Intake Information for Mental Health

Case information and intake information
Presenting Problem:
The patient is a Caucasian female that is 29 years old. She presented the symptoms and signs of a mental health condition. Apart from having sleepless nights, she stated that she often felt sad, had crying spells almost daily, and that she was overeating. She stated that her sleeping was not right in the sense that it took her a couple of hours before finally falling a sleep. She also added that during certain nights, falling a sleep was impossible and if it happened, she would only sleep for few hours. She mentioned that she found herself thinking a lot and worrying during the time that she was awake. She said that her worries included the thoughts of her not being a good mother, and she felt as though she was a burden to her husband. She also acknowledged that she often thought about her family and her the unhealthy relationship between her and her mother.
She mentioned that she felt as if her situation become worse following her third child’s birth that happened almost one year ago. At the first intake interview, the patient said that she was feeling “all right, always down”. Her “all right “answer came out almost immediately, and after pausing for a bit, she added the “always down” response. She disclosed that she was ever in deep thoughts and worries, and she felt as if everyone was looking at her. She denied having any suicidal thoughts or behavior. She stated that running away from her issues would be great, but she knew that that she could not take her life.
She acknowledged that her condition was negatively affecting her life. First, she said that it was the relationship between her and her husband and kids. Second, she mentioned that her condition was socially affecting her since it was preventing her from taking part in family events. She also added that her condition was affecting her financially since she felt incapable of working outside at her house at that time. She concluded by saying that she is unhappy and no longer the person that she used to be.
History of the complaint:
The patient mentioned that she searched for help regarding her post-partum depression about six months after giving birth to Zeke, her third-born. She mentioned that she got depressed after finding out that she was expectant, and her depression worsened after the birth of her child. She recalls being exhausted sad, often crying, and having no energy during the first months of her pregnancy. She said that even though she felt tired, sleeping was still an issue. She added that those feelings continued even after the birth of Zeke. Her gynecologist recommended 20 milligrams of Paxil that she took for a couple of months. She mentioned that she stopped taking the drugs because she felt that they were not helping her. She said that there were not working as her condition was not improving. She also added that she just does not like taking medicine. She mentioned no other instances of past depression cases.
Current family relationships:
The patient stays with the husband, with whom they have been married for six years, together with their three kids. One of the kids is from her previous marriage. Her husband owns a roofing business where puts in several hours per day. The patient, on the other hand, stays at home with the children.
She remembers being ill when pregnant during her third pregnancy. She said that despite being on birth control she still got pregnant. It was not a planned pregnancy and she constantly felt depressed and drained all through the pregnancy. She added that Zeke changed her entire life right from the instance he was born. Her relationship with Zeke is a massive stress source for her, though she mentions that she equally loves each of her kids and that she tries to be the best mother to them.
Depression DSM-5 Diagnostic Criteria
The criteria has been chosen for diagnosing the mental health condition the patient is experiencing. DSM-5 lists the following criteria in making a depression diagnosis. The patient must experience more than five symptoms during a period of two weeks and one of the symptoms should either be a depressed mood or loss of pleasure/ interest.
Below are the some of the other symptoms:
1. Depressed mood for most part of the individual’s day, almost daily
2. Considerably reduced pleasure or interest in nearly all activities for most part of the individual’s day, almost daily
3. Considerable weight loss without dieting, or increased or decreased appetite
4. A decrease in physical movements and a slowdown of thoughts, observed by others around
5. Exhaustion or energy loss almost daily
6. Thoughts of being worthless or feelings of guilt most part of the individual’s day, almost daily
7. Recurrent suicidal thoughts without an specific plan, or a suicidal attempt or planning to commit suicide
To get a depression diagnosis, the above symptoms should cause the patient medically considerable impairment or distress in occupational, social, or any other important functioning areas. These symptoms should not be an outcome of drug abuse or another health condition. In fact, according to DSM-5, the diagnosis of a MDE (major depression episode) requires at least five symptoms to be presented by the patient within two weeks (American Psychiatric Association, 2013). At least one of the symptoms should either be loss of pleasure or interest (anhedonia) or depressed mood. MDE’s secondary symptoms include weight or appetite changes, difficulties sleeping (hypersomnia or insomnia), psychomotor retardation or agitation, energy loss or exhaustion, reduced ability to concentrate or think, feelings of guilt or worthlessness, and suicidal thoughts. The above symptoms get rated in an all or none manner. The DSM-5 criteria has thus been chosen for this particular case since as per the information presented, most of the required symptoms are present.
