduces symptoms significantly without side effects to the unborn child.
Issues Influencing Decision-making on Pharmacological Intervention
The use of any form of drugs during pregnancy should be considered carefully due to the potential risks of exposing the same to the unborn child. One of the issues that influence my decision-making process relative to pharmacological interventions for Jane would be the effects of the recommended drugs on the pregnancy. According to Bérard, Zhao, and Sheehy (2017), exposure to antidepressants during the second and third trimesters could lead to embryotoxicity, which is associated with health defects in fetuses commonly known as congenital malformations. Jane’s pregnancy is 16 weeks old, and thus she is in her second trimester, which places her unborn child at the risk of embryotoxicity. The commonly used antidepressants during pregnancy can cross the placenta and enter the fetus’ blood to cause developmental complications. Epstein et al. (2014) note that exposure to paroxetine and fluoxetine is closely linked with heart defects in unborn children. Therefore, before making any decision on the appropriate pharmacological intervention for Jane, I would consider the associated side effects for each drug. I would actually consider non-pharmacological interventions before recommending any drugs for her condition.
Intervention for James
I think James warrants an intervention given that he is aged 18 months and “the rapid changes in emotional and cognitive development make children especially vulnerable to the effects of maternal depression during this time” (Goodman & Garber, 2017, p. 368). James is too young to participate in any meaningful intervention in the absence of his mother. Therefore, the best form of intervention would be toddler-patient psychotherapy (TPP). The aim of this therapy is to improve parenting so that toddlers could have healthy development and secure attachment (Goodman & Garber, 2017).
In this case, I would recommend Jane and James to attend joint therapy sessions to promote positive relations between them. Currently, the two seem to be doing well because Jane says that she remains indoors to take care of James because he is what has remained of Jake. However, she also admits that she does not have the energy to face life alone. Therefore, James needs to feel protected and have trust that his mother will always be available for him no matter what happens. As such, Jane needs to become more accepting of her situation and trust her parenting capabilities. These tasks are based on the second stage (autonomy vs. shame/doubt) of Erikson’s theory. According to Chavez (2016), children at the age of James start developing autonomy to become independent individuals. In this case, Jane should guide and support James to initiate healthy exploration and self-control in the absence of Jake.
Military and Government Resources for Jane
As a military wife, Jane could seek help from the U.S. Department of Veteran Affairs using the following link. She may qualify for health care services under programs such as TRICARE, the Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA), and the Program of Comprehensive Assistance for Family Caregivers.
Community Resources for Families of Veterans Killed in Combat
In Miami, young widows, widowers, and families of veterans killed in combat could access help in the different VA health clinics in the area. Some of these include Miami Flagler VA Clinic, 1492 West Flagler Street Suite 102 Miami, FL 33135-2209, Bruce W. Carter Department of Veterans Affairs Medical Center Facility, 1201 Northwest 16th Street Miami, FL 33125-1624, Hollywood VA Clinic Facility, 3702 Washington Street Suite 201 Hollywood, FL 33021-8283, and Pembroke Pines VA Clinic Facility, 7369 Sheridan Street Suite 102 Hollywood, FL 33024-2776. Others include Homestead VA Clinic Facility, 950 Krome Avenue Suite 401 Homestead, FL 33030-4443, William “Bill” Kling Department of Veterans Affairs Outpatient Clinic, 9800 West Commercial Boulevard Sunrise, FL 33351-4325, Deerfield Beach VA Clinic, 2100 Southwest 10th Street Deerfield Beach, FL 33442-7690, Boca Raton VA Clinic, 901 Meadows Road Boca Raton, FL 33433-2300, Key Largo VA Clinic, 105662 Overseas Highway Key Largo, FL 33037-3010, and Delray Beach VA Clinic, 4800 Linton Boulevard Suite E300 Delray Beach, FL 33445-6597. All these facilities offer mental health services for veterans and their families.
References
BĂ©rard, A., Zhao, J.-P., & Sheehy, O. (2017). Antidepressant use during pregnancy and the risk of major congenital malformations in a cohort of depressed pregnant women: An updated analysis of the Quebec Pregnancy Cohort. BMJ Open, 7(1), 1-13. Web.
Chavez, R. (2016). Psychosocial development factors associated with occupational and vocational identity between infancy and adolescence. International Journal of Early Childhood, 1(4), 307-327.
Epstein, R. A., Moore, K. M., & Bobo, W. V. (2014). Treatment of nonpsychotic major depression during pregnancy: Patient safety and challenges. Drug, Healthcare and Patient Safety, 6, 109-129. Web.
Goodman, S. H., & Garber, J. (2017). Evidence-based interventions for depressed mothers and their young children. Child Development, 88(2), 368-377. Web.
Mayo Clinic. (2018). Depression (major depressive disorder). Web.
Tolentino, J. C., & Schmidt, S. L. (2018). DSM-5 criteria and depression severity: Implications for clinical practice. Frontiers in Psychiatry, 9(450), 1-9. Web.
Qu, F., Wu, Y., Zhu, Y. H., Barry, J., Ding, T., Baio, G., … Hardiman, P. J. (2017). The association between psychological stress and miscarriage: A systematic review and meta-analysis. Scientific Reports, 7(1), 1731-1739. Web.