Name
Purdue University Globle
NU566 NP I – Introduction to Primary Care for the Nurse Practitioner
Prof. Name
Date
Jerome’s symptoms are most concerning for recurrent depressive symptoms occurring alongside anxiety, insomnia, occupational stress, and increasing alcohol consumption. Although the information currently available is not sufficient to confirm Major Depressive Disorder (MDD), his six-week history of fatigue, low motivation, sleep disruption, and depressed mood warrants a comprehensive biopsychosocial assessment. The clinical approach should include depression and anxiety screening, suicide risk assessment, evaluation for medical conditions that can mimic depression, assessment of alcohol use, and development of an individualized treatment plan. Early evidence-based intervention can reduce symptom severity, improve daily functioning, and lower the risk of worsening depression or substance-related problems.
Jerome is a 35-year-old welder who lives with his partner and two young children. He presents to primary care with approximately six weeks of persistent fatigue, low energy, decreased motivation, and disrupted sleep. Although he feels overwhelmed by occupational stress, he continues to work.
A significant concern is his recent increase in alcohol consumption. Jerome previously drank approximately twice a week but is now drinking three bottles of beer every evening to cope with difficulty sleeping. This change is clinically important because alcohol can interfere with sleep quality and may contribute to or worsen depressive and anxiety symptoms.
Jerome also has a history of anxiety, panic attacks, and moderately severe depression. His previous depressive episode responded well to sertraline. He completed approximately six months of treatment five years ago, discontinued the medication, and subsequently remained symptom-free without additional mental health follow-up.
During the current examination, Jerome appears sad, emotionally withdrawn, and apathetic, although his physical examination is otherwise unremarkable. Taken together, these findings raise concern for a recurrence of depression with associated anxiety symptoms. His increased alcohol consumption may be both a coping mechanism and a factor contributing to his current symptoms.
The first step should be establishing a supportive therapeutic relationship that encourages Jerome to discuss his emotional health openly. Depression and anxiety assessments are more effective when patients feel comfortable discussing sensitive subjects such as alcohol consumption, suicidal thoughts, family responsibilities, financial concerns, and workplace stress.
The clinician should obtain a detailed psychiatric and psychosocial history that explores previous episodes, current symptoms, functional impairment, treatment history, and potential risk factors.
Important areas of assessment include:
Previous depressive and anxiety episodes
Current occupational and family stressors
Sleep patterns and changes in daily functioning
Alcohol and other substance use
Family history of mental health disorders
Previous response to antidepressant therapy
Medication adherence and reasons for discontinuation
History of suicidal thoughts, self-harm, or suicide attempts
Available family and social support
Because Jerome previously responded positively to sertraline, it is also important to determine why treatment was discontinued and whether there were concerns about adverse effects, adherence, access to care, or the perception that treatment was no longer necessary.
A complete assessment should not automatically attribute Jerome’s fatigue and low motivation to depression. Medical conditions, medications, substance use, sleep disorders, and psychosocial stressors can produce similar symptoms.
Validated screening instruments can help identify symptom severity and establish a baseline for monitoring treatment response. However, screening tools should support—not replace—clinical judgment and diagnostic interviewing.
The Patient Health Questionnaire-9 (PHQ-9) is widely used in primary care to identify depressive symptoms and estimate their severity. It can also be repeated over time to evaluate whether symptoms are improving during treatment.
The Generalized Anxiety Disorder-7 (GAD-7) is commonly used to screen for anxiety symptoms and assess their severity. Given Jerome’s history of anxiety and panic attacks, evaluating current anxiety symptoms is particularly important.
The Alcohol Use Disorders Identification Test–Consumption (AUDIT-C) can help determine whether Jerome’s recent drinking pattern represents hazardous alcohol consumption. His change from drinking twice a week to consuming alcohol every evening warrants further assessment rather than being viewed simply as a sleep aid.
Other instruments, such as the Quick Inventory of Depressive Symptomatology–Self Report (QIDS-SR), may also be useful when a more detailed evaluation of depressive symptom severity is appropriate.
Screening results should be interpreted alongside a clinical interview and the diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR).
Suicide risk assessment is an essential component of evaluating any patient with significant depressive symptoms. Jerome should be asked directly and nonjudgmentally about suicidal thoughts and other indicators of self-harm risk.
The assessment should consider:
Current suicidal thoughts or ideation
Intent to act on suicidal thoughts
Specific plans
Previous suicide attempts or self-harm
Access to firearms, medications, or other lethal means
Substance use
Protective factors
Family and social support
Immediate safety concerns
A patient should not be assumed to be at low risk simply because suicidal thoughts were not mentioned spontaneously. Direct questioning can help identify risk that may otherwise remain undisclosed.
