II. Identifying Information
Client is a 46 y/o white female w/depression and suicidal ideation for the past 4-5 months. Client has children and it is believed she is currently single. Client is not homeless and works on and off. The environmental context is unknown.
Client reports feeling sad and depressed with suicidal ideation everyday for the past 4-5 months. Client stated, “I have been sad depressed most of my life…. In high school I had a headache for a year and half and that’s kind of when it started. I remember different times in my life when I wanted to end it all.” “I have been having a really bad time since May, there doesn’t seem to be a reason for it.” “I got mad at my children and went to bed for two days.” Almost everyday, I try not to think about it (suicide), but almost everyday it comes into my thoughts. “Yes, sometimes I have to fight off the impulse, not this week (suicide).” I was suicidal those two days, a wreck, I was mad at myself and children.” Client doesn’t feel this way when she is at work, though she has a hard time getting ready for work.
Client and Historical Information
Client reports that on and off for her entire life she has been depressed and thought about suicide, and that she thought it was normal.
Social History: Works on and off. Reports systematically cutting her friends and family out of her life, expect for her children.
Medical History: Unknown client did report having a headache for a year in high school. Psychiatric History: suicidal ideation and self diagnosed depression, estimated it to have happened at 15-20 times in her life.
Family history, trauma history, substance abuse, legal involvement...
... middle of paper ...
...that client partake in psychotherapy and speaks to a psychiatrist regarding medication. A more comprehensive suicide risk assessment is required. A safety plan and ongoing suicide risk management is recommended, if inpatient treatment is unneeded after the suicide assessment. Explore the impact of her children being in college on the client. Client would benefit from steady employment. Explore what kind of work she enjoys and if there are activities associated with this type of work that client could participate in independent of work. Assist the client in discovering activities outside her children and work that could bring her pleasure. Ask client if she enjoyed physical activity in the past, as this could be a possible healthy coping mechanism.
Major depressive Disorder, Recurrent severe with suicidal ideation (296.23). Suicide risk chronic moderate
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