Currently 50% Mdd, C&p The Other Day...here's How It Went Down

[brokensoldier244th]

Doc was good, session took about an hour. Hit all the fine points and let me work off my list of notes and somewhat direct the conversation. I know that without the report yet, its difficult to say, but what are the thoughts based on this? Last C&P was almost 2 years ago. Does any of this warrant a possible increase from 50% to 70%? It looks like under the new DSM that my prior diag. of MDD actually could fall under MDD/W mixed features. Not sure if that matters now-can C&P doctors change a diagnosis that has been previously established?

Had my sit down with C&P MH the other day. Its been a year and a half since my last one-over that time ive increased meds twice (once from just counseling to meds, then a year later an increase to those), and between my wife and I compiled a list of things that are either newly evident or worse than they were when I was rated 50% for MDD.

Increases in work absences (14 in that prior year, 38 this last year in 11 months)

Actual write ups at work for client/co-worker demeanor and attitude-on 'improvement plan over next 6 months' if I don't improve Ill be terminated (IT/Support). Reduced duties, no travel, no unsupervised local client visits

-last job I had for 10 months before that, lost because of customer attitude/emotional anger outbursts (IT/Support)

-job before that and being rated at all I had for 5.5 yrs, but the last year and a half I had same issues as above and when company was sold I was not retained, same field.

Picking on nails/cuticles until bleeding-never did that before, now I do it constantly on my thumb and index fingers-noticed during exam as well.

She (wife) handles almost all the money now because my frequency of spending has increased to where we had to file 13 a year ago (just me)

weekend when she does not see me because I don't get out of bed

not showering/shaving 3 or more days a week in a row

increased withdrawal from family and friends-wife travels alone w/kids increasingly

Here is the current list of issues as discussed on Friday

- separate parts of the house

-comes home-whirlwind through common areas/LR/Kitchen-if unkept immediately starts cleaning. No asking about day, no “hi honey/hi kids, how was school”. Oldest daughter thinks he doesn’t care about anything about her. Youngest daughter scared of him when he gets angry.

-house damage-holes in wall from hitting, chairs. Broken glass stove top, requiring new stove

unkept yard/grass/trash-neighbor complaints. Vehicle maintenance not kept up, doesn’t remember oil, gas, tires. His car is a mess of wrappers/cups, etc-yet house has to be spotless?

- random yelling/throwing tantrums about little things like a small change in a plan, or something not being picked up. will be up at all hours of the night cleaning/sweeping/picking up things. Was pulling up carpet in daughters room-3 am WHILE they were sleeping in there.

-Does not go to mall, social get togethers with friends/family, opting to stay home. Has said more than once, increasing in the last few years that “if I just had an internet connection I would be happy” Will ‘zone out on internet for hours, with us in the room. Does not remember familiy dates/birthdays, phone numbers. Does not remember to take medication consistently-has internet reminders and sticky notes everywhere

-will spend literally all weekend in bed, even if I have to work

-Discussed SI for the first time, no plan, but I did relate starting the car in the garage one day to warm it up, and then falling asleep in the drivers seat with the car running, and that Ive had increasing thoughts in the last year since I have a job with benefits that life insurance isn't a bad thing-even though the better part of me knows that SI and Life insurance don't mix and it would probably be denied

-financial irregularities!!! bills not paid unless I do them, shut off notices at least once a month for something. Spends money on watches, mostly-constantly mailing watches out (selling) or buying them off internet.

-had to file BK last year to save house

-Dropped out of Masters program in compu/Sci/Security due to memory problems, late assignments/projects, missing meetings with advisor, and financial problems.

-consistency with employer-38 absences from Feb to Dec 2013. Performance Imp plan for work, have to clear any and all absences-even for PTO.

-loss of opportunity-cannot travel, inconsistent demeanor with clients, liability

-Co-workers don’t like him, don’t want to work with him, despite his knowledge of networking/products.