In order to make a thorough and complete diagnosis of the patient’s health condition, it would be important to have an understanding of the patient’s upbringing, particularly her family’s situation and her upbringing, with major focus on the nature of the relationship between her parents and their roles in their children’s upbringing. Depression is often a result of complex interactions among biological, psychological, and social factors. Individuals that have experienced adverse events (such as bereavement, unemployment, psychological trauma) will most likely develop depression (World Health Organization, 2018). In turn, depression can result to more dysfunction and stress and even worsen the individual’s life.
Depression management involves three components. First, support that ranges from discussing contributing stresses and practical solutions, to education of family members. Second, psychotherapy, also referred to as talking therapies like CBT (cognitive behavioral therapy). Third, drug treatment involving antidepressants (MacGill, 2017). Before choosing a treatment option, it is important to first understand the patient’s upbringing, situational stressors, and her support structure.
Historical treatments/interventions
At the final part of analysis, doctors started to imply that the root of the patient’s health condition was aggression. Treatments like music, diet, drugs, and exercise were recommenced. The doctors even suggested sharing her problems with her friends and family. According to other doctors, depression arises from internal conflicts within you; what is right and what you want (Gilbert, 2016). Depression is presently considered to be as a result of several causes, including social, biological, and psychological factors. Medicines and psychotherapy that mainly target molecules are known as neurotransmitters and they are the preferred treatments, even though electroconvulsive therapy might be used in some cases, like treatment-resistant cases of depression or serious cases that require immediate relief.
Risk and resilience assessment
In Western countries, several other factors are recognized as important signs of depression, including use of alcohol, disability, as well as academic, community and familial responsibilities. Disability and alcohol abuse have been consistently identified as important depression signs amidst college students (Davaasambuu et al., 2017). Use of alcohol is one of the strongest depression signs amidts young adults. Disabilities, within physical and cognitive realms, are also signs of suicidal behavior. Finally, stresses linked with community and household responsibilities are also predictors of suicidal behavior and depression (Davaasambuu et al., 2017). Several resilience factors particularly crucial when dealing with suicidality and depression have also been revealed. These factors include positive future expectations and social support.
When left untreated, depression often worsens resulting in health, behavioral, and emotional problems, which affects all aspects of your life. Below are a few complications linked with depression:
· Physical illness or pain
· Drug or alcohol misuse
· Excessive weight gain or obesity that can result in diabetes and heart disease
· Social phobia, panic disorder, or anxiety
· Social isolation
· Relationship difficulties, school or work problems, and family conflicts
· Self-harm like cutting
· Premature deaths
· Suicidal attempts (Hammen, 2018).
Strengths-based assessment techniques
Modern approaches to mental health care in communities are more about encouraging individuals to determine and build their strengths in pursuit of their goals. Many strategies, practice methods, and policies have been developed to help individuals build their strengths (Xie, 2017). Those who advocate for these new approaches to mental health care, believe that individuals have strengths that they can rely on to recover and, therefore, work with them to help them nurture or use their strengths. Considering the fact that they are based on strengths, these modern approaches are collectively referred to as strengths-based approaches. The approaches have three principles. First, every individual has strengths that he or she can use to enhance their life quality. Second, the motivation of individuals to have better lives usually comes from their strengths. Lastly, there are resources in all environments to help individuals to build their strengths.
Exception finding assists consumers to recognize their present and past strengths, to rekindle their beliefs in themselves, to cope better, to draw upon their previous triumphs and responses to issues, to use past triumphs to deal with current problems, and to start making deliberate efforts to get better (Scheel, Davis & Henderson, 2013).
In the last 15 years, there has been a significant increase in the body of knowledge on depression including increase in information about how to identify at-risk persons for prevention, how to prevent depression, the underlying risk factors, and how to intervene in various cases of depression. There is a substantive body of knowledge showing that preventive interventions can significantly help in reducing the prevalence of depressive disorders (Buntrock et al., 2016; Muñoz et al., 2010). Some of the factors that have been found to protect against depression include resilience, (mental fitness, strength, and fortitude), personal competencies (agency, self-understanding, social skills, and intelligence), and social support. The definition of resilience is finding resourceful ways to cope with challenges. Having resilience can help reduce the impact of stressors that cause depression.
Therapists can help clients by motivating them to change, encouraging them to continue changing, listening to them, appreciating their hard work, validating their experiences, affirming their successes, and validating their experiences (Scheel et al., 2013).
