CLINICAL CASE REPORT

● Reason for Referral & Presentation of the Problem

- Client’s been diagnosed with Depression ( Major Depressive Disorder ).

According to his summarization within his perspective towards the case, he is
under the experience of emptiness and hopelessness in every problem he
encounters. May it be within his family, friends or personal status he worries
much and has suicidal thoughts roaming in his head. Client has been through a
physical exam and done several lab tests to make sure that the client’s thyroid is
functioning well. Client is under the influence of antidepressants specifically in the
category of Selective Serotonin Reuptake Inhibitor (SSRI) intaking Citalopram (
Celexa ). Unfortunately, in the perspective of the client, he finds the medication
insufficient. Hence, approaching this clinic he hopes to find a treatment that is
suiting his mental situation.

● Description of the Client ( Physical, Behavioral, and Social )

- Client is at 16 years of age, male, speaks in Tagalog Language but is very

comfortable and also fluently speaking english at the moment of session and
during the entire therapy. Client is a student, with a civil status of being single,
and is in a living situation wherein he still receives support from his parents. In
the client's first visit he appears to be a decent boy but fear resembles in his eyes
like he is not used to communicating or having interaction towards other people.
But once he got comfortable he got to speak up and became very confident and
seems to be very skillful in talking and seems to be very responding to every
question asked. Client experiences nervousness each time he tries to interact
with people, but he seems to be very logical and intelligent from the way he talks
and answers. Behavior towards the therapist is at a good and stable condition, no
bad habits observed, he seems to be very formal toward the therapist.

● Brief Pertinent Life History

- Client composition and relationship amongst family members is somehow

unstable and not that open according to the words of the client. He stated that his
family is granted a lot of wealth but within that wealth he still can’t contain himself
and is still experiencing sadness and loneliness. One factor of his loneliness may
be caused by the fact that he is the only child of his parents. According to the
client, his parent’s always come home late from work and have no time to bond
with him since even when they come home it’s still work that has their focus on.
According to the client both parents aren’t diagnosed with any known illness or
even mental illness, meaning to say both parents are healthy and may be the
client’s illness came from the environment he is dwelling upon. Client also stated
that he has problems communicating with people since his parents alone can’t
 even communicate with him. Client also clearly said that his parents never forget
about occasions and his birthdays but his parents always ask the personnels in
their house to prepare something for the client or buy him whatever he wants
since both parents are just too busy to assess him on their own. Client also has
friends but he described them as not true to him since client feels like he is just a
background friend who just fits whenever he is needed and client feels he is not
also that important for them.

● Psychiatric History and Past History Treatment for the Presenting Problem

- Client has been diagnosed with depression starting from when he was at the age
of 15. Hospitalization history is blank since he was not yet hospitalized with his
given situation. According to the client his former Psychiatrist prescribed him with
Selective Serotonin Reuptake Inhibitor ( SSRI ) specifically Citalopram ( Celexa )
to help him overcome his illness. Client is now almost a year under the influence
of the prescribed medication but still feels like his illness has not yet much
improved.

● Treatment Planning

- Client’s treatment will now include Cognitive Behavioral Therapy (CBT) to further
observe the improvement of client’s mental behavior, weekly journal of the client,
each of his thoughts must be written and will be read by the therapist,
examinations and assessments will be handled out to the client in order to
examine more of what the client is experiencing in his mind and thoughts, and
client is also recommended to intake a new medication. Tricyclic Antidepressants
is a recommendation for the client since SSRI’s as stated above gave the client
not much of an improvement. This may cause the client a few side effects more
than newer antidepressants but it is found to be very effective amongst other
antidepressants. Client is required to attend a weekly seminar about his mental
illness after he is counseled and examined by the therapist.

● Clinical Case Formulation

- Solutions to the client’s mental illness are all stated above in the Treatment
Planning section. But to further know what the therapist is up to, the goal of the
therapist is to develop an excellent patient-therapist relationship to have the client
be more confident to open up to the therapist making it look like the therapist is
his friend that he can approach each time he is in the encounter of a problem or a
dilemma. The goal of this patient-therapist relationship is to break the barriers
that are holding the client from opening up and let him express himself in his own
ways where he is comfortable and he feels like it is his safe zone.