Hello and welcome. My name is Cyrus. I’m a psychiatric

Hello and welcome. My name is Cyrus. I’m a psychiatric nurse practitioner, and today we’ll be doing a psychiatric evaluation. So tell me a little bit about what brings you in today. Well, I’ve suffered from depression pretty much as long as I can remember. And at this point, it just feels like I don’t know what else to really do. It hasn’t been this bad before, so a friend of mine suggested that I maybe try to speak with someone. OK. Yeah, so you’ve been struggling with depression for a very long time, but it seems to be getting worse lately to a point that really your friends have become quite concerned and referred you on to treatment. OK. When in the history of your life is the first time that you experienced symptoms of depression? Well, it’s pretty much as far back as I can remember. I remember being a happy kid around five or six, and then 10 years old I remember that it was pretty much all that I could think about or talk about with my friends, the few friends that I had, and pretty much ever since then I remember being depressed. If it wasn’t constant, it was off and on, something like that. But I don’t really remember not being depressed. Yeah. So around 10 years old is the first time that you experienced these symptoms. Yeah. What was going on when you were 10 years old? Was there anything going on in your life? Honestly, I don’t think so. I don’t remember. For some reason, it just was. Yeah, it just was. What was your family life back then? It was all right. My parents were sleeping in separate bedrooms, my sister had gone off to college, but everything seemed all right from what I remember. Nothing was out of place. I was just removed from everything and felt isolated. Your parents in different bedrooms, was that because there was conflict? My father said it was because there was too much stuff, so he just needed his own space. Yeah. OK. Then, do you believe what your father said? I don’t know. I’m sure it was related to other stuff as well, but nothing that they ever talked about. Yeah, and it wasn’t something that you were either directly or indirectly aware of, of any sort of tension, no conflict? Not really. I guess if there was anything, they didn’t show it to us. OK. How about school? What was school like for you back in I guess late elementary, middle school? Well, I wasn’t ever really a very good student. I didn’t really try to do more than the bare minimum, and then that didn’t get any better. High school, I actually got kicked out of my first high school because I just stopped. I just stopped doing everything. OK. Yeah. Did you have a lot of friends through school? It sounded like maybe you didn’t have very good connections. I had a few. The few that I did have, I confided in a lot. But no, I always felt removed from everyone, like the cool kids and then also even the non-cool kids. I just couldn’t really connect with most people I felt. OK. Yeah, and then so through those earlier years and through your teens you continue to struggle with your mood, you struggled a bit with connection. And then, I guess, leading up to now where you said that things have been getting worse, if you were to think about the worst years of your life, I guess, when would those have been? A few years ago, 2015. I’m not sure why. I guess I’d gone through a pretty bad breakup, and I don’t know. Just everything seemed really hard. Everything that I wanted to do seemed unimportant and everything just seemed difficult. Getting out of bed was difficult, going to work was difficult, and none of it seemed to really matter at the same time. How long did that period last for? It’s just continued off and on, like I said. Sometimes it would fade away a bit more, but then the periods where I did feel depressed just got longer. OK. Yeah. So really since 2015 you’ve really struggled a lot with your mood having these very, very low lows and then some periods of time where you hadn’t felt quite as bad only to drop back down again. And the periods where I did feel not as bad still– It’s like you’re always waiting for the other shoe to drop because you know eventually that you’d go back. And it always feels more comfortable actually, funnily enough, being depressed, because it just feels like that’s the natural state and everything else just feels like a lie. Yeah. So you feel like depression is almost insulating for you, almost like a cocoon where you don’t have as many things you have to worry about because the depression is the thing. And then when you’re not feeling depressed, things get a little bit more complicated because suddenly you’ve got more things that you’re trying to deal with, but you’re also concerned that if you get started with anything, then depression might come in and to make it a lot harder to keep those things up. OK. All right. So this recent period of depression, the one that you’re experiencing right now, when did that start? Like I said, it just feels almost in