Clinical Logs: Major Depression
Name: C.Y
Age: 40 years
Diagnosis: Major Depression
S: C.Y is a 40-year-old client that came to the unit for her third follow-up visit, after she was diagnosed with depression four months ago. The client was diagnosed after she experienced symptomsthat included depressed mood in most of the days for every day. She was also socially isolated as he lacked interest in things and pleasure. She reported that the depressed mood had made it difficult for her to engage in her occupational roles.
The client also reported that her ability to make decisions was also significantly affected. He level of irritability was also high. Based on the above, the client was diagnosed with major depression and initiated on psychotherapy and antidepressants.
O: The client appeared appropriately dressed for the occasion. She reported that her mood has been improving with the adopted treatments. The client was oriented to self, others, time, and events. She denied illusions, delusions, and hallucinations. She denied suicidal thoughts and attempts. She denied current suicidal plans. The client does not have a current suicidal plan. Her speech was reduced in terms or rate and volume.
A: The symptoms of depression have improved. The client reports that the treatment has been effective, as she experiences minimal depressive symptoms.
P: The client was advised to continue with the current treatment. She was also advised to come for a follow-up visit after four weeks.
Major Depression
Name: R.T
Age: 40 years
Diagnosis: Major Depression
S: R.T is a 40-year-old male who came to the clinic today for his follow-up visit after being diagnosed with major depressive disorder three months ago. The client has been on antidepressants and group psychotherapy treatments. R.T was diagnosed with major depressive disorder after he came to the clinic with complaints that included the feelings of sadness almost every day. The client also felt intense guilt that made him socially isolated. There was also the change in the sleeping habits of the patient. Accordingly, he noted the increasing difficulties he was experiencing to fall asleep and maintain sleep. The client also reported lack of energy, and suicidal ideations and attempts. There were also the complaints of lack of interest in the social and occupational roles that the patient used to engage in before the diagnosis. Based on the above symptoms, the client was diagnosed with depression and initiated on antidepressants and group psychotherapy.
O: The patient appeared appropriately dressed for the occasion. He was oriented to self, place, time and events. The rate and volume of speech of the patient was normal. The self-reported mood of the client was normal. The client denied illusions, delusions and hallucinations. He also denied recent history of suicidal thoughts, attempts, and plans.
A: The client is responding well to the treatment. The improvement in symptoms is in accordance with the developed treatment objectives. The client is also tolerating the adopted treatment interventions.
P: The decision that the patient continues with the current treatment was made. This was based on the improvement in the symptoms of depression.
Major Depression
Name: D.K
Age: 37 years
Diagnosis: Major Depression
S: D.K is a 37-year-old client that came to the clinic today for the sixth follow-up visit after being diagnosed with major depression seven months ago. He has been on antidepressants and group psychotherapy treatments. D.Kwas diagnosed with depression after she presented with complaints of feeling sad most of the days almost all the days, feeling worthless and guilty most of the times. There was also the complaint of decline in appetite, as she died not want any type of food. Her interest in pleasure also declined significantly.
The client also reported suicidal thoughts without attempts or plans. The symptoms had affected significantly her ability to perform as expected in her occupational roles. The symptoms could not be attributed to other causes such as medication use, medical conditions or substance abuse. She was therefore diagnosed with major depression and has been undergoing treatment in the facility.
O: The patient appeared dressed appropriately for the occasion. She was oriented to self, place, time and events. Her judgment was intact. She denied any suicidal thoughts, attempts or plans as well as illusions, delusions and hallucinations. Her mood was normal.
A: The client has responded well to the treatments. Her mood has improved. She also tolerates the adopted treatments as expected.
P: Psychotherapy sessions were terminated
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