Mental Health Management Plan and Analysis

Management Plan

Primary Diagnosis

Given the patient’s symptoms, the main diagnosis is major depressive disorder (MDD). MDD is a major mental health condition that is marked by continuously depressing emotions and bad moods. According to the DSM-5 TR, a patient must exhibit at least five signs that have persisted for longer than two weeks to be diagnosed with MDD. Some of these symptoms include a depressed mood, lack of interest in any activity, appetite loss, extreme fatigue, inappropriate guilt, suicidal thoughts, lack of focus, restlessness, and psychomotor slowness (APA, 2022). The patient’s main MDD symptoms are helplessness, hopelessness, and sad moods.

Recommended Diagnostic Testing Based on Clinical Practice Guidelines

I would advocate a mix of lab tests and plain old conversations with the patient for diagnostic testing. A healthcare professional needs to know about particular indicators of depression to identify and address depression properly. To check for depression, he could ask several common questions. In addition to learning about the patient’s general health from a physical exam, the doctor can diagnose depression by learning additional information about the patient through conversation (Kennedy, 2022). The first physical examination may involve conventional tests since the patient reports on aspects including daily emotions, conduct, and lifestyle choices. Blood tests to examine the functioning of the kidneys, the functioning of the liver, and electrolytes could be a few of them. Drugs for treating depression are excreted from the body by the liver and kidneys, and therefore damage to one or both of these two structures may result in drug accumulation.

A physician may follow up with inquiries that are expressly designed to test for depression after talking with the patient about their mood and how it impacts their daily lives. A clinician may utilize questionnaires and tests to help diagnose depression, but this is only one step in the procedure (Kennedy, 2022). But occasionally the doctor can learn more about the patient’s mood from these exams. He can utilize them to diagnose the problem more accurately. An illustration of a screening instrument is a questionnaire with two parts that have been scientifically proven to be extremely reliable in determining the possibility of depression.

Based on clinical recommendations, I would advise using selective serotonin reuptake inhibitors (SSRIs). This is because they are generally less irritating and safer than other antidepressants (Currie & MacLeod, 2020). I would particularly advise the patient to take Lexapro. This medication significantly and dose-dependently inhibits human serotonin transport. 10 mg of Lexapro should be taken once a day. Research suggests that both 10 mg and 20 mg of Lexapro are beneficial. However, it does not highlight an additional advantage of 20 mg above 10 mg. This should happen at least a week after the first dose is increased to 20 mg.

Non-Pharmacological Interventions

I would choose cognitive behavioral therapy (CBT) for the patient because it is a supported by scientific approach. This is so that I can use cognitive behavioral therapy (CBT) to change the patient’s thoughts to change their behaviors and emotions (Erjavec et al., 2021). I can utilize cognitive behavioral therapy (CBT) to assist the patient in identifying their undesirable behavioral responses and thought patterns to demanding and stressful situations. Cognitive-behavioral therapy is one of the best ways to effectively treat anxiety and depression. Because CBT is based on science, it prevents relapses in the future better than medicine. By taking into account my area of expertise and the client’s values, we may work together to change a person’s environment, behavior, and cognition (Currie & MacLeod, 2020). An intervention for health promotion is suitable for the client’s regular exercise. To do this, she must continue to be active. The client can greatly benefit from meditation in overcoming her mental anxieties. He should therefore create a structured schedule that incorporates yoga, meditation, and balanced food. Sleeping soundly and on schedule can cure 50% of illnesses.

Recommended Follow-Up Schedule and Referrals with Rationale

I advise conducting a follow-up within between one and three weeks of the first diagnosis of depression to evaluate pharmaceutical adverse reactions along with treatment compliance (regardless of whether that be medication, therapy, or self-management). Support staff members, such as a care manager, can carry out this task, the speaker claimed. Suicide risk should also be evaluated at this time because it can occasionally rise when patients undergo treatment and get more active (Voineskos, Daskalakis, & Blumberger, 2020). It could be necessary to adjust or increase medication, intensify psychotherapy, and/or boost self-management assistance measures if the patient encounters a decrease between two to four points at the follow-up visits. This suggests that the client may not have responded adequately to treatment.



The regions of the neural system that control mood, dopamine reaction, and executive processes have been found to have abnormalities in numerous structural as well as operational studies. An autopsy as well as studies on neuro-imaging have discovered structural abnormalities in the frontal lobe and hippocampus, the regions that have attracted a lot of interest in depression research studies of animals. These abnormalities were manifested by decreases in the density of the glial and volume of grey matter (Miller & Campo, 2021). It has also been suggested that depression frequently coexists with ongoing stress and HPA axis stimulation (leading to persistent hypercortisolemia). It is now clear that the onset of depression necessitates a complex gene-environment interaction that alters a person’s response to challenging life conditions. Undoubtedly, chemicals are involved in this process, but it is not as straightforward as having one molecule in the wrong amount and the other in the perfect amount (Erjavec et al., 2021). On the contrary, several factors are at work both inside and outside the boundaries of nerve cells. A framework that influences people’s emotions, attitudes, and worldviews is created by millions or possibly billions of chemical processes.

