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Running head: MENTAL HEALTH CASE STUDY

Depression and Schizoaffective Disorder: Case Study

Emily Marino

Nursing Department, Youngstown State University

NURS 4842: Mental Health Nursing

Professor Teresa Peck

September 18, 2020

The following case study describes the disease process of a patient that has a chronic history of

depression with suicidal ideation and schizoaffective disorder. The subject of the study is J.H, a

47-year-old Caucasian male that was admitted to the psychiatric unit as a result of command

hallucinations urging him to harm himself. The subject was prescribed various medications to

stabilize his condition upon admission such as anticonvulsants, antipsychotics and

antispasmodics. Various research articles have been collected and reviewed to support the

patient’s case. Nursing care on the unit focused on medication compliance, symptom

management and coping skills. This paper summarizes the diagnoses of depression and

schizoaffective disorder, alongside the patient’s history and background.

Objective Data

J.H is a 47-year-old male patient admitted to the psychiatric floor on September 9, 2020

with a psychiatric diagnosis of depression with suicidal ideation and a chronic diagnosis of

schizoaffective disorder. J.H has previously been admitted to the psychiatric unit and emergency

department numerous times in the past for suicidal ideation and hallucinations.

Upon admission, J.H stated that called a crisis hotline because voices in his head were

telling him to cut his wrists. Police officers arrived at the scene and transported him to the

emergency department in the ambulance. This proves he was involuntarily admitted. After the

patient was stabilized, he was transferred to the psychiatric unit. He was not compliant with his

medications and stated to be experiencing auditory hallucinations.

Upon interviewing the patient on September 11, J.H initially responded to the

conversation within cultural and social norms. With the introduction, he appeared friendly and

open to sharing his personal experiences. His hair was unkept, but dress was neat and appropriate

for the weather. J.H responded appropriately and timely to the broad questions asked. Without

initiation of more specific questions, the patient stated, “Where should I begin?”. From this point

on, the patient touched on many aspects of his past history and struggles with no interjection of

general leads. Firstly, he was able to identify his diagnoses and state what he experiences on a

daily basis because of them. He verbalized that every day he struggles with depression and

finding a purpose to live. J.H stated he stopped taking his medications due to auditory

hallucinations and that is why he was having such difficulties controlling his impulsivities and

feelings. He is unemployed, single and lives with his mother. He stated that he has very few

pleasures in life, one of which is chain-smoking cigarettes on his swing. This indicates poor
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MENTAL HEALTH CASE STUDY
coping skills and lack of initiative to improve his well-being. At this point in the conversation,

J.H was visibly displaying hand tremors and couldn’t stop moving his upper body. This

presented itself as extrapyramidal symptoms as a result of taking antipsychotics and possible

anxiety upon discussing more personal subjects.

The second portion of the interview, J.H was questioned about any previous or current

substance abuse. He stated he started “casually” drinking alcohol around the age of seven and

began heavily drinking from ages ten through fourteen. When asked to specify the reasoning of

these behaviors, the client stated, “I was drugged and molested repeatedly by my cousin’s friend

from the age of ten to fourteen. He threatened to hurt me if I told anyone.” He associated alcohol

with forgetting and blocking these traumatic events. As this conversation unveiled itself, he

continually stated that he has an “addictive personality.” The patient was continually trying to

justify his past habits, even as a young child. This justification of these behaviors created an

unhealthy pattern in this patient’s life. After the age of 21, J.H stated that he advanced to abusing

crystal meth and heroin. He told many stories on near-death experiences, obtaining the drugs and

how it made him feel both physically and mentally. He stated he has been sober since the age of

40 and his sobriety is attributed to “getting sick of the drugs.” He currently is only smoking

cigarettes. By the end of the conversation, J.H had a blunted affect and seemed slightly agitated.

J.H is currently prescribed several medications. In relation to the diagnosis of

schizoaffective and bipolar disorder, he is taking gabapentin (Neurontin) 800mg four times daily.

