Mental Health Case Study Depression

Demographics Patient is a Hispanic male, aged 31. He is the father of one son, aged 10. The patient is Puerto Rican, and was born and spent his childhood in Puerto Rico. He came to live in the U.S. at age 11. He now lives in Brooklyn, New York. The patient is separated from the mother of his son. His son lives with his mother. The patient currently lives alone and is unemployed.

Chief Complaint The chief complaint of the patient is that he is "feeling down and alone recently," and that he also feels separated from his family: "I also haven't seen my son for a while." Clearly he is depressed about his living situation, his prospects, and his health. History of Present Illness The patient's present illness is related to drug abuse, of which the patient has a considerable history.

Essentially, the patient reports that over the past two weeks, he has felt depressed, can't sleep, has little to no energy, can't concentrate, and can't eat. He does not indicate that has had any major fluctuations in his mood -- no elevations or expansiveness. He does have auditory hallucinations (mumbling voices) but does not have visual hallucinations. He does not state any awareness of have paranoid ideation or ideas of reference. He does not have delusions.

He is not currently taking any psychiatric medication but this is only because he has not followed up on his hospital discharge prescription from 7 months prior. Patient's son has been with his mother for the past few months, adding to the patient's increasing isolation and depression. The patient has a poor relationship with his son's mother and that his son has a developmental problem with which the patient would like to help. Not being near his son makes this difficult.

Family Medical and Psychiatric History The patient's family history consists of 4 brothers and 4 sisters born and raised in Puerto Rico. The large family emigrated to the U.S. when the patient was 11 years old. The patient has indicated that there has not been any history of sexual, emotional or physical abuse in his family. He has provided no other history of his family, no medical history or psychiatric family history. All that he has affirmed is the number of siblings and their nationality as Puerto Ricans.

He has also affirmed that his family does still help to support him financially while he is unemployed, so there is the indication that he still maintains some contact with his siblings/parents. Personal Medical and Psychiatric History The patient's medical history consists of two prior hospitalizations, the most recent one being 7 months prior when the patient was demonstrating suicidal tendencies related to drug abuse: he had stepped in front of bus and required medical assistance.

The patient has also received detox and rehabilitation treatment on different occasions, the last occasion following the suicide attempt. The patient is dependent upon opioids and marijuana. The patient has Hepatitis B and C, chronic back pain secondary to getting hit by a car, and received back surgery in 2007. The patient's psychiatric history consists of Mood Disorder diagnosis (DSM-IV-TR), given at the age of 23. The patient has not given any details or specifics regarding his hospitalizations as he is "embarrassed" by them.

He has asserted that he has failed to commit to outpatient psychiatric referrals and has not used the prescriptions provided him in the past. Mood Disorders are little changed from DSM-IV to DSM-V, with a few exceptions: "missing from DSM-V is the DSM-IV entity of mood disorder NOS, which has been replaced with unspecified bipolar disorder and unspecified depressive disorder; people who present with an unclear pattern will have to be designated as one or the other" (Parker, p. 187, 2014).

Thus, DSM-V diagnosis for this patient would most likely be "unspecified depressive disorder" as there is little indication of bipolar disorder. Developmental/Educational/Occupational History The patient's developmental history is scarce and his educational history consists of a GED. There is no indication of employment history other than that he is currently unemployed.

Social History The patient's social history consists of being expelled from school in the 11th grade due to smoking marijuana and getting into a fight at school, after which he was hospitalized (he did not give any specific details about this hospital stay or the fight). The patient did go on to earn his GED. The patient affirmed that he was only violent in this fight and was never violent at the hospital.

He has spent some months in jail (the patient did not divulge how many) for dealing drugs (he did assert that he was arrested twice, thus marking him as a repeat offender). For the time being he has no job and receives assistance from his family. Substance Abuse History & Current Use The patient has a history of substance use and abuse and is currently abusing heroin, using 5-8 bags per day for the past 3 years. He has smoked marijuana occasionally.

The patient has undergone multiple detox and rehab treatment for opioid dependence, most recently 7 months prior. Mental Status Examination The appearance and behavior of the patient indicated displeasure with himself: he is a Hispanic male who looks his age. He was sniffling and grimacing, but he made adequate eye contact. However, he looked like he was physically uncomfortable with both himself and his surroundings. He was sufficiently groomed, not unkempt, and had no distinguishing feature. His speech was articulate, with a normal rate, volume and rhythm.

His English was fluent and his word choices appropriate. His thought processes were appropriate and linear and he was clearly goal-oriented in his thinking, not wandering. The patient's focus is on obtaining relief from his symptoms of drug withdrawal and he admits that he needs detox. The patient did indicate perceptual disturbance with auditory hallucinations. He does not demonstrate suicidal ideation nor violent ideation. His mood is depressed, causing him to be anxious and dysphoric. His impulse control is intact.

His cognitive functions are oriented to person, time, place and situation; in short, he is not disoriented. His ability to think abstractly is sufficient with his age and education and his attention span is fair. He has insight into his own symptoms and detects the presence of illness and need for rehab. His judgment, however, is poor or soft, given his tendency to relapse. Diagnosis The patient suffers from Mood Disorder and Depression.

Therapeutic Intervention Plan Cognitive-Behavioral Therapy (CBT) would be an appropriate intervention plan for this patient as it has been used to treat both depression and other mental disorders (McKay et al., 2015). The core concepts of CBT are that it effectively addresses current problems of a patient by helping the patient to change harmful thinking and behavior through deliberate use attention-focusing techniques.