my mind like they were just continuing one long period. But I would say more recently in the last six months or so. Maybe actually the last year. I had a lot of friends who committed suicide or just a lot of friends who died for other reasons. It just has been more difficult. OK. So over the past year or so, there’s been a lot of loss in your life. So it’s been harder to maintain a normal mood. And then whenever I start to feel like I’m getting over something, then there’s another one. Yeah. Yeah. What does depression feel like for you? So what sort of symptoms do you experience from day to day right now? It feels heavy. I feel sluggish and cold, removed from everything. The sun feels too bright and at the same time very dim and cold. Everything just feels a little bit like walking through a fog or a thick sort of water. Everything feels kind of gray and blue. Yeah. So the world has lost its vividness and instead everything is just very blunted. And it’s hard, it sounds like, to move through life right now. Most things also seem to be like they agitate me a bit. When I’m by myself, I feel comfortable in it. And then when something comes along that is asking me to step outside of that or penetrate that bubble, it just irritates me that I have to even– to take me out of that comfort zone that I have. Yeah. All right. So in looking at these symptoms, it sounds like you’ve got low mood. It sounds like you’re not enjoying things the way that you normally would. This feeling like you’re moving through a fog. I guess does that make it harder to get up and do things? Are you finding difficulty with your motivation? It’s both on the one hand being difficult to motivate and also comfortable to not motivate. So it removes any ability that you have to do. Yeah. Yeah, so not a lot of that internal motivation. If someone externally tries to motivate you, you almost feel like they’re prodding too much and so you’ll lash out a little bit. And it also makes me want to retreat even further into my own space of comfort. So you’ve been isolating yourself from others. A lot, yeah. Sometimes people who feel this way, they sleep a lot, or they can’t sleep, or they sleep at the wrong time. So what does your sleep look like? It’s I sleep either a lot or not at all. I tend to be up when other people are down and vice versa. And when I’m in my little space, time blends together so it doesn’t matter whether it’s daytime or nighttime. It’s whatever few things I might want to do, like watch TV, I’ll just watch a lot of TV and eat whenever I feel like eating or not. OK. Have you had any change in your weight at all over the past few months? Yeah. I’ve gained some weight. Eating is one of the few things that I do still enjoy to some extent and it doesn’t feel like– in my space it doesn’t really matter, so I just eat whatever I feel like eating whenever I feel like eating it. Yeah. So you’re doing less things and then you’re also eating more, because that’s one thing that you find is at least a little bit enjoyable. You said a few pounds. Do you have any idea what you weighed maybe three months ago and then what you weigh now? I think I gained something about 40 pounds, something like that in about maybe a six-month period. OK. Yeah. So about 40 pounds in about six months. And with that eating, do you find that once you start eating you struggle with stopping? Yeah. I mean, since I enjoy it and there’s not much else and, I don’t know, I’m not going anywhere if I can avoid it, it just doesn’t bother me. And I’ll eat pretty as much as I feel like or till I don’t want to anymore, until it runs out. Yeah. Do you ever feel uncomfortable after eating that amount, like either feeling mentally uncomfortable with yourself or feeling physically uncomfortable from eating too much? I think there’s a bit of a sense of shame because I know that other people would– they’d view it negatively or, I don’t know. If you eat a box of cereal in one sitting, it does feel a little– but in terms of my own perception or my own feelings, I don’t really care that much. And physically, you’re not feeling nauseous? You’re not getting sick after eating this amount? Uh-uh. OK. All right. How have you been feeling in regards to, I guess, to your safety? Have you had any thoughts of harming yourself? I wouldn’t say they’re really thoughts. More like sometimes, especially when I’m outside, I get flashes or images that pop into my head of like if there’s, I don’t know, just like a gun in my mouth or something like that or a blade to my wrist. But it’s not something I’m thinking about actively. The image will just pop into my mind. Yeah. So you’ll have these intrusive thoughts that interrupt you with what you’re doing where you visualize yourself causing harm to yourself. How often does that happen? I’d say maybe a few times a day. It just pops in. And I push it out pretty quickly, because it’s not something I really want to do, I don’t think, but it just keeps coming into my mind. Do you get