Patient
S. H., 32, female, Caucasian, single, was referred by the patient’s mother since the patient has been exhibiting changes in behavior.
Problem
The patient complains about lack of sleep, tiredness, loss of interest in leisure, irritability, and trouble concentrating. She states that these symptoms have been prominent for two months, except sleep distortion, which was established approximately three weeks ago. The sleep distortion is the most intense of the symptoms, with the patient being able to sleep for three to four hours during the night and one more during the day. The patient reasons that the symptoms were caused by stress and lack of rest since her father’s cancer diagnosis and that she needs good sleeping pills. The counselor’s perception, in this case, is that the patient suffers from depression.
DSM-5-TR Diagnosis
Major depression disorder 296.21 (F32.0)
V/Z codes: Z63.7 – ill or disturbed family member
The diagnosis is based on prominent symptoms such as lack of sleep, tiredness, loss of interest in activities, irritability, and trouble concentrating.
Medication
Citalopram, 20 mg a day, to help with sleep issues, needs to be taken in the morning. Primary care physicians and psychiatrists can prescribe citalopram.
Treatment Goals and Plan Items
Goal one is to take prescribed medication and report changes to the doctor (one month).
It is necessary to monitor the changes within the symptomatic picture and adjust the medication accordingly.
Goal two is to start participating in individual or group counseling (six months).
Counseling helps find support and minimize the effects of isolation (Geng et al., 2018).
Goal three is to learn coping and relaxation techniques (one month).
Being able to cope and relax healthily (exercising, meditating, asking for help) would allow reducing depression symptoms (Geng et al., 2018).
Adjunct Services
Collaborative agencies are counseling groups and individual therapists. The key constituents in the patient’s care are her father’s health and the support and help she received in caring for him. Therefore, the plan is to connect the patient with a cancer caregiver. In the future, the patient can use mobile apps that track sleep and journaling to monitor the symptoms of depression.
Client Strengths
S. H. is patient, determined, and precise, which has been proved by how she takes care of her father. This would allow her to keep up with her medication schedule and not miss counseling sessions.
Discharge Criteria
The services could be terminated when the patient exhibits continuous and complete disposal of depression symptoms.
Reference
Geng, H. M., Chuang, D. M., Yang, F., Yang, Y., Liu, W. M., Liu, L. H., & Tian, H. M. (2018). Prevalence and determinants of depression in caregivers of cancer patients: A systematic review and meta-analysis. Medicine, 97(39), e11863.