Information on contemporary responses and evidence that this will serve as the guide
It is important that the intervention being provided for a condition is based on the symptoms the condition. Diagnosis of a condition depends on clinical reasoning and it should be patient-centered. The definition of clinical reasoning is that it is a cognitive process utilized to assess and manage medical problems. The process is based on dual process theory, a theory which is widely utilized in decision-making. It integrates both non-analytical and analytical decision-making models including fast system 1 and slow system 2 (Kahneman, 2011).
However, when the “explicit diagnostic criteria” was introduced in mental health care research and was later adopted in the DSM-III for clinical practice, it turned things around. It helped therapists to avoid the subjectivity and vagueness of previous conventional diagnostic processes (Maj, 2013), that affected the reliability of diagnoses. The utilization of set diagnostic criteria, of course, also affects clinical judgment. The right use of criteria is only possible when the therapist has sufficient clinical knowledge and experience especially in psychopathology (Maj, 2013). Nevertheless, the above would only be recommended with the clinician able to decide whether to use it or not.
Critique of the diagnosis
The criteria of diagnosis can be regarded an instance of actor-observer bias in social science. This bias refers to the propensity to stress internal causes (traits) when describing or explaining an individual’s behavior but at the same time regarding one’s own behavior to be a result of situational or external factors e.g. stress. Studies have shown that cognitive beliefs among observers could be their motivation for mindless use of diagnosis criteria especially among mental health professionals. Therefore, the argument is that normality conceptions lifted from the utilization of the criteria are largely anchored on ideas of social conformity. In places where clinicians are only utilizing social conventions plus some previously learned knowledge, for example, DSM categories, in making their judgments about clients, they are less likely to look for new information, techniques, or strategies that may help them make better judgments or decisions (Khoury, Langer & Pagnini, 2014). Mindlessly focusing on the past can seriously compromise therapy or result in misdiagnosis or mistreatment. In conclusion, the criteria is a mindless way of categorizing conditions and it encourages mindless use of the table to box patients with certain symptoms and not to look deeper with the help of other clinical data, approaches, and techniques.
Implications for special populations
One of the biggest issues in mental health care, affecting both research and clinical work, is the low reliability of diagnostic procedures utilized in the field. The condition identified utilizing the procedures could differ based on the system that has been used, how the patients report the symptoms, and their severities. This has resulted and continues to result in contradictions and inconsistencies in mental health research and, therefore, necessitates the need for further techniques to be used to provide accurate diagnosis. Considering that standardization of the criteria may not be proper for everyone especially minorities, there is a need to have this in mind to reduce incidences of misdiagnosis and mistreatment.
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders. BMC Med, 17, 133-137.
Buntrock, C., Ebert, D. D., Lehr, D., Smit, F., Riper, H., Berking, M., & Cuijpers, P. (2016). Effect of a web-based guided self-help intervention for prevention of major depression in adults with subthreshold depression: a randomized clinical trial. Jama, 315(17), 1854-1863.
Davaasambuu, S., Aira, T., Hamid, P., Wainberg, M., & Witte, S. (2017). Risk and resilience factors for depression and suicidal ideation in Mongolian college students. Mental health & prevention, 5, 33.
Gilbert, P. (2016). Depression: The evolution of powerlessness. Routledge.
Hammen, C. (2018). Risk factors for depression: An autobiographical review. Annual review of clinical psychology, 14, 1-28.
Kahneman, D. (2011). Thinking, fast and slow. Macmillan.
Khoury, B., Langer, E. J., & Pagnini, F. (2014). The DSM: mindful science or mindless power? A critical review. Frontiers in psychology, 5, 602.
MacGill, M. (2017). What is depression and what can I do about it? Medical News Today. Retrieved from https://www.medicalnewstoday.com/kc/depression-causes-symptoms-treatments-8933.
Maj, M. (2013). “Clinical judgment” and the DSM?5 diagnosis of major depression. World Psychiatry, 12(2), 89-91.
Muñoz, R. F., Cuijpers, P., Smit, F., Barrera, A. Z., & Leykin, Y. (2010). Prevention of major depression. Annual review of clinical psychology, 6, 181-212.
Scheel, M. J., Davis, C. K., & Henderson, J. D. (2013). Therapist use of client strengths: A qualitative study of positive processes. The Counseling Psychologist, 41(3), 392-427.
World Health Organization. (2018). Depression. Retrieved from https://www.who.int/news-room/fact-sheets/detail/depression.
Xie, H. T. (2017). Nursing Consumers with Mental Illnesses towards Recovery Using the Strengths-based Approach. GSTF International Journal of Nursing and Health Care (JNHC) 1(1), 75-79.