Depression’s precise origin is uncertain. Researchers think that a variety of factors contribute to its development. One of them is genealogy. If a person has a first-degree family member (biological mother or brother) who suffers from the condition, their risk of having depression is almost three times greater than that of the general population (Kennedy, 2022). Depression may also be brought on by painful experiences, divorce, losing loved ones, being alone, and a lack of support. Additional factors that can contribute to depression include continuous pain and chronic illnesses like diabetes. Additionally, depression is a negative side effect of several medications.


It is okay to take Lexapro to treat mild to severe depressive symptoms. Serotonin levels in the brain rise as a result, and this causes it to work. Serotonin is regarded to be beneficial for mood, emotion, and sleep, according to Currie & MacLeod (2020). Fluoxetine has fewer negative effects than some other medications and aids in the recovery of many depressed patients. There is no doubt that Lexapro effectively treats MDD. Serotonin functions for a longer amount of time because Lexapro prevents serotonin from being reabsorbed from the synaptic cleft (APA, 2022). Serotonin is one of the monoamines that might enhance brain plasticity and decrease depression. There has been some change in the way they work.

Additional Analysis

A thorough examination is required for the management of depression, and I employed numerous best practices to diagnose the patient and develop a therapy plan. Correct diagnosis-setting was the initial clinical recommendation. The evaluation was based on thorough historical, physical, and psychological checks (Kennedy, 2022). All sources of information, particularly the family, were used to gather history. The diagnosis was noted using the most recent diagnostic standards. To assess for prior episodes and the existence of depressive symptoms, a long-term life course viewpoint was crucial. In addition, the longitudinal course method considered the patient’s reaction to earlier therapy as well as whether they had experienced full or partial remission or had not responded to treatment.

Since the client had previously undergone treatment, it was crucial to assess the data regarding the type of antidepressants used, dosage of medicine used, adherence to medication, leads to poor compliance, causes of medicine elimination, how she responded to treatment, side effects encountered, etc. Because the medication was altered, it was necessary to assess the rationale for the change as well. In addition to individuals, knowledge regarding the illness was also acquired from the carers, and it is important to assess their comprehension of the condition, attitudes toward treatment, the effect of the sickness on them, and their personal and social resources.

Follow-up and Referrals

There are legitimate explanations for the general practitioner to actively participate in the patient’s continued care as well as regularly work with the expert, irrespective of the specialized mental health practitioner to whom the patient is referred. The GP must make sure that both the client and their caregivers are happy with the expert they have been recommended to, and that the patient doesn’t get lost in the weeds of a convoluted mental health system. The client’s long-term monitoring aims to avoid relapse and spot early signs of recurrence. Frequent review meetings promote treatment plan commitment and guarantee that medical attention, such as checking cardiovascular disease risk factors and quitting smoking, is not overlooked.


Several things I discovered during the weekly session had an impact on how I went about writing the management plan for my customer. I discovered that it can be challenging for those who are depressed to reach out for help. They might require assistance from family, friends, or a medical professional. Nobody has ever successfully individually recovered from depression (Kennedy, 2022). The positive aspect is that a variety of medications, medical specialists, and support services are accessible to assist with depression. I also discovered that persons with depression have a lot of options for taking care of themselves. In the instance of the client, his complaints may be alleviated through acquiring knowledge about the condition, making lifestyle adjustments (such as engaging in regular exercise), and receiving psychiatric counseling from a mental health expert or through online e-therapies.

Combining medical therapies with these additional treatments is probably necessary. This teaches me how to approach someone who is depressed in the future. I’ll handle my client’s medications for depression going forward. I also discovered that it could take a drug up to six weeks to start working, so be patient. The most widely practiced treatments for psychological disorders include CBT (Voineskos, Daskalakis, & Blumberger, 2020). To be better prepared to handle the pressures and difficulties of daily life, it helps those who have depression keep an eye on and alter their destructive thought patterns.

Coding and Billing

Major depressive disorder, recurring, without psychotic features: F33.2 are the correct ICD-10 code for the client (Kennedy, 2022). Any specialist in mental health, including medical professionals and non-medical professionals, including certified social workers with clinical experience (CSWs) who have been licensed by the government of the state and clinical psychologists who are authorized by the state and subject to state requirements, who are practicing within the state’s defined scope of their practice, are eligible to bill.















American Psychological Association (APA). (2022). Depression.

Currie, J. M., & MacLeod, W. B. (2020). Understanding doctor decision making: The case of depression treatment. Econometrica88(3), 847-878.

Erjavec, G. N., Sagud, M., Perkovic, M. N., Strac, D. S., Konjevod, M., Tudor, L., … & Pivac, N. (2021). Depression: Biological markers and treatment. Progress in Neuro-Psychopharmacology and Biological Psychiatry105, 110139.

Kennedy, S. H. (2022). Core symptoms of major depressive disorder: relevance to diagnosis and treatment. Dialogues in Clinical Neuroscience, 10(3), 271-277.

Miller, L., & Campo, J. V. (2021). Depression in adolescents. New England Journal of Medicine385(5), 445-449. DOI: 10.1056/NEJMra2033475

Voineskos, D., Daskalakis, Z. J., & Blumberger, D. M. (2020). Management of treatment-resistant depression: challenges and strategies. Neuropsychiatric Disease and Treatment, 221-234.



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