RUNNING HEAD: CASE STUDY: ADOLESCENT DEPRESSION 1

Case Study: Adolescent Depression

Kayla Sterling
Mental Health Clinical
Youngstown State University
CASE STUDY: ADOLESCENT DEPRESSION 2

Abstract
SA an adolescent female was admitted to Belmont Pines Hospital to be in a safe

therapeutic environment due to her suicidal ideation with a plan. She has a very long history of

bullying in both schools she has attended. She has not been able to handle the stress of being

bullied which has caused her to develop depression and disruptive mood dysregulation disorder.

She had not been compliant with her antidepressant medication, which could have caused her

suicidal ideation to increase. She is depressed, suicidal, has poor social skills and poor impulse

control. She has trouble sleeping and has been seeing figures at nighttime. Due to precipitating

events, SA needed to be hospitalized at Belmont Pines to get her mental health to a stable and

safe place.
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Psychiatric Mental Health Comprehensive Case Study

Objective Data

SA, 16 year old female, was admitted to Belmont Pines Hospital – Acute care setting on

September 27th, 2019. Her mother had taken her to the emergency room earlier that day because

she was starting to have a breakdown at her new school. SA has an extensive history of bullying

and recently moved to a new school because of the severity of the bullying. She texted her

mother while she was at school stating that she could not handle the stress of bullying any longer

and that she wanted to kill herself. She told the nurses that she had planned on slitting her throat

or hanging herself and she wanted to do it that night. She stopped responding to her mother’s text

messages, so her mother picked her up from school and took her to the emergency room where

she was eventually recommended to spend the week at Belmont Pines. She had been diagnosed

with disruptive mood dysregulation disorder, major depressive disorder, social phobia, suicidal

ideation, insomnia, and has a history of epilepsy. Her lab results were drawn and are as follows:

cholesterol 194, triglycerides 151, HDLs 38, and LDLs 126. All of them are elevated except for

the HDLs, which are low. She was taking 10mg of Prozac prior to her hospitalization, but stated

she forgets to take them or had not been taking them regularly. Prozac is an antidepressant used

to treat major depression. The doctor increased her dose of Prozac to 20mg daily. She also is

taking Keppra 500mg twice a day for her seizure disorder. She was also prescribed melatonin

3mg daily at the hours of sleep to relieve her insomnia. During her stay she has attended group

therapy, sees the doctor daily, and is under unit restrictions as well as self-harm precautions.

Treatments will include medication compliance and attending the Family Resource Center in

Salem for counseling and therapy appointments. Prior to her hospitalization, she was feeling

hopeless, depressed, suicidal. She has been struggling with social skills and impulse control. On

October 1st, she stated that she was feeling happy and that she felt the medications were helping
CASE STUDY: ADOLESCENT DEPRESSION 4

her overall mood. These statements were congruent with the affect that she displayed while

talking with her.

Summary of psychiatric diagnoses

SA has four current psychiatric diagnoses. Those diagnoses are disruptive mood

dysregulation disorder, major depressive disorder, social phobia, and insomnia related to the

stressors in her life. Disruptive Mood Dysregulation Disorder (DMDD) is a childhood condition

of extreme irritability, anger, and frequent intense temper outbursts (National Institute of Mental

Health, 2019). A child with DMDD will experience an irritable or angry mood most of the day,

almost every day, severe temper outbursts three or more times per week, trouble functioning due

to the irritability (National Institute of Mental Health, 2019). Major Depressive Disorder is

characterized by depressed mood or loss of interest or pleasure in usual activities. (Morgan and

Townsend, 2017). Patients who are diagnosed with Major Depressive Disorder have five or more

symptoms that have been present during the same two week period and have changed their level

of functioning. These symptoms include, depressed mood most of the day, nearly every day,

diminished interest in activities, significant weight loss or weight gain, insomnia or hypersomnia,

psychomotor agitation, fatigue, feelings of worthlessness, diminished ability to concentrate, and

suicidal ideation (Morgan and Townsend, 2017). “The point prevalence of adolescent depression

in North America is 3% to 8%, with a lifetime prevalence of 20% by the time the adolescent

transitions into adulthood” (Lorna Bennett RN, MN, 2012). This quote shows healthcare

providers that the depression rates are increasing. She also stated that there is a higher incidence

of depression among girls following the onset of puberty. Depression can become associated

with higher rates of substance abuse and an increased risk of suicide (Lorna Bennett RN, MN,

2012). Social phobia is an anxiety disorder that is characterized by an intense fear of being
CASE STUDY: ADOLESCENT DEPRESSION 5

judged, negatively evaluated, or rejected in a social situation (Anxiety and Depression

Association of America, 2018). SA’s social phobia is most likely to her long history of bullying

in school and never being able to escape from the bullies. Insomnia is the inability of sleeping or

staying asleep at night. SA stated that she hasn’t been able to sleep since watching the Annabelle

Doll movie, but the insomnia could also be related to the stress that she hasn’t been able to get

under control.

