Identifying Information:
The client is a 49-year-old male who has been married to his high school sweetheart for 21 years and with two adult children. For the past 20 years, j]he has worked as a metallurgical engineer in a mill in the local state. He has not experienced any divorce or marital issues.
Presenting Problem:
The client is a 49-year-old male presenting with symptoms of depression. He explains that he used to enjoy going to work but now “he would rather just stay home”. He has been feeling blue and his appetite has decreased. He feels like life is not worth living. He has no interest in the activities he once used to enjoy. These days, he would rather stay alone in his bedroom. He reports irritability and low energy, more physical pain in the back and neck area, difficulties sleeping.
Life Stressors:
Emotional problems such as Irritability and Physical pain.
Substance Use: 1 Yes 0 No
The client reports drinking two to three beers a night although he used to drink more when he was younger. Apart from drinking, there are no reports of other use substance use.
Addictions (i.e., gambling, pornography, video gaming)
David has no reported addictions.
Medical/Mental Health Hx/Hospitalizations:
There is no reported medical, mental health, or hospitalization history.
Abuse/Trauma:
David does not have a history of trauma.
Social Relationships:
David describes his relationship to his wife as “typical ”. He explains that they do little as a couple even though they eat dinner and attend family gatherings together. For his social activities, he used to enjoy watching TV, playing golf, reading. His relationship with his son and sister is not described in the case.
Family Information:
Lisa, David’s sister, used to have the same problems as David. She battled depression for more than 10 years. Currently, she receives help from a counsellor and a psychiatrist.
Spiritual:
No spiritual about David is provided in the case.
Suicidal:
There are no reported suicidal ideations.
Homicidal:
David does not report homicidal ideations.
Assessment:
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Initial Diagnosis (DSM):