Discussion: Applying Differential Diagnosis To Depressive And Bipolar Disorders: The Case Of Sam

What is it truly like to have a mental illness? By considering clients’ lived experiences, a social worker becomes more empathetic and therefore better equipped to treat them. In this Discussion, you analyze a case study focused on a depressive disorder or bipolar disorder using the steps of differential diagnosis. You also describe lived experiences of depression.

To prepare: View the TED Talk “Depression, the Secret We Share” (TED Conferences, LLC, 2013) and compare the description of Andrew Solomon’s symptoms to the criteria for depressive disorders in the DSM-5. Next review the steps in diagnosis detailed in the Morrison (2014) reading, and then read “The Case of Sam,” considering Sam against the various DSM-5 criteria for depressive disorders and bipolar disorders.

By Day 3

Post a 300- to 500-word response in which you address the following:

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  • Provide the full DSM-5 diagnosis for Sam. For any diagnosis that you choose, be sure to concisely explain how Sam fits that diagnostic criteria. Remember, a full diagnosis should include the name of the disorder, ICD-10-CM code, specifiers, severity, medical needs, and the Z codes (other conditions that may be a focus of clinical attention). Keep in mind a diagnosis covers the most recent 12 months.
  • Explain the diagnosis by matching the symptoms identified in the case to the specific criteria for the diagnosis.
  • Recommend a specific evidence-based measurement instrument to validate the diagnosis and assess outcomes of treatment.
  • Describe your treatment recommendations, including the type of treatment modality and whether or not you would refer the client to a medical provider for psychotropic medications.

    The Case of Sam

    Sam is a 62-year-old, widowed, African American male. He is unemployed, receives Social Security benefits, and lives on his own in an apartment. Sam has minimal peer relationships, choosing not to socialize with anyone except his daughter, with whom he is very close. Sam raised his daughter as a single father after his wife passed away. Melissa is 28 years old and works as an emergency medical technician (EMT). When Sam was 7 years old, he was placed in foster care and has had very limited contact with his extended family.

    Prior to September 11, 2001, Sam had a steady employment history in food services and retail. He had no psychiatric history before that time. Sam reported his religious background is Catholic, but he is not affiliated with a congregation or church.

    Sam became depressed and psychotic sometime after 9/11 and had to be taken to an emergency room. He was hospitalized at that time for several weeks. His mental status exam (MSE) and diagnostic interview showed no history of alcohol or substance abuse issues, and he had no criminal background or current legal issues. Sam was released to outpatient care but was deemed unable to return to work. At that time, he had a diagnosis of major depression with psychotic features; he also has a history of high blood pressure and migraines. After several additional multiple psychiatric hospitalizations, he was gradually stabilized.

    Sam has been seeing a psychiatrist once a month for over a decade for medication management and is currently prescribed Depakote®, Abilify, and Wellbutrin®. Sam has a positive history of medication and treatment compliance. He was treated by a social worker at an outpatient program for about 2 years after his hospitalizations for his psychosis and depression. He gradually stopped attending sessions with the social worker after his symptoms stabilized, and his termination from the outpatient program was deemed appropriate; he continued to see the psychiatrist monthly for medication management.

    After about 10 years of seeing only the psychiatrist, Sam scheduled a meeting with this social worker for increased feelings of depression. These feelings were brought on after his daughter moved out of the apartment they had shared for many years to live with her boyfriend. He reported difficulty adjusting to living alone and said he often feels lonely and anxious. He reported during sessions with his social worker that he speaks to his daughter frequently, and although she only lives 10 blocks away, he misses her terribly.

    Our sessions for the last 3 months have focused on his mixed feelings around his daughter’s new life with her boyfriend. He said he is happy that she is happy but misses her very much. I emphasized his strengths and helped him reframe his situation by focusing on the positive changes in her life as well as his own life. Our goals were to help him reduce his symptoms of anxiety and begin searching for new opportunities for socialization outside of his daughter.



