FOR NICOHWILLIAM ONLY

Name: ______________________________ Date: _________________ DOB: ________________

Age: ________________________________ Start Time: ____________ End Time: ___________

Identifying Information:

____________________________________________________________________________________ David is a 49 years old man. He is married with two children. He has been working in a steel mill as a metallurgical engineer for 20 years.

Presenting Problem:

David has lost interest in doing the things he used to do such as watching TV, attending family gatherings, and playing golf, and instead spends a lot of time in his bedroom alone. He has lost appetite and also doesn’t sleep well. He doesn’t feel the need for living anymore but believes he will recover from this sour mood.

Life Stressors:

David’s sister’s condition may have contributed to his condition since she has been struggling with depression for 10 years.

Substance Use: FORMCHECKBOX Yes FORMCHECKBOX No

____________________________________________________________________________________ David has had a problem with alcohol abuse. He drinks more at night because he has sleep disturbances.

Addictions (i.e., gambling, pornography, video gaming)

David has a problem with alcohol addiction. However, he has changed his drinking patterns and takes two to three drinks perf night unlike previously when he used to drink frequently.

Medical/Mental Health Hx/Hospitalizations:

David hasn’t sought help previously from any healthcare facility in regard to this condition.

Abuse/Trauma:

David doesn’t have major traumatic events. However, Lisa’s condition may have traumatized him.

Social Relationships:

David has for the last 6 months withdrawn himself from family gatherings and mostly spends time in solitude.

Family Information:

David has not lost any member of his family. However, losing a family member can be traumatic and lead to depression.

Spiritual:

David does not give any information about his spiritual inclinations. However, spirituality can be a cause of mental health problems as well as recovery.

Suicidal:

David admits that he feels that life isn’t worth living. Therefore, it is most likely he is suffering from depression.

Homicidal:

David does not show any signs of violence towards his friends and family, or threatening or attempting to kill them.

Assessment:

Assessment is done to determine whether David is depressed or not. If yes, it should establish the level of depression he is in. Depression can be mild, moderate, severe or the symptoms can be subthreshold depressive (Maj, 2013). First, subthreshold depressive disorder would occur in case David exhibits fewer than five symptoms of depression. This is always the first stage of depression. Second, mild depression requires David to exhibit more than five symptoms of depression. In this case, David would have a minimal functional impairment. Third, moderate depression means David would have significant functional impairment although the symptoms would not be severe. Fourth, severe depression is diagnosed if David has most of the symptoms of depression (Maj, 2013). In this case, the symptoms would be capable of interfering with David’s functioning.

Initial Diagnosis (DSM):

The DSM-5 Diagnostic Criteria of depression outlines that if David has experienced five or more symptoms of depression at the same time in a period of two weeks with at least one of the signs being loss of pleasure or interest, David is likely to be suffering from depression (Maj, 2013). The critical signs highlighted in the DSM-5 model are (1) loss of pleasure or interest in normal activities, increased or decreased in appetite, slowing down of physical movement and thought, loss of energy or fatigue, feelings of worthlessness, indecisiveness, and suicidal thoughts (Maj, 2013). David has been experiencing most of the symptoms highlighted by the DSM-5 model. David’s symptoms are, therefore, sufficient to warrant a depression diagnosis.

Initial Treatment Goals:

The symptoms that David has experienced in the last two months shows that he has been suffering from moderate to severe depression. The following treatments are recommended for the treatment of depression.

1) Antidepressants - These are tablets used to treat depression symptoms. There are various types of antidepressants that are available for use by David.

2) Combination therapy - David can be prescribed to use a combination of antidepressants and therapy. This combination of treatments works better than using only one type of treatment (Davidson, 2010). David may be referred to a mental health support team which may be a psychiatrist, occupational therapist, specialist nurse, or a psychologist for counseling while at the same time taking antidepressants.

Therapists provide the following talking treatments to patients with moderate to severe depression like David.

(a) Cognitive-behavioral therapy (CBT). The aim of CBT is to help a patient to understand their behavior and thoughts that affect them. CBT takes a period of 10 to 12 weeks with 6 to 8 sessions when David would spend time one-on-one with a counselor (Davidson, 2010).

(b) Psychodynamic psychotherapy. David can be assigned a psychodynamic therapist to encourage him to give more information about his thoughts to find out whether there are hidden patterns that are influencing his behavior (Davidson, 2010).

(c) Counseling. Counseling can help David solutions of how to deal with the problems he is facing. The counselor would give David practical advice within 6 to 12 sessions of counseling.

Plan:

Due to the severity of David’s symptoms, he will be required to start taking paroxetine antidepressants immediately. Paroxetine is a type of Selective serotonin reuptake inhibitors (SSRIs) that are recommended for they help improve the mood of a patient through a natural chemical known as serotonin. David will also be required to attend therapeutic sessions. He will be seeing the doctor once a week to assess his progress. If David responds well to the medication, he will continue with the same dose of paroxetine. If there are no changes in the symptoms of David, the doctor will change the medication and prescribe a different antidepressant such as Vortioxetine. During the period of medication, David may have some side effects such as dry mouth, headaches, and nausea. However, the side effects should improve with time.

Name: _____________________________________________ Date: __________________

References

Davidson, J. R. (2010). Major depressive disorder treatment guidelines in America and Europe. The Journal of clinical psychiatry, 71, e04-e04. DOI: 10.4088/JCP.9058se1c.04gry 

Gore, W. L., & Widiger, T. A. (2013). The DSM-5 dimensional trait model and five-factor models of general personality. Journal of abnormal psychology, 122(3), 816. Doi: org/10.1037/a0032822

Maj, M. (2013). “Clinical judgment” and the DSM‐5 diagnosis of major depression. World Psychiatry, 12(2), 89-91. doi: org/10.1002/wps.20049

Schwitzer, A. M., & Rubin, L. C. (2014). Diagnosis and treatment planning skills: A popular culture approach (2nd ed.). Los Angeles, CA: Sage Publications. ISBN-13: 9781483349763