Case Study
Patient Demographic: Client Age: 25 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Single Counseling Setting: Counseling Clinic Type of Counseling: Individual Presenting Problem: Depression and Suicidal Ideation Diagnosis: Major Depressive Disorder, Recurrent, Mild (F33.0)
Mental Status Exam: Mental Status Exam: The client appears to not have bathed recently because his hair is greasy and unkempt. The client has food stains on his clothing; however, he is dressed appropriately for the season. His motor movements are within normal limits. He is engaged in therapy, but he appears anxious as evidenced by hesitating before speaking and by his hand wringing. The client reports suicidal ideation with no plan or intent. The client reports a depressed mood more often than not and difficulty enjoying most activities. The client is oriented to person, place, time, and situation. The client reports that his appetite has increased lately and that he is experiencing hyperso
Presenting Problem: You are a resident in counseling practicing in a private practice agency. During the initial counseling session, the 25-year-old single male client reports feeling depressed and hopeless. He has difficulty enjoying activities that he has enjoyed in the past and feels unsatisfied with most areas of his life. The client identifies that he is not happy at work and wants to make a career change. The client verbalizes feeling sad more often than not, and that this has been going on for about 2 years. The client decided to start counseling when he began experiencing suicidal thoughts. The client reports no plan or intent to attempt suicide but is concerned about his own well-being.
Other Contexts:    mnia. Family History: The client reports that he has two younger brothers who are 19 and 22 years old. His parents divorced when he was 10 years old, and he grew up living with his mother but maintained a strong consistent relationship with his father. The client reports no history of trauma, neglect, physical abuse, sexual abuse, or emotional abuse. The client denies drug or alcohol use, although he reports that his father previously was an active alcoholic

Question: What area is most important for you to further assess to confirm a diagnosis of major depressive disorder, recurrent, mild?
(A): The timeline of the depressive symptoms
(B): The presence or absence of social supports
(C): The association of symptoms to drug and alcohol use
(D): Functioning at work, home, and socially

Correct Answer: Functioning at work, home, and socially
Explanation: All of these elements are important foci for treatment planning purposes. The timeline was already identified in the first session (2 years); therefore, it does not need to be assessed further to confirm this diagnosis. The client already relayed that he does not use drugs or alcohol; therefore, this has also already been addressed. The DSM-5-TR requires at least five depressive symptoms in order to meet the criteria for diagnosis of major depressive disorder, in addition to four additional criteria: the impact of symptoms on functioning in critical areas of the individual’s life, the episodes are not attributed to substance use or other disorders, the episodes are not attributed to psychotic disorders, and the episodes are not also accompanied by alternating manic episodes. Enough symptoms were identified for the diagnosis; however, it is important for you to further assess the impact of these depressive symptoms on functioning across multiple areas of the client’s life in order to confirm this diagnosis. Therefore, the correct answer is (D)
Competency: intake, assessment, and diagnosis