The CBT therapist acknowledges that harmful actions sometimes emanate not from rational choice but from a lack of control of passions, or what Aristotle called akrasia -- a softness of the will. By focusing on both behavioral and cognitive aspects of the patient's life, the therapist is able to guide the patient towards overcoming a stimulus-avoidance response characterized by repeated lapses in judgment and relapses into drug abuse, demonstrated by this particular patient.

Thus, the core concept of this therapy intervention is to address the relationship between thought and action and help in aligning the two so that there is less risk of relapse do to avoidance issues (Beck, 2011). Interpersonal psychotherapy might also be beneficial as this orientation allows the counsellor to draw attention to the patient's surroundings -- i.e., how he or she relates to various persons in his or her life (Rogers 2012). To this end, supportive psychotherapy could also be useful.

Supportive psychotherapy essentially views every individual's character as a work in process and that structural changes to that work should come from the individual himself rather than from the therapist. Supportive therapy helps the patient to relieve his or her symptoms and to live with them as opposed to attempting to eradicate them from the individual's life over a series of sessions, be they weeks, months or years long. CBT and supportive psychotherapy are somewhat opposite in extremes, but a combination of the two could be useful in this case.

Primarily CBT is the recommended main therapeutic intervention because of the diagnosis of mood disorder, drug dependence, and depression. Guidance from a therapist could be crucial in making the difference. The rationale for CBT is that one's self-awareness and self-concept contribute to one's "acting self" -- but so, too, does one's body (Tsakiris, Haggard, 2005, p. 387). The acting self is part of a response to various factors, both conscious and sensory.

In other words, one "acts" on various levels, which may be understood as "automatic" in a sense and as "pre-arranged." The acting self is a composite of one's intellectual beliefs, physical attributes, and will to power. If one's self-concept is how one views oneself on an intellectual/role-playing plane, and self-awareness is how one interprets one's self (actions, beliefs, etc.), self-esteem is how one views one's emotional self -- whether one feels positive or negative about one's self.

In simple terms, one who has good self-esteem generally feels "good" about oneself: he or she is confident and secure. One who has low self-esteem generally feels less confident and more insecure. Self-esteem generally generates such feelings as pride or shame, exultation or despair (Hewitt, 2009, p. 217).

Sarason (2005) notes that while psychoanalytic theories offer a penetrating viewpoint into the psychological makeup of a patient who suffers from depression, behavioral therapy is often needed to accentuate the psychological and behavioral development of the patient as they work in tandem, each serving to reinforce the other. Sarason observes that "psychoanalytic theorists have suggested that clinical episodes of depression happen because the events that set off the depression revive dimly conscious, threatening views of the self and others that are based on childhood experience" (p. 349).

But in the case of the present patient, there appears to be no indication of childhood trauma. However, the uprooting of the family from Puerto Rico and transporting them to the U.S. may actually have some significance in the patient's inability to adapt, as the move occurred at a rather impressionable age for the patient. Thus, Sarason's approach would suggest that both psychoanalysis and CBT would be beneficial here.

By bringing to the patient's consciousness the inner conflict that resides in his subconscious, the psychoanalyst hopes to ease the affliction and ultimately free the patient from the depressive attacks. From the standpoint of the theory of psychoanalysis, depression can best be treated through therapy sessions in which the patient, through discussion, uncovers the cause of the affliction within his own psyche. The school of behaviorism combines different subject areas in order to better diagnose patients: it uses theory, philosophy, and methodology to cultivate an understanding of behavior.

There are various schools of behaviorism, such as radical behaviorism, which relates to pragmatic philosophy and egoism. Today behaviorism is better known as behavior analysis. It applies to my own life in the sense that I often take a pragmatic approach to dealing with people and combine different fields of knowledge/science in order to help both myself and them. Classical conditioning is based on the Pavlov theory, which showed that we can be conditioned to respond in a certain way to stimuli over a period of time.

This differs from operant conditioning, which is based on the work of Skinner, in that it looks at voluntary actions on the part of the subject and shows how such actions are affected by environment consequences. Both differ from observational learning in that sense that the latter occurs more from social observation (i.e., the subject actively watching rather than the subject being acted upon).

CBT as a therapeutic approach would be the best intervention for this patient because of its goal-oriented approach and it would also assist the patient in changing certain patterns with his thinking and actions. This should alleviate his anxiety and lighten his depression as it will be more helpful for him in managing his feelings effectively. However, because the patient is withholding information about his past, it may be necessary to administer a psychological test (MMPI).

This could also help to rule out any possible personality disorder (which could be manifested in his previous suicidal tendency). Interventions A standard intervention would require face-to-face time. 6 to 18 bi-monthly sessions of one hour would be sufficient. Thus, twice a week, the patient would meet with the CBT therapist and the effectiveness of the therapy would be monitored over these sessions. The patient is given assignments or task on which he is supposed to focus in between sessions.

The tasks are designed to orient his mind and behavior towards relinquishing the attachment to narcotics and towards establishing a more positive cognitive-behavioral development. For example, because the patient suffers from depression, a good assignment would be for him to do something social in nature, such as attend a church meeting or a community event. Fulfilling simple tasks like this are relatively easy and reinforce the commitment to change that CBT is intended to effect.

The therapy sessions can be supported by a detox program or rehab stint that helps the patient progress through the physical aspect of withdrawal. This method of intervention can utilize a prescription, but given the patient's prior refusal to take the prescriptions given as an outpatient, it may be more effective for the CBT sessions to provide an effective base or foundation before this intervention is used and an appropriate weaning prescription provided. The step-by-step CBT therapy should continue bi-monthly over the course of at least six months.

An interval of one week between sessions allows the patient time to adjust and apply whatever thinking tools or activity tasks the therapist.