Answer

Major Depression Case Study

This discussion focus on Alejandro, who is a 34-year old Hispanic male returning to the clinic for further diagnosis. The patient claims that he has reduced motivation, sadness, and feels that things are worsening.

Additional Questions

Alejandro has a history of Major Depressive Disorder, according to the DSM-5 diagnosis. However, it is imperative to further examine the increase in the severity of the symptoms and the possibility of new clinical manifestations. Additional questions in this regard include

1. Is your preference staying at home or going out and engaging in new things? This question is aimed at recognizing withdrawal and isolation, which are common depression signs.
2. How is your sleep pattern? Has it changed with medication? This is aimed at evaluating the risks of sleep disturbances.
3. Do you feel hopeless?
4. Do you still feel fatigued and lose energy?
5. Do you have challenges with concentration and decision making?
6. Have you experienced recurrent suicidal ideation or homicidal thoughts?
7. Are you easily irritated?
8. Was the hunting rifle removed? Do you have access to any other weapons?
9. Who do you live with?
10. Do you have any family supervision?

These questions are aimed at evaluating the severity of the depression, the risks, the patient’s social environment, and the effectiveness of Prozac 20 mg.

Diagnosis

The diagnosis remains depression but changes to dysthymia, which is a combination of chronic major depressive disorder and dysthymic disorder. According to Parker and Malhi (2019), this state of depression lasts for more than two years. In Alejandro’s case, he feels like the symptoms have increased, including reduced motivation and heightened feelings of sadness. Besides, he had been diagnosed with the condition when he was in high school.

Medication

Alejandro should continue with the selective serotine reuptake inhibitors (SSRIs), Prozac (fluoxetine). However, the dosage should be increased to 40 mg per day since the symptoms have not improved upon the administration of 20 mg/day dose. Besides the drugs, the patient should undergo cognitive behavioral therapy (CBT) to assist in coping with the symptoms. According to Machmutow et al. (2017), psychotherapy is essential in promoting the patient’s recovery. A combination of the pharmacological and therapeutic intervention is vital in enhancing the individual’s quality of life and reducing a recurrence of the symptoms.