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The patient is a 15‐year‐old Puerto Rican adolescent female living with both her parents and a younger sibling. Her parents presented with significant marital problems, had been separated several times and were discussing divorce. Her mother reported having a history of psychiatric treatment for depression and anxiety and indicated that the patient’s father suffered from bipolar disorder and had been receiving psychiatric treatment. He was hospitalized on multiple occasions during previous years for serious psychiatric symptoms.
The patient is failing several classes in school, and her family was in the process of looking for a new school due to her failing grades and difficulties getting along with her classmates. She presented the following symptoms: frequent sadness and crying, increased appetite and overeating, guilt, low self‐concept, anxiety, irritability, insomnia, hopelessness, and difficulty concentrating. In addition, she presented difficulties in her interpersonal relationships, persistent negative thoughts about her appearance and scholastic abilities, as well as guilt regarding her parents’ marital problems. She states that sometimes she feels the world would never know if she disappeared.
The patient’s medical history reveals that she suffers from asthma, used eyeglasses, and is overweight. Her mother reported that she had been previously diagnosed with MDD 3 years ago and was treated intermittently for 2 years with supportive psychotherapy and anti‐depressants (fluoxetine and sertraline; no dosage information available). This first episode was triggered by rejection by a boy for whom she had romantic feelings. Her most recent episode appeared to be related to her parents’ marital problems and to academic and social difficulties at school.
Chafey, M. I. J., Bernal, G., & Rossello, J. (2009). Clinical Case Study: CBT for Depression in A Puerto Rican Adolescent. Challenges and Variability in Treatment Response. Depression and Anxiety, 26, 98-103. https://doi.org/10.1002/da.20457
This assignment requires a comprehensive SOAP format. So, all information from the subjective, objective, assessment, and plan must be included. In the plan portion make sure to include the following:
Pharmacological treatment needs to be specific; give a particular medication with dosing and frequency
Non-pharmacological treatment-give a specific example like CBT, MBSR, Patient Education Referral to other providers, Follow-up.
Use the Case Study template to show your assessment collection data as well as the thought processes for diagnosis and treatment. Support your diagnosis and treatment plan with a minimum of two references in APA form.
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