Clinical Case Report
Case No 1: Afzal
Age: 35
Marital Status: Married
Occupation: Accountant
Referral Details: Referred by a general practitioner for depressive symptoms.
Central Problem: Persistent low mood, anhedonia, and difficulty concentrating.
Case History
History of Presenting Complaint: Afzal has felt sad and fatigued for 6 months, with loss of
interest in work and social activities, sleep disturbances, and decreased appetite. Stress at
work appears to have triggered the episode.
Past Psychiatric History: No prior psychiatric diagnoses or treatments.
Past Medical History: No significant medical conditions or surgeries.
Family History: Family history of depression; father treated for MDD.
Personal History: Stable childhood, higher education, consistently employed. Reports marital
strain due to his current mood.
Mental State Examination (MSE)
General Appearance and Behavior: Fatigued, slumped posture, minimal eye contact.
Speech: Slow, soft-spoken, minimal engagement.
Affect and Mood: Restricted affect, predominantly low mood.
Depersonalization and Derealization: Absent.
Thought (Stream, Form, Content): Coherent but negative; hopelessness.
Perception: No hallucinations or illusions.
Cognition: Intact; oriented to time, place, and person.
Judgment: Impaired by depressive cognition.
Insight: Acknowledges his depressive state and need for help.
Rapport: Initial difficulty but opened up gradually.
Psychological Testing and Assessment
Tests Administered: Beck Depression Inventory (BDI-II), Hamilton Depression Rating Scale
(HAM-D).
Rationale for Test Selection: Both tools are validated measures for assessing severity of
depression.
Test Results and Interpretation:
o BDI-II score: 29 (Moderate depression)
o HAM-D score: 21 (Moderate depression)
o Results indicate moderate depressive symptoms, consistent with clinical
observation.
Assessment Summary: Afzal is experiencing moderate major depressive disorder without
psychotic features.
Physical Examination
No physical findings contributing to psychological symptoms.
Summary and Diagnosis
Afzal presents with moderate major depressive disorder, as per DSM-5-TR criteria.
His symptoms are impacting his functioning, particularly in his professional and
personal life.
Formulation
Predisposing Factors: Family history of depression; chronic work stress.
Precipitating Factors: Increased job pressure and work-related stress.
Perpetuating Factors: Lack of social support; unresolved work stress.
Protective Factors: Stable employment; motivation to seek help.
Management
Short-term Management Plan: Initiation of selective serotonin reuptake inhibitor (SSRI)
therapy and referral for cognitive-behavioral therapy (CBT).
Long-term Management Plan: Ongoing therapy, monitoring of medication effectiveness, and
stress management strategies.
Prognosis: Favorable with adherence to treatment; potential challenges include stressors at
work.
Sessions
Session 1
Date and Duration: 50 minutes
Goals for the Session: Introduction to therapy; psychoeducation on depression and
treatment options.
Interventions Used: Psychoeducation, exploration of stressors.
Patient’s Response: Engaged; expressed hopefulness.
Summary and Notes: Follow-up scheduled for medication review and continuation of
therapy.
Session 2
Date and Duration: 45 minutes
Goals for the Session: Assess response to SSRI and explore negative thoughts.
Interventions Used: Cognitive restructuring, review of SSRI side effects.
Patient’s Response: Reported slight improvement; engaged in identifying negative thoughts.
Summary and Notes: Plan to increase focus on CBT techniques for stress management.
Session 3
Date and Duration: 50 minutes
Goals for the Session: Develop coping strategies for work-related stress.
Interventions Used: Problem-solving therapy, relaxation techniques.
Patient’s Response: Actively participated, shared work challenges.
Summary and Notes: Encouraged Afzal to practice relaxation techniques daily.
Session 4
Date and Duration: 45 minutes
Goals for the Session: Review progress and address marital strain.
Interventions Used: Communication skills training, review of depressive symptoms.
Patient’s Response: Opened up about marital issues; expressed willingness to work on
communication.
Summary and Notes: Plan to include marital counseling in future sessions.
Session 5
Date and Duration: 50 minutes
Goals for the Session: Consolidate gains, plan for relapse prevention.
Interventions Used: Relapse prevention planning, reinforcement of coping strategies.
Patient’s Response: Positive; reported feeling more in control of stressors.
Summary and Notes: Scheduled follow-up to maintain progress.