scared that you might follow through with one of those thoughts, one of those impulses? I don’t think so, but it does bother me or worry me that I seem to keep thinking about it, that the images keep popping up and they seem to be a little bit more frequent. Yeah. OK. So increasing frequency, increasing intensity of these thoughts. Have you ever struggled with self-harm before or had a suicide attempt? I never attempted suicide, but I did in high school around the same time, but before I got kicked out, I started cutting. I didn’t really know why. It was also the first time that I drank, oddly enough. I do it sometimes here and there. I don’t know. There was a period of time for years where I hadn’t done it. And then more recently, I did it again and I didn’t really know why. But a friend of mine once said it was like addiction. That if you ever started doing it, that it would always– the instinct to do it would always be with you. You never really fully get over it. So that’s something that’s stuck in your mind, that engaging in self-harm may be something that’s almost like an addiction that if you get started, you may not be able to stop. It’s never something that I plan to do. It’s almost like an idea forms. Not even an idea. It’s like a knowledge that you’re just going to do it and then you do. OK. When’s the last time you engaged in self-harm? A few years ago. Recently, it was 2018, 2019. And I hadn’t done it in at least five years before then. Yeah. How close have you got recently to either engaging in self-harm or following through with one of these impulses, one of these flashing thoughts? I’d say that more recently the idea has popped into my head a bit more, but it hasn’t fully formed as the knowledge yet and I’ve been more able to try to push that instinct off. I don’t know if it’s just I’m older, but I do still have this, I don’t know, this gut feeling of wanting to sometimes, especially when I’m feeling a little bit more alone. Yeah. So like a gut feeling or this draw to engage in self-harm. How do you distract yourself from that or what helps to relieve some of those symptoms? Something else that I might want to do, playing a video game, or a TV show that I like watching, eating something that I might like also. But I enjoy a drink. If I’m drinking and I get more depressed, then more likely to cut again. But at the same time, the same feeling that makes me want to cut makes me also want to drink. So if I do one I’m more likely to do the other, but I’m really more inclined to do one to avoid the other. So it doesn’t really make any sense. OK. All right. And when it comes to engaging in self-harm or suicide, do you have access to knives? Do you have any access to firearms? No firearms, but we have regular kitchen knives. These ones with this nice– When I was younger, I always used the same one, oddly enough, with a white mother of pearl handle. I don’t know. So when I think about it, it would still be the same knife. OK. All right. Have you ever been treated for depression before? Yeah, I started seeing a psychiatrist in 2015 like I mentioned, but they stopped taking my insurance. And I’d been on anti-depressants for a while, so I figured maybe that would be a good time to just see how I was without them. And I was seeing a therapist as well. When they stopped taking my insurance, I stopped taking antidepressants. And therapy was very helpful. Are you currently engaged in therapy? Yeah, I do still see my same therapist off and on. There was about a year recently where I didn’t, and I don’t know. I tried seeing her again, but then I stopped. I don’t know. I find myself starting and stopping a lot. I don’t know why. What medications have you been on before? I took Wellbutrin was what I was prescribed before and lamotrigine and mirtazapine and some sleeping medication as well, but I don’t often take the sleeping pills for some reason. I guess they make me feel heavy and groggy. And there’s this, I guess when I’m up, I just want to be up. When I’m down, I want to be down. So I don’t regularly take the sleeping pills. Because like I said, I don’t really want to. Yeah. Did you find any of those medications to be beneficial in the past? It’s hard to say. The Wellbutrin, the only way that I knew that it was working was when I stopped taking it, I would get some headaches if I missed a couple of days. But I couldn’t say for sure that it made me feel one way or another. I did take the– I upped to the highest dosage while I was on it, but I don’t know. It’s hard to say. I didn’t really feel that it helped, but it didn’t feel like it hurt either. So I just kept taking it. All right. All right. Well we’re going to explore some other symptoms now, just check in make sure that we don’t miss anything, and then after that we’ll talk about where to go from here to help you to maybe get through this depression and start meeting your goals. create a mental status examination (MSE)

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