If Jerome reports active suicidal intent, a specific plan, or an inability to remain safe, immediate safety intervention and appropriate emergency or crisis services would take priority over routine outpatient follow-up.
Depression is a clinical diagnosis, but several medical conditions can produce symptoms that resemble depression. Jerome’s fatigue, low energy, and sleep disturbance therefore warrant evaluation for potential physiological contributors.
Potential differential diagnoses include:
Hypothyroidism
Iron-deficiency anemia
Vitamin B12 deficiency
Vitamin D deficiency
Diabetes mellitus
Chronic liver disease
Chronic kidney disease
Cardiovascular disease
Chronic infections
Neurological disorders
Obstructive sleep apnea
The clinician should also review prescription and nonprescription medications because some medications can contribute to fatigue or mood changes.
Alcohol-related problems should be considered as part of the differential assessment. Jerome’s increased alcohol consumption may worsen sleep quality and mood and may complicate treatment of an underlying depressive or anxiety disorder.
The available information does not yet establish that Jerome meets the full diagnostic criteria for Major Depressive Disorder.
Under DSM-5-TR criteria, a major depressive episode generally requires at least five symptoms during the same two-week period. At least one symptom must be depressed mood or markedly diminished interest or pleasure.
Based on the information provided, Jerome currently demonstrates:
Depressed mood
Fatigue or decreased energy
Sleep disturbance
However, several other diagnostic symptoms have not yet been adequately assessed. These include:
Loss of interest or pleasure in activities
Appetite or weight changes
Feelings of worthlessness or excessive guilt
Difficulty concentrating or making decisions
Psychomotor agitation or retardation
Recurrent thoughts of death or suicide
His symptoms may ultimately meet the criteria for MDD after a more detailed assessment, but it would be premature to make that diagnosis based solely on the information currently available.
The clinician should also consider whether alcohol use, a medical condition, or another psychiatric disorder better explains some or all of his symptoms.
A comprehensive evaluation should address both psychological and physical contributors to Jerome’s presentation.
Depending on his history and examination findings, laboratory evaluation may include:
Complete blood count (CBC)
Thyroid-stimulating hormone (TSH)
Comprehensive metabolic panel (CMP)
Blood glucose or hemoglobin A1c
Vitamin B12
Vitamin D when clinically indicated
Iron studies when anemia or iron deficiency is suspected
Liver function testing, particularly given increased alcohol consumption
Laboratory testing should be individualized rather than performed automatically as a substitute for psychiatric assessment. Additional diagnostic testing should be guided by symptoms, medical history, physical findings, and risk factors.
If Jerome is ultimately diagnosed with a depressive or anxiety disorder that warrants medication, his previous positive response to sertraline is clinically relevant. Restarting an SSRI such as sertraline could be considered after reassessing his current diagnosis, treatment preferences, alcohol use, medical history, and potential contraindications.
SSRIs are commonly used as first-line pharmacologic treatments for depression and several anxiety disorders.
Patient education should include the following:
Therapeutic improvement may take several weeks.
Some adverse effects can occur early in treatment and may decrease over time.
Medication should be taken consistently as prescribed.
Antidepressants should not be stopped abruptly without discussing discontinuation with a healthcare professional.
Follow-up is important for evaluating symptom response, adverse effects, adherence, and safety.
Because alcohol use has increased substantially, Jerome should also receive counseling about reducing or avoiding alcohol and should be assessed for problematic alcohol use and possible withdrawal risk if he is drinking heavily or has developed dependence.
Psychotherapy should be considered an important component of Jerome’s treatment plan. Evidence-based psychological interventions can be used alone in some circumstances or combined with medication when clinically appropriate.
Potential approaches include:
Cognitive Behavioral Therapy (CBT)
Behavioral activation
Problem-solving therapy
Interpersonal therapy
CBT may be particularly useful because it addresses unhelpful thought patterns and behaviors associated with depression and anxiety. Behavioral activation can also help patients gradually reintroduce meaningful and rewarding activities when depression has reduced motivation.
A referral to a qualified mental health professional should be considered based on symptom severity, patient preference, available services, and clinical need.
Lifestyle changes can complement psychotherapy and medication and may help Jerome develop healthier strategies for managing occupational and family stress.
Key recommendations include:
Reduce or avoid alcohol consumption.
Establish a consistent sleep and wake schedule.
Engage in regular physical activity as tolerated.
Maintain a balanced and nutritious diet.
Reintroduce enjoyable or meaningful activities.
Strengthen supportive relationships with family and friends.
Develop healthier stress-management strategies.
Address workplace stressors when possible.
Alcohol should not be relied upon as a treatment for insomnia. Although it may initially make someone feel sleepy, alcohol can disrupt normal sleep patterns and contribute to poorer sleep quality.