This drug specifically helps stabilize moods in patients with bipolar disorder. Additionally, J.H is

prescribed Haldol 10 mg two times daily to treat severe agitation and Ativan 1 mg two times

daily to act as a sedative in response to tension, anxiety or to aid in sleep. J.H is prescribed

trihexyphenidyl (Artane) 5 mg two times daily to treat and prevent the worsening of
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MENTAL HEALTH CASE STUDY
extrapyramidal symptoms. This is an antispasmodic that has been given in response to his

prescription to the antipsychotic Haldol. Extrapyramidal symptoms are a side effect of

antipsychotics and characterized by uncontrollable or involuntary muscle movements. Finally,

J.H was prescribed Lipitor, Zestril and Hydrodiuril as preventable treatment of metabolic

syndrome.

Laboratory values were assessed. Firstly, the patient’s blood glucose was routinely

checked for two reasons. J.H is a diabetic and requires insulin. However, a substantial increase in

blood sugar may indicate patient stress. Therefore, it is important to get a baseline blood sugar to

identify any underlying stress and explanation for certain psychotic symptoms. His blood sugar

was trending around 113, which is not elevated enough to the point of concern. The toxicology

report was negative, and this supports his statements of sobriety. His hemoglobin, red blood cells

and hematocrit were all within normal limits. This promotes insight into the patient’s

oxygenation levels. His ALT and AST were within normal limits, indicating that his liver is

functioning normally and efficiently. Finally, his white blood cells were increased at 14.6. This

can be related to the traces of white blood cells and bacteria found in his urine sample. J.H may

have a possible urinary tract infection.

On the day of care, safety and security measures were maintained. J.H was ordered

suicide and self-harm precautions. He was closely monitored, with every fifteen-minute visual

checks. Upon admission, all shoelaces, belts, sharp objects and other dangerous items were

removed from the patient. Limits and standards for behavior were established. With any

escalation in mood or behavior, consequences would have been verbalized and “show of force”

would be obtained by staff. Medication side effects were discussed for patient’s safety. A low

stimulus level was maintained, and adequate staff was present at all times.
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Summary of Depression

The Psychiatric-Mental Health Nursing book defines depression as a mood disorder. In

the text, depression is described as:

Two weeks or more of a sad mood or lack of interest in life activities, with at least four

other symptoms of depression such as anhedonia and changes in weight, sleep, energy,

concentration, decision-making, self-esteem and goals (Videbeck, 2020 pg. 288).

According to the research article Consistency of trajectories of suicidal ideation and

depression symptoms: Evidence from a randomized controlled trial, depression is often

considered to be a strong risk factor for suicidal ideation. Within this research article, increased

use of antidepressants correlated with substantially lower rates of suicidal ideation. However,

depressive states are not the only contributing factor to suicidal ideation. This article states,

“Symptoms of other mental disorders are hopelessness, trauma, substance abuse, physical health

conditions and a range of other psychosocial factors demonstrate clear independent associations

with suicidal thoughts after accounting for depression symptoms,” (Batterham et. al, 2018).

Summary of Schizoaffective Disorder

Schizoaffective disorder is diagnosed when a patient is severely ill and has a mixture of

psychotic and mood symptoms. The symptoms may occur simultaneously, but they could also

alternate between psychotic and mood disorder symptoms. The onset of this disorder can either

be insidious or abrupt. However, most clients diagnosed with schizoaffective disorder develop

signs and symptoms gradually (Videbeck, 2020). The text further states, “…symptoms such as

social withdrawal, unusual behavior, loss of interest in school or at work, and neglect hygiene”

(Videbeck, 2020 pg. 256).

reviewed to support this patient’s case. In this article, it is stated that individuals with these

psychotic disorders are three times more likely to adopt heavy alcohol use. One of the

hypotheses that was created stated that schizoaffective disorder patients may drink alcohol in an

effort to relieve themselves of the symptoms of their disorder or the side effects from their

antipsychotic treatment (Archibald et. al, 2019). This article directly states:

In addition, multiple genetic determinants of risk for schizophrenia may contribute to the

risk for both psychosis and addiction…Strong associations between substance use disorder,

including AUD, and the polygenic risk score for schizophrenia indicate that shared genetic

liability may contribute to the co-occurrence of these disorder (Archibald et. al, 2019 pg. 52).

With this being said, obtaining a detailed history is crucial. As a nurse, it is a priority to

determine whether a patient is experiencing substance-induced psychosis or a primary psychotic

disorder. If it is substance-induced psychosis, acute care and management will be implemented.

This includes abstinence and decreased stimuli. However, if the patient has a primary psychotic

disorder alongside AUD, it will require long-term antipsychotic medication (Archibald et. al,

2019).

