Case Study
Patient Demographic: Client Age: 32 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Caucasian Counseling Setting: Community Mental Health Agency Type of Counseling: Individual Presenting Problem: Depressed Mood Diagnosis: Bipolar II 296.89 (F31.81), current episode depressed
Mental Status Exam: Mental Status Exam: The client is dressed casually and is somewhat disheveled. She avoids eye contact and displays a flat affect. The client admits to having suicidal thoughts in the past but currently denies both suicidal and homicidal ideations. Her speech is soft in volume and tone. She tends to provide one-word responses but is cooperative when asked to elaborate. The client denies audio-visual hallucinations, and her thought content is coherent. The client’s mood is depressed, and her affect is flat. She appears tired and reports she has insomnia at night and is sleeping most of the day. The client has experienced depression off-and-on, beginning in late adolesc
Presenting Problem: You work at a community mental health agency providing outpatient services to adults. Today, you are meeting with a 32-year-old female who presents with her husband for an initial intake session. The client’s husband is concerned about his wife’s depressive symptoms. She is experiencing sadness, decreased appetite, and hypersomnolence. The client also expresses hopelessness and has lost interest in doing the things she once enjoyed. Until recently, the client worked at an art gallery. When employed, she reports that she, “just couldn’t get out of bed” and was eventually let go due to excessive absences. After her employment ended, her depressive symptoms worsened. The client was able to recall a time nearly one year ago when she felt “almost the opposite” of how she feels now. During this time, she experienced increased energy and felt more inspired and creative. The client explains that she and her husband used to travel selling their art at juried art exhibitions most weekends, but it has been awhile since she has joined him.
Other Contexts:    ence. Family History: The client is married and has a 10-year-old daughter from a previous marriage. The client explains that her father was “distant and quiet unless he was drinking.” She remembers hearing that her paternal grandfather declared bankruptcy “at least once” due to gambling losses. The client’s mother has been diagnosed with bipolar disorder, with acute episodes requiring hospitalization. The client indicates that a former therapist also diagnosed her with bipolar disorder, but she rejects the diagnosis stating her symptoms are “nothing like my mother’s

Question: Based on the client’s diagnosis, which assessment instrument would you use to obtain baseline data on the client’s current level of functioning?
(A): Brief Psychiatric Rating Scale (BPRS)
(B): Level of Care Utilization System (LOCUS)
(C): DSM-5-TR Level 1 Cross-Cutting Symptom Measures
(D): Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES)

Correct Answer: DSM-5-TR Level 1 Cross-Cutting Symptom Measures
Explanation: The DSM-5-TR Level 1 Cross-Cutting Symptom Measures is “intended to help clinicians identify additional areas of inquiry that may have significant impact on the individual’s treatment and prognosis. In addition, the measure may be used to track changes in the individual’s symptom presentation over time” There are 13 domains for adults, including depression and mania, making DSM-5-TR Level 1 Cross-Cutting Symptom Measures a solid choice for obtaining baseline data. The Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES) is a self-administered instrument used to help determine an individual’s motivation to change alcohol-related behaviors. Level of Care Utilization System (LOCUS) is an assessment instrument specifically designed to determine an appropriate level of care for individuals with addiction and psychiatric comorbidity. Finally, the Psychiatric Rating Scale (BPRS) measures psychosis and psychosis-related symptoms of schizophrenia or major psychotic disorders. Therefore, the correct answer is (A)
Competency: intake, assessment, and diagnosis