Close follow-up is particularly important during the early stages of treatment. Monitoring allows clinicians to identify worsening symptoms, medication adverse effects, adherence problems, alcohol-related concerns, or emerging suicide risk.
Follow-up should include:
Reassessment shortly after treatment begins or symptoms significantly worsen
Monitoring of medication adherence and adverse effects
Repeated PHQ-9 and GAD-7 assessments when appropriate
Ongoing suicide risk assessment
Monitoring alcohol consumption
Evaluation of sleep and daily functioning
Adjustment of treatment according to clinical response
Treatment should be individualized rather than based solely on a numerical screening score.
Jerome’s presentation is most consistent with recurrent depressive symptoms accompanied by anxiety, sleep disturbance, occupational stress, and increased alcohol use, but further assessment is required before confirming Major Depressive Disorder.
The most important clinical priorities are to:
Complete a comprehensive mental health assessment.
Use validated tools such as the PHQ-9, GAD-7, and AUDIT-C.
Assess suicidal thoughts and other safety concerns.
Evaluate potential medical contributors to fatigue and mood changes.
Assess the relationship between alcohol use, sleep disturbance, anxiety, and depression.
Consider psychotherapy and antidepressant therapy when clinically indicated.
Address sleep, alcohol consumption, physical activity, stress, and social support.
Maintain close follow-up during treatment.
A biopsychosocial approach is especially important because Jerome’s symptoms may be influenced by several interacting factors rather than a single diagnosis.
Jerome appears to have recurrent depressive symptoms with associated anxiety, sleep disturbance, and increased alcohol use. However, the available information is insufficient to confirm Major Depressive Disorder. A complete psychiatric assessment is needed to determine whether he meets DSM-5-TR diagnostic criteria.
The PHQ-9 is one of the most commonly used depression screening and symptom-monitoring instruments in primary care. It can help quantify symptom severity and monitor changes over time, but a positive result should be followed by clinical assessment.
Jerome’s alcohol use has increased from occasional drinking to three beers every evening. Alcohol can contribute to sleep disruption, worsen depressive symptoms, increase health risks, and complicate treatment. Screening can help determine whether additional intervention is needed.
Conditions such as hypothyroidism, anemia, vitamin deficiencies, diabetes, chronic liver or kidney disease, sleep apnea, neurological disorders, and other chronic illnesses can cause fatigue, low energy, cognitive changes, or mood symptoms.
Sertraline previously worked well for Jerome, making it a potential treatment option if he is again diagnosed with a condition for which an SSRI is appropriate. However, restarting medication should follow a current clinical assessment, consideration of his alcohol use and medical status, and discussion with the prescribing clinician.
Patients may not always spontaneously disclose suicidal thoughts. Direct, respectful assessment can identify previously unreported risk factors and helps clinicians determine whether additional safety measures or urgent intervention are necessary.
Jerome’s six-week history of depressed mood, fatigue, low motivation, and disrupted sleep, combined with his history of depression and anxiety, raises significant concern for a recurrence of depressive symptoms. His increased alcohol consumption and occupational stress may further contribute to his current presentation. However, the available symptoms do not independently establish a diagnosis of Major Depressive Disorder.
The appropriate approach is a comprehensive biopsychosocial assessment that includes validated depression and anxiety screening, suicide risk assessment, alcohol-use evaluation, consideration of medical causes, and review of previous treatment response. Depending on the completed assessment, treatment may include psychotherapy, an SSRI such as sertraline, lifestyle interventions, alcohol-use counseling, and regular follow-up. Early recognition and individualized treatment can improve functioning, reduce symptom severity, and support long-term recovery.
American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.; DSM-5-TR). American Psychiatric Association Publishing. https://doi.org/10.1176/appi.books.9780890425787
Maurer, D. M., Raymond, T. J., & Davis, B. N. (2018). Depression: Screening and diagnosis. American Family Physician, 98(8), 508–515. https://www.aafp.org/pubs/afp/issues/2018/1015/p508.html
U.S. Preventive Services Task Force. (2023). Screening for depression and suicide risk in adults: U.S. Preventive Services Task Force recommendation statement. JAMA, 329(23), 2057–2067. https://jamanetwork.com/journals/jama/fullarticle/2806228
American Psychiatric Association. (2010). Practice guideline for the treatment of patients with major depressive disorder (3rd ed.). American Journal of Psychiatry, 167(10 Suppl.), 1–152. https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/mdd.pdf
National Institute on Alcohol Abuse and Alcoholism. (2024). Understanding alcohol use disorder. National Institutes of Health. https://www.niaaa.nih.gov/publications/brochures-and-fact-sheets/understanding-alcohol-use-disorder