- Emotional inconsistency daily-on days he is 'on' he can almost be hyper, funny, over engaging. On days when he's down, he is reclusive, aloof, and surly.

-Last three jobs: Terrascan, 5+ years (2006-2011), but the last year was so inconsistent, and resulted in write ups for job performance, accuracy, customer demeanor, and eventual firing

-Xotic PC, as Service Manager (March 2011-Jan 2012) -was fired for cust demeanor, verbal clashes with boss/owner

-Stanley Healthcare (Feb 2013-Present) -has received negative writeups from customer (directly referencing him) as a negative influence. Inconsistency/accuracy with job duties-forgets online meetings, forgets client followups, cannot go to local repair/install jobs unsupervised. No promotability. Currently on 'performance improvement plan' for 6 months. If no improvement, looking at termination.

-Prior job record and BK is a liability for security clearance for work/HIPPA data/client servers. Inconsistency in relations with co-workers, and unpredictability/panic in unfamiliar situations has barred him for travel to other offices (Boston, Ottawa, Calif.)

-has used company credit card for personal purchases, groceries/gas due to his problems with spending family money-has had that card taken away.

Edited February 17, 2014 by brokensoldier244th

[brokensoldier244th]

Here's some of my more recent treatment notes.

LOCAL TITLE: MHC PSYCHIATRIST NOTE

STANDARD TITLE: MENTAL HEALTH PHYSICIAN NOTE

DATE OF NOTE: FEB 24, 2014@13:10 ENTRY DATE: FEB 24, 2014@13:10:40

AUTHOR: FIK EXP COSIGNER:

URGENCY: STATUS: COMPLETED

*** MHC PSYCHIATRIST NOTE Has ADDENDA ***

TIME IN: Feb 24,2014@12:00 TIME OUT: Feb 24,2014@12:50

Patient was seen for scheduled appointment

Interval History:Pt seen for increasing issues over the past six months

per his report. He confirms what is reported in the meail sent to RN

Neujahr through secure messaging and endorses increased irritability.He

takes his anger over small stressors on inanimate objects. He does have

impulsivity buying mechanical watches which hurts the family finances.

his wife has set up an allowance so that this is less of a drain. He is

also noting diffculty sleeping with frequent wakenings despite ongoing

use of CPAP. He has found therapy along with the focus of coping skills

when he saw Dr Esseks and is wishing to re-engage in this as well. He

notes that due to his performance improvement plan and scrutiny at work

due to his complaints from customers he would prefer SATURDAY am appts

for both therapy and medication followup.

Active Outpatient Medications (excluding Supplies):

Active Outpatient Medications Status

=========================================================================

1) GABAPENTIN 800MG TAB TAKE ONE TABLET BY MOUTH EVERY ACTIVE

MORNING AND TAKE TWO TABLETS AT BEDTIME

2) MELOXICAM 15MG TAB TAKE ONE TABLET BY MOUTH EVERY DAY ACTIVE

3) OMEPRAZOLE 20MG EC CAP TAKE ONE CAPSULE BY MOUTH ACTIVE

EVERY DAY FOR THE STOMACH

4) SERTRALINE HCL 100MG TAB TAKE ONE AND ONE-HALF ACTIVE

TABLETS BY MOUTH EVERY MORNING AS NEEDED FOR

PREMATURE EJACULATION

5) SILDENAFIL CITRATE 100MG TAB TAKE ONE-HALF TABLET BY ACTIVE

MOUTH AS NEEDED 1 HOUR PRIOR TO SEXUAL ACTIVITY

(REPLACES VARDENAFIL)

Pending Outpatient Medications Status

=========================================================================

1) TRAZODONE HCL 50MG TAB TAKE ONE TABLET BY MOUTH AT PENDING

BEDTIME

6 Total Medications

Recent Labs: None previously ordered by this provider.