Stressors and behaviors that precipitated current hospitalization

The biggest stressor in SA’s life is bullying. It is heavily affecting her ability to function,

and she hasn’t been able to cope with the bullying. She has experienced bullying most of her

childhood. One key risk factor for suicide is bullying victimization, including electronic and

school bullying victimization (Nancy Pontes, Cynthia Ayres, Manuel Pontes, 2015). The Health

Behavior in School-Aged Children Survey (1997-1998) holds some of the earliest data on

bullying and negative outcomes. This study showed a positive association between bullying

victimization and negative psychosocial adjustment (Nancy Pontes, Cynthia Ayres, Manuel

Pontes, 2015). She stated that her previous school did not do anything about the bullying, so her

mom needed to move her to a different school. She had been home-schooled for some time due

to her epileptic episodes, but now they are under control. She recently moved to Salem High

School a week ago from Thursday, but the bullying had started already at her new school. She

has a twin sister that she has been inseparable with, but they do not have classes together at this

new high school. That is another stressor for SA because she is used to being with her sister all

the time and feels more comfortable around her sister. Another stressor that could be causing her

suicidal ideation and depression is the loss of her paternal grandmother. SA seems to place an
CASE STUDY: ADOLESCENT DEPRESSION 6

importance on her family, and they are a big support system for her. So, losing a grandparent has

been another big life event that potentially is precipitating her events.

Patient and Family History of mental illness

No family history of mental illness was noted in SA’s documentation. But, when

speaking with her, she revealed that her mother is also struggling with depression. She stated,

“that’s where I get it from, my mother”. A study done by Weissman MM, et al. (2016) showed

that a family history of depression doubles the risk for depression. “Biological children of

parents with depression had significantly higher risk for major depressive disorder, any

disruptive disorder, substance dependence, any suicidal ideation or gesture, and poor functioning

compared to children without depression” (Weissman MM, et al. 2016). Those statistics showed

a 95% risk. Her mother is also taking Prozac to manage her depression. When asked, SA stated

that it does bother her to see her mother depressed. Seeing her mother depressed, ultimately can

affect her depression because seeing her mother sad can make her feel the same way from being

in this environment. SA stated that no one else in her immediate family is struggling with a

mental illness or any form of substance abuse.

Psychiatric Evidence Based Nursing Care

While at Belmont Pines Hospital, SA attended all the group therapy sessions. She explained that

she had learned some healthy coping mechanisms and the importance of medication compliance.

For her, the medication compliance session was probably the most important one because she

hadn’t been taking her antidepressant medication regularly. Belmont Pines Hospital maintains a

milieu environment by providing the children their physical needs first. The nurses and staff

provide a very structured schedule for them, which is important for psychiatric patients.
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Providing group therapy sessions is important, as well as providing their medication on a

schedule. Seeing the doctor every day is also important and they do this at the hospital to keep

the children healthy and monitor the changes of behaviors. Therapeutic nursing care is most

effective when using cognitive behavior therapy with depression diagnoses. Nurses need to focus

on the affect and the way the person is thinking in order to change the patients’ behaviors.

Cognitive behavior therapy focuses on distorted thinking and the belief systems contributing to

sad affect and mood (Lorna Bennett RN, MN 2012).

Ethnic, Spiritual, and Cultural Influences

SA is a Caucasian, heterosexual female. She is in 10th grade and recently moved to Lima

Senior High School. Culturally, she doesn’t have anything major that would impact her health

status or diagnoses. Spiritually, she does believe in God. She doesn’t have a specific

denomination that she identifies herself with, but she does believe that some type of greater

power exists. She doesn’t attend church regularly. When she does go to a church service, she

said the specific church doesn’t matter and that she could go to any church service.

Psychosocially, she seems to have a good support system. She lives with her mom, stepdad, and

twin sister. She has several older siblings, also, that she gets along with well. Her closets

relationships are between her mom and her twin sister. She feels that she can talk to them about a

lot of topics, if not everything. Her sister is someone who helps her with her outbursts and

suicidal ideation. She has stopped her from harming herself and talked her out of her thoughts of

killing herself. Her mom is involved with her care. She has hidden the items that SA could

potentially harm herself with and wants to make sure she is taking her medication now. Some

coping mechanisms that SA likes to do when she is feeling stressed are listening to music,
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coloring, writing, baking cakes, making pudding, doing dishes, drawing, and playing video

games.

