How should I complete the PEC (Patient Evaluation/Eligibility/Coordination) form for a 60‑year‑old female with major depressive disorder, medication non‑compliance, and total assistance required for activities of daily living?

Completing a PEC Form for a 60-Year-Old Female with Major Depressive Disorder and Severe Functional Decline

This patient requires immediate psychiatric evaluation and likely involuntary commitment proceedings, as her refusal of all ADLs combined with medication non-compliance represents a life-threatening emergency that meets criteria for grave disability.

Critical Assessment Components

Document Immediate Safety Concerns

• Suicide risk assessment is mandatory – document any suicidal ideation, plan, or intent, as recurrent thoughts of death are a core symptom of major depressive disorder 1
• Assess for elder abuse or neglect – determine if the patient's condition represents self-neglect requiring protective services 2
• Evaluate nutritional status – refusal to eat for any extended period constitutes a medical emergency requiring documentation of weight loss, dehydration status, and potential need for emergency medical intervention 2

Functional Status Documentation

• ADL impairment level: Document that the patient requires total assistance with bathing, dressing, and eating – this represents the most severe level of functional impairment (unable to perform any ADL items independently) 2
• Specify duration: Note how long the patient has been refusing ADLs, as this timeline is critical for determining urgency of intervention 2
• Cognitive status: Assess whether refusal stems from depressive symptoms (psychomotor retardation, apathy, feelings of worthlessness) versus cognitive impairment or catatonic features 1, 3

Psychiatric Status Documentation

Depression Severity Indicators

• Document all DSM criteria present: The patient likely meets criteria for severe major depressive disorder given the profound functional impairment – note presence of depressed mood, anhedonia, psychomotor retardation, fatigue, feelings of worthlessness, and poor concentration 1
• Medication non-compliance details: Specify which medications were prescribed, dosages, duration of non-compliance, and stated reasons for refusal – up to 50% of patients with major depressive disorder are non-adherent 4
• Previous treatment history: Document all prior antidepressant trials, their adequacy (minimum 4 weeks at therapeutic dose), and responses 4

Capacity Assessment

• Decision-making capacity: The patient's refusal of basic care requires formal assessment of whether she has capacity to refuse treatment – severe depression can impair judgment sufficiently to warrant involuntary intervention 2
• Document specific deficits: Note if the patient cannot understand consequences of refusing food/fluids, cannot appreciate her medical situation, or cannot rationally manipulate information 2

Medical Comorbidities

Essential Medical Screening

• Rule out medical causes: Document thyroid function, complete blood count, comprehensive metabolic panel, and vitamin B12 levels to exclude medical contributors to depression 1
• Assess dehydration and malnutrition: If refusing food/fluids, document vital signs, orthostatic changes, skin turgor, mucous membrane status, and recent weight loss (>3 kg is significant) 2
• Comorbidity burden: Document all medical conditions, as ≥3 comorbidities affects treatment planning and prognosis 2

Social Support and Living Situation

Environmental Factors

• Current living arrangement: Specify if patient lives alone, with family, or in assisted living – this determines feasibility of outpatient management 2
• Available instrumental support: Document who can assist with medications, meals, transportation, and housework – any items requiring "some help" or "unable" status indicate need for intervention 2
• Emergency contacts: Identify who the patient can contact in crisis and document health care proxy 2

Treatment Recommendations for PEC Form

Immediate Interventions Required

• Psychiatric hospitalization is indicated – this patient meets criteria for grave disability (unable to provide for basic needs) and requires inpatient treatment for severe depression with catatonic features or severe psychomotor retardation 5, 6
• Consider electroconvulsive therapy: For severe depression with life-threatening refusal of food/fluids, ECT is the most effective acute intervention and should be documented as a treatment option 7, 3
• Initiate antidepressant therapy: Once in controlled setting, start selective serotonin reuptake inhibitor at standard dose, though note increased risk of upper GI bleeding in patients over 65 years 2

Ongoing Management Plan

• Multidisciplinary team involvement: Document need for psychiatry, social work, nursing support, occupational therapy for ADL retraining, and nutritionist consultation 2
• Medication monitoring: Plan for directly observed therapy to ensure adherence, with weekly toxicity checks initially 2
• Treatment duration: Document that treatment must continue for at least 16-24 weeks after remission to prevent recurrence 1

Common Pitfalls to Avoid

• Do not attempt outpatient management – a patient refusing all ADLs and medications cannot be safely managed outside a controlled setting 2
• Do not delay intervention for "watchful waiting" – severe depression with functional collapse requires immediate aggressive treatment 5
• Do not assume treatment resistance prematurely – verify that previous medication trials were adequate (4-6 weeks at therapeutic dose with documented adherence) before labeling as treatment-resistant 4
• Screen for bipolar disorder – ensure this is not bipolar depression, as antidepressant monotherapy could worsen the condition 4

Document clearly that this represents a psychiatric emergency requiring immediate higher level of care, as the combination of severe depression, medication refusal, and inability to perform basic self-care constitutes grave disability warranting involuntary treatment if the patient lacks capacity to refuse. 2, 5