Finally, J.H reported being molested at a young age. The article Psychosis and sexual

abuse: An interpretative phenomenological analysis analyzes how a young child could be

permanently impacted from sexual abuse. According to the article, there have been multiple

studies conducted that have linked childhood sexual abuse to future feelings of shame, suicidal

attempts, lack of trust and possible development of psychosis. This article states, “Given that

extended abuse is likely to leave its traces on multiple aspects of a person, in expectations or

even neuropsychological functioning, then it seems reasonable to hypothesize that in an adult

emotions, and meaning,” (Rhodes et. al, 2018 pg. 547). Since his molestation from ages ten

through fourteen, J.H has been diagnosed with schizoaffective disorder, bipolar disorder,

depression and anxiety. There is a great possibility that his sexual abuse as a child influenced the

way his brain developed and how it reacts to stimuli, feelings and interactions with others.

Stressors and Behaviors that Precipitated Hospitalization

When questioned about stressors, J.H stated that thinking about his childhood molestation

makes him feel depressed, unworthy and anxious. He stated that he thinks about this trauma

frequently and it has been the main reason for many of his past hospitalizations. Another

contributing factor to his hospitalization and suicidal ideations was noncompliance with his

previous prescribed medications. He did not maintain his medication regimen and stated that

voices convinced him that he didn’t need them. J.H recognizes that complying with his newly

prescribed medication regimen is the best way to improve his quality of life.

The patient verbalized that he smokes outside with his mother to deal with the stress and

unwanted thoughts. No other coping skills were mentioned or have been effective for this

patient. He states that he has no temptation to return to his previous drug dependent behavior,

even with the presence of stress. On recommendation and offering of community support and

activities, J.H stated that his nurse already provided him with resources. He stated he wants to try

to make an effort in going to group therapy sessions.

Patient and Family History of Mental Illness

J.H has a history of schizoaffective disorder, bipolar disorder, depression and anxiety. He

did not mention that any members of his family had been diagnosed with mental illnesses.

However, he denied family history of alcohol and drug use. J.H did not seem very family
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oriented and said very few things about his home life. In the patient’s chart, family was stated

only to describe his place of living.

Milieu Therapy and Evidenced Base Nursing Care

Milieu therapy was implemented and maintained for the length of the patient’s stay on

the psychiatric unit. Being able to manipulate and control the social environment is very

beneficial to psychiatric patients. This low stimulus, safe environment allows patients time to

improve social functioning and prevents self-destructive behavior. As previously mentioned,

potentially dangerous belongings and items are removed from the patient’s possession upon

admission. This includes shoelaces, belts, sharp objects, and cigarettes.

On this particular psychiatric unit, there were many factors that were manipulated and

changed for the benefit of the patients. The bathroom doors in each room were slanted, which

prevents any suicide attempts. The outside door to the patient’s room has pressure sensors for the

same reason. If there is a weight of more than five pounds on the sensor, loud alarms will

immediately alert the staff. The mirrors in the bathrooms are not glass, preventing the use of

broken glass to harm oneself. Around the entire unit, the walls are colored light to increase the

therapeutic effect of calmness. The chairs and tables are weighted to help decrease the occasion

of an aggravated patient throwing it and causing injury to themselves or others. There are no

visible screws or nails for the patient to see, remove and use as a weapon. There was no visible

plumbing in the patient rooms or shower. This prevents manic patients from tearing the

plumbing out of the walls and flooding the facility. Finally, the lights are dim and timed to

facilitate calmness and provide structure to the patients.

In regard to evidenced base nursing care, there were two therapy sessions conducted on

the day of care. J.H attended the first session but went to his room to sleep as the second session
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was occurring. He was provided with blood sugar checks and corresponding insulin

requirements before every meal. On the psychiatric unit, personal limits were set and

communication was encouraged. His nurse provided him with community resources in relation

to group sessions, coping skills and job opportunities. If he had any questions related to his

treatment and care, the nurses and other staff were available. Additionally, J.H was given Haldol,

Neurontin and Ativan around the clock in response to his prescribed pharmacological therapy.

Ethnic, Spiritual and Cultural Influences

J.H did not specify a specific religion or identify any spiritual practices that are a part of

his everyday routine. He is a single, 47-year-old Caucasian male. He failed to mention his

socioeconomic status, but he has been living with his mother, sister and niece for a while. J.H

appears to have been influenced by his past traumatic experiences and may feel more safe living

at home with his family. Familial relationships or personal enjoyments were not emphasized

heavily. He focused on the past and was hesitant to share about his current state of wellness and

stability.