MENTAL STATUS EXAM:

Appearance: Patient was cooperative and pleasant with good hygiene.

Patient appeared stated age.

Mood: Mood is described as depressed.

Affect: Affect is blunted.

Speech: Speech is spontaneous, RRR, with normal tone with appropriate

vocabulary.

Thought Processes are goal-directed and logical.

Thought Content and Behavior show normality with no psychosis noted.

Lethality: Patient denies wishes to harm self, Patient denies wishes to

harm others.

Fund of Knowledge: not formally tested but showing no signs of change.

Judgment and Insight: Excellent.

Psychomotor Activity: Within normal limits.

Intelligence estimated to be average.

Patient voices pain issues: YES will see pc clinic today

ASSESSMENT: Diagnosis is based on DSM-5. MDD rec

Medication History

Veteran is a resident of a nursing facility: No

If Veteran is not a resident of a nursing facility, review medication list

with Veteran or Caregiver and complete the following questions 1-4.

1. Were there any changes to the medication list below?

Yes

Veteran omits medication or takes medication differently than

prescribed.

takes sertraline five times a week.

2. Do you take any Herbal or OTC Medications?

Yes

Document here:

ibuprofen prn

3. Do you take any Non VA prescription medications?

No

4. Have you taken ALL of your medications today?

Yes.

Source of Medication History: Patient

BRIEF SUICIDE RISK ASSESSMENT

Does patient have a "High Risk for Suicide" Flag?

No

1. Is the patient feeling hopeless about the present/future?

No

2. Has the patient had any suicidal thoughts in the last week?

No

3. Has the patient used/abused drugs or alcohol in the last week?

No

4. Is the patient presently experiencing a moderate to severe level of

stress? (relational, health, financial, legal, emotional, vocational,

housing etc)

Yes

a. What are the stressors? financial, job reaching out for treatment

5. Is a detailed suicide assessment needed?

No

EDUCATION

PLAN:

Medication Review: Changes as ordered: trazodone 25-50 mg qhs prn

sleep. SE including sedation, xerostomia, priapism, headache.

Strongly encouraged 7 day adherence to sertraline.

Side Effects: No observed side effects

Therapy: Supportive therapy and medication education given. .

Labs Ordered: None indicated at present

Consults Requested: No

Follow-up Plan: Follow-up in. 2 days MHC RN phone

Emergency procedures reviewed on visit. The patient has also been

provided contact information for the Clinic and the On-call care nurse.

Other/Comments:Will ask Dr Bad rth to consider seeing

veteran in Saturday clinic March 8th.

Time spent in psychotherapy: 30 Time spent in medication management: 15

Informed Consent for treatment was obtained through discussion of

potential benefits, side effects, and alternatives.

/es/ JUL MD

Psychiatrist

Signed: 02/25/2014 09:21

Receipt Acknowledged By:

02/25/2014 09:37 /es/ PATRICIA J. BOHART,MD

PSYCHIATRIST

* AWAITING SIGNATURE * BYOEN F

02/25/2014 10:57 /es/ AGE

02/25/2014 ADDENDUM STATUS: COMPLETED

psychiatry addendum

e -- please offer this veteran appt (either 9am or 10am) in my

L/MHC psychiatry weekend clinic. Next available is March 8, 2014.

Thanks.

/es/

PSYCHIATRIST

Signed: 02/25/2014 09:39

[Navy04]

The only sentence that matters, is where the Psych Doc states what your " Occupational and Social Impairment is " really nothing else matters. I wish you the best. I know how you feel I was low balled in 2012 with 30% PTSD, and I had my exam two weeks ago and it is going to go up to 70-100% soon I hope, but what is crazy that the C&P Doc wrote on my report " Service Member met criteria for 70% minimum per guidelines in 2012" I have a CUE here, but It is not worth fighting the VA for 3K in back pay. Nice to know that the VA actually admitted to a mistake. God bless and keep us posted bud. We are here for you.