A 48-year-old patient who reports a diagnosis of obsessive-compulsive disorder has transferred to your care after moving from out of state. You are unable to obtain medical records and must rely on the patient for information. During the initial appointment the patient says reports a very stressful home life. She has a school-aged daughter with severe chronic illness who requires 24-7 total care, as well as some other stressors related to her other children and finances. The patient says that for several years she has been in exposure-response therapy with intermittent, inconsistent improvement, and took fluvoxamine 300 mg daily which seemed to help for a while but then stopped. Her primary symptom presentation is related to obsessive thoughts, although there is a strong chronic anxiety and depressive component. The obsessive thought patterns are markedly worse when there is a stressful life event, and she has had periods of relief when things are calmer at home.

Which of the following aspects of her history is a favorable prognostic indicator?

A. Precipitating triggers

B. Reported history of treatment

C. Presence of children in the home

D. Lack of comorbid compulsions

A patient with bipolar I disorder is currently being managed with lithium, 60 mg q.h.s. along with quetiapine 300 mg daily. The patient presents today for follow-up and reports that her mood has been very stable. Her work as a pastry chef has been really stressful around the holiday season, but she has handled it well and has no concerns about any mood deviations, either manic or depressive. She is sleeping approximately 7 hours nightly. Her last blood work was 7 months ago, and at the time there were no alarm findings in her lithium level, renal function tests, TSH, or liver function tests. On physical examination the PMHNP appreciates a fine, symmetrical tremor of the hands that gets worse when the NP asks her to write her name. This finding was not present on previous examinations.

The NP should take which of the following actions?

A. Draw a TSH, lithium level, and metabolic panel with eGFR in the office today

B. Instruct the patient to proceed to the emergency room immediately

C. Hold the lithium and order a lithium level to be drawn in one week.

D. Hold the quetiapine and order a metabolic panel with eGFR in one week.

A 27-year-old patient presents for evaluation at the suggestion of his intimate partner who thinks he might have depression. During the initial evaluation the patient admits that he is often “down,” has a really hard time feeling happy even when really good things happen. He denies any particular precipitating factor and in retrospect thinks he has been like this for “years.” He denies any difficulty sleeping, although says he never really wakes up feeling “well-rested and ready to go.” His appetite is fine, he denies any thoughts of death, suicide or self-harm, and denies a sense of hopelessness about life.

He likes his job with a property management company, although he says it’s not especially exciting. He admits to generally having no mental or physical energy. Sometimes he wants to do things, but cannot get himself to do it. It is beginning to be a problem with his relationship, which is why he made the appointment. He has not medical conditions, takes no medications, and the rest of his history and ROS is within normal limits.

What is the most likely diagnosis?

A. Depressive mood due to substance use disorder

B. Adjustment disorder with depressed mood

C. Major depressive disorder, recurrent

D. Persistent depressive disorder

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