Evaluation of Patient Outcomes

During his stay on the psychiatric unit, J.H was able to remain free of injury and adhere

to the unit’s guidelines. Upon initiation of his new medication regimen, the auditory

hallucinations stopped, and he was able to be reoriented. He stated that the hospitalization

needed to happen for him to get back onto his medications and stabilize his condition. On the day

of care, J.H attended a group session and participated appropriately. He appeared coherent and

content with the unit activities. During the interview, the patient was able to recognize past

destructive behavior and the impact it has made on his life. J.H seemed motivated to quit

smoking, attend group sessions once discharged and adapt heathy coping skills.
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Summarized Plans for Discharge

Upon discharge, J.H will be returning to his mother’s house where his mother, sister and

niece reside. He is instructed to take Artane 5 mg two times daily, Ativan 1mg two times daily,

Neurontin 800mg four times daily and Haldol 10mg two times daily. Medication education and

compliance will be planned prior to his discharge. This includes reporting any worsening of the

extrapyramidal symptoms. J.H is to maintain his sobriety and attend AA meetings if he feels it is

necessary. He will be instructed to review the community resources available and plan to use

them on a regular basis. J.H states his goals are to improve coping skills and quit smoking.

Prioritized List of Actual Nursing Diagnosis

 Disturbed thought processes related to schizoaffective disorder and biochemical

alterations in the brain as evidenced by auditory command hallucinations and impaired

judgement.

 Ineffective individual coping related to inadequate social support and past sexual abuse as

evidenced by history of substance abuse, destructive behaviors, and lack of goal-directed

behavior.

 Risk for self-harm related to persistent and reoccurring suicidal ideation

 Disturbed sensory perception related to schizoaffective disorder as evidenced by auditory

hallucinations and commands.

 Chronic low self-esteem related to repeated past failure and feelings of shame as

evidenced by chronic depression, suicidal ideation, rejection of positive feedback and

refusal to help self.

 Interrupted family process related to multiple psychiatric diagnoses and ineffective

coping as evidenced by lack of supportive relationships with family members

 Risk for self-directed violence

 Impaired mood regulation

 Stress overload

 Risk for loneliness

Conclusion

In conclusion, J.H was a patient that was able to hold a very intelligible, appropriate

conversation. He was able to identify his past mistakes and experiences, stating he wants to

improve his physical and mental well-being. If J.H attends group sessions after his discharge and

remains taking his medications, I believe that he will see a great improvement in his motivation

and sense of worth. To function at his optimal health, J.H will need to adhere to his medication

schedule, create healthy relationships, attend group sessions and adapt healthy coping

mechanisms.
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References

Archibald, L., Brunette, M., Wallin, D., & Green, A. (2019). Alcohol Use Disorder and

Schizophrenia or Schizoaffective Disorder. 40, 51-59.

Batterham, P., Van Spijker, B., Mackinnon, A., Calear, A., Wong, Q., & Christensen, H. (2018).

Consistency of trajectories of suicidal ideation and depression symptoms: Evidence from a

randomized controlled trial. 321-329. doi:10.1002/da.22863

Rhodes, J., O'Neill, N., & Nel, P. (2018). Psychosis and sexual abuse: An interpretative

phenomenological analysis. 540-547. doi:10.1002/cpp.2189

Videbeck, Sheila L. Psychiatric-Mental Health Nursing. 8th ed., LWW, 2020.

Student Name ____________________________________

Pt Identifier _____________

Date of Care _________________

_______________ Objective Data presentation the patient, treatments, medications

_______________ Discuss patient/ family history of mental illness

_______________ Identify stressors and behaviors that precipitated current hospitalization

_______________ Summarize the psychiatric nursing interventions with rationales

_______________ Evaluate patient outcomes for nursing care provided

_______________ Analyze ethnic, spiritual and cultural influences that impact care of patient

_______________ Summarize discharge plans and community care

_______________ Actual nursing diagnoses, prioritized, using R/T and a.e.b

_______________ List of potential nursing diagnoses

_______________ Conclusion paragraph

_______________ Style, spelling, grammar, clarity, organization, APA format