    During our last two sessions, I became concerned because Sam, who was normally articulate, had been appearing confused and slightly disorganized. I asked him if he had a recent medication change and if he had been compliant with his current medications, but he denied noncompliance or any recent medication adjustment.

    I asked Sam if he was experiencing any physical health problems. He denied any ongoing problems but mentioned that he had collapsed on the street recently. He reported that he had been hospitalized and had undergone a number of tests, which he thinks were all negative. He said he still feels “foggy” at times, and sometimes time seems to be “missing.”

    I reviewed his medications with him. As he went down the list, he reported taking Cogentin® and Ativan®, which according to his chart history had been discontinued months ago. When I asked Sam where he obtained these medications, he stated, “I got them out of the bag.” Sam reported he has a bag at home in which he puts all leftover and discontinued medications. He could not explain why he was taking discontinued medication or for how long. Sam stated, “I thought I was supposed to take it.”

    I called his daughter, and she verified he had recently been hospitalized and that the MRI, CT scan, and EEG tests were negative. I requested that Melissa go to her father’s apartment to look for the bag of medications he mentioned, because it seemed likely that her father was taking discontinued medications. I then scheduled a meeting with Sam and his daughter for later that week. During that session, Melissa reported that she found multiple vials of old medication on the kitchen counter mixed in with her father’s current medications. Melissa reported that she collected and disposed of all the old medications. I recommended obtaining a daily medication planner. Although the hospital tests were negative, I recommended scheduling an appointment with a neurologist, and both agreed.

    Sam saw a neurologist who reported that his test results were negative but did not rule out the possibility of a seizure disorder. The neurologist recommended a follow-up appointment in 3 months. He also contacted Sam’s psychiatrist and recommended that the Wellbutrin be discontinued because it is known to have the potential to cause seizures and that Sam should start on another antidepressant. Sam began to focus and become more cognitively alert after the discontinued medications were disposed of and the Wellbutrin was discontinued.

    I scheduled another family session for Sam to discuss his feelings regarding Melissa moving out. Sam was tearful when he told Melissa he missed her and her dog Sonny. He also told her he was concerned he would not be financially able to remain in the apartment. Melissa reported working long and odd hours but did call her father often and invited him over to her apartment. She further reported that he often declined her invitations. Sam reported he declined because he did not want to intrude on her life or her boyfriend. Melissa assured her father that both she and her boyfriend wanted him to visit and be part of their lives. I asked Sam if Melissa’s dog had been company for him, and he replied, “Yes, and I miss him.” I asked Melissa if it would be possible for Sonny



    to spend some time with her father. Melissa reported her long work hours were making it difficult to take care of Sonny and asked her father if he would like Sonny to live with him. Sam replied, “I would like that.”

    I discussed with Sam how he spends his time, which normally consists of reading a newspaper, watching television, or listening to talk radio. I suggested Sam increase his socialization and recommended a social club for older adults that is near his home. Sam said he would consider this idea. I asked Sam to discuss his financial concern that he may not be able to remain in his apartment. Sam stated that Melissa had been contributing to the household expenses but stopped when she moved out. He stated he had been too embarrassed and ashamed to discuss this with Melissa and had been keeping this to himself. Although Sam is on a fixed income, he is currently able to meet his expenses. However, he is concerned about his rent, which is his largest expense.

    I explored state and federal rent assistance programs for seniors and the disabled. I found a program through which tenants who qualify can have their rent frozen at their current level and be exempt from future rent increases. Sam met the program requirement of being at least 62 years of age, currently living in a rent-controlled apartment, and having a household income that was within the specified guidelines. I obtained the required forms and personal documentation from Sam and completed the application, sending it to the appropriate agency.

    Adapted from: Plummer, S.-B., Makris, S., & Brocksen, S. (2013). Social work case studies: Concentration year. Baltimore, MD: Laureate Publishing.