Patient Outcomes

The nurses came up with some patient outcomes during her stay to help her learn ways to

handle her depression in a healthy way. One of the outcomes is to identify at least two things that

are bothering her besides being away from her sister in the classrooms. She should also identify

at least two positive activities that she can do to relax her and relieve her from stressful

situations. During her hospitalization, one outcome is to talk with her doctor every day and let

him know if she is continuing to have thoughts of suicidal ideation. It is important for her talk to

her provider if she is still having suicidal thoughts because the health care providers need to keep

her in a safe environment until she is able to cope with those thoughts and feelings. An outcome

that she can use at home is to identify at least two way her family can help with her self-harm

behaviors and with her experiences with bullying. A very important part of recovery is having a

great support system. If she is able to incorporate her family into her daily care, she will be able

to feel better and cope a little easier. The number one intervention the nurses can do to help her is

making sure her medications are working effectively and to identify if the medication dosages

need changed. She will also be on a safety plan to prioritize her safety.

Summary of Discharge Plans

SA’s discharge instructions are to have little to no suicidal ideation. She needs to be

committed to her therapy appointments to help her cope with her depression. Her therapy

sessions will be scheduled at the Family Resource Center in Lima. Medication management is

important for her to maintain a mood balance in her life. One way the nurses can help her stay
CASE STUDY: ADOLESCENT DEPRESSION 9

compliant is by keeping a medication box with the days of the week on it. This way she will be

able to visualize if she forgot to take her medications. She could also set reminders on an

electronic device. Lastly, she should keep up with the coping mechanisms she has learned and

continue the healthy ones that work for her.

Prioritized list of actual diagnoses

1. Risk for Violence: Self-Directed as evidenced by agitated behaviors and verbal threats against

self (suicidal threats).

2. Risk for suicide as evidenced by suicide plan.

3. Impaired Social Interaction related to fear of rejection as evidenced by dysfunctional

interaction of peers and social phobia.

4. Chronic Low Self-Esteem related to biochemical/neurophysiological imbalances evidenced by

repeated expression of worthlessness.

5. Social Isolation related to past experiences of difficulty in interaction with others as evidenced

by insecurity in public (school).

6. Insomnia related to anxiety and depression as evidenced by interrupted sleep due to watching

the Annabelle doll movie.

Potential Nursing Diagnoses

1. Risk for Injury

2. Ineffective Individual Coping
3. Self-Care Deficit
4. Disturbed Thought Processes
5. Interrupted Family Processes
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Conclusion

In conclusion, SA is a 16 year old female that was admitted to Belmont Pines Hospital

for suicidal ideation, depression, and disruptive mood dysregulation disorder. She came to the

hospital because she was not able to handle the stress of being bullied and the effect this has been

having on her as been significant. She had come up with a plan to kill herself the night of

September 27th, so her mom needed to take her to a hospital to keep her safe and help her get

better. While at Belmont Pines, she started to feel better and happy due to being on a medication

schedule and in a therapeutic environment. She has learned that she needs to be compliant with

her medications and ways to use coping mechanisms in a healthy way. Hopefully, keeping her on

a correct dosage and schedule of medication, along with therapy sessions at the Family Resource

Center in Lima, SA will make a healthy recovery.

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References

Bennett, Lorna R., RN, MN. (2012). Adolescent Depression: Meeting Therapeutic Challenges

Through an Integrated Narrative Approach. Journal of Child and Adolescent Psychiatric

Nursing. Retrieved on 04 October 2019 from http:/journals.ohiolink.edu.

Disruptive Mood Dysregulation Disorder. National Institute of Mental Health. Retrieved on 03

October 2019 from https://www.nimh.nih.gov/health/topics/disruptive-mood-dysregulation-

disorder-dmdd/disruptive-mood-dysregulation-disorder.shtml

Martin, Paul, BSN, RN. (2016). 6 Major Depression Nursing Care Plans. Nurselabs. Retrieved

on 03 October 2019 from https://nurseslabs.com/major-depression-nursing-care-plans/4/

Pontes, Nancy M.H., Ayres, Cynthia G., Pontes, Manual C.F. (2018). Additive Interactions

Between Gender and Bullying Victimization on Depressive Symptoms and Suicidality:

Youth Risk Behaviors Survey 2011-2015. Nursing Research. Volume 67. 2018. Pp 430-

438.

Social Anxiety Disorder. Anxiety and Depression Association of America. Retrieved on 03

October 2019 from https://adaa.org/understanding-anxiety/social-anxiety-disorder

Townsend, M. C., & Morgan, K. I. (2020). Essentials of psychiatric mental health nursing:

concepts of care in evidence-based practice. Philadelphia: F.A. Davis Company.

Weissman MM, et al. (2016). Family history of depression doubles risk for depression. Healio

Psychiatry. Retrieved on 04 October 2019 from

http:/healio.com/psychiatry/depression/news/online.