June 18, 2017

Major Depression Case Study Example Format Psychology


Name: ..... Age: 50 years Sex: Male Education: 10th
Marital Status: Unmarried SES: Lower middle Self: Self Domicile: ....
Reliable and adequate: The obtained information is reliable and adequate

Chief complaints:

Low mood
Death wishes
Anxious thoughts about future
Restlessness Current duration: 1 month
Loss of interest
Disturbed sleep

History of present illness:

The patient was brought to the hospital with the above mentioned complaints with an insidious onset, fluctuating course and deteriorating progress. On 6th of March he went to Dr. ... because he was feeling anxious, having low mood, feeling restless and had disturbed sleep. He was anxious because he was feeling that he is not married and how will he take care of himself in future. He is also physically weaker as compared to when he was young. As a result he felt low and had sad mood. He lost interest in watching television and listening to music on his phone.

He was tired of watching T.V until late night because he was he was unable to sleep and had headaches. He could not sleep until 1.00 at night and woke up early in the morning. Sometimes he felt that it would be better if he was dead. The doctor gave him some medicines for one month but he had bought these medicines only for a week. The patient thought of going to hospital but since it is private hospital, he came to ....where he was admitted 15 days back.

Past psychiatric and medical history:

He was asymptomatic till 2000. He owned a garments shop and used to run business of dairy products along with his friend. His garments shop was destroyed during the riots. Since then he started having anxious thoughts about the future and had disturbed sleep. He did not feel that his condition was serious and continued with his dairy business. His symptoms worsened in 2003 and he was unable to fall asleep even after working for the entire day. Even if he did fall asleep he would wake up early in the morning and would feel tired. He would keep worrying about his future and had repetitive thoughts about what he will do in the future.

He went to a psychiatrist named Dr. .... for his sleep disturbance in 2005 and took treatment from him for a year. Although he felt better and did not have sleep disturbance after 2 months, he continued with the treatment so that the problems would not recur. However, after one year he discontinued his treatment because he said that he will have to continue with the medications for lifetime. Then he took treatment in ... hospital.

In 2009 he was given 6 ECTs because he started having death wishes. He reported that he was taking his medications regularly but he used to drink alcohol at that time so the medications were ineffective. He was given Trazonil with some other tablets at that time. But he was given the wrong tablets and he was not able to sleep with the medicines that he took. So he threw away those medications and went to Dr. ... where he was admitted for 10-12 days and then discharged. At that time was unable to sleep and had tremors in his hands. After that he was maintaining well with the medications but again started having symptoms like restlessness, loss of interest, disturbed sleep and anxious thoughts because his mother was ill and admitted in ICU. There he used to see patients dying and felt depressed. He used to be worried about his mother and felt restless.

Due to all these difficulties, he could not stay in the hospital for a long time to take care of his mother; his brother used to stay in the hospital and the patient used to go back home. In 2013 his mother passed away and he started having difficulty in sleeping, low mood and loss of interest. He did not feel like watching T.V or listening to music which he used to like doing before. At that time he went to .....and took treatment from him for 3 years. His symptoms improved and he no longer had sleep disturbances. He reported that his mood was better and since he could sleep well, he felt fresh in the morning and could work efficiently. He discontinued with his treatment because of financial reasons.

In 2015 he started having sleep problems again. He used to be awake until late night while others used to sleep. At times he would not sleep for the entire night so he went to ...hospital. He was given Calm, Trazonil (50mg), Mirtez, and Qumind. With these tablets he started feeling better within 5 days. Since the dose was high he used to get sleep within 10 minutes after taking the tablets. He was maintaining well until March 2017.

Negative history:

No history of head injury
No history of alcohol use or tobacco use
No history of hearing voices, feeling that people are talking about him or that other people are trying to steal his thoughts
No history of big talks, increased speed and amount of mental and physical activity
No history of excessive fear of crowded places, travelling alone or being away from home
No history of headaches, dizziness, becoming unconscious after stressful events/situations
No history of repeated symptoms despite negative findings
No history of low intelligence

Family history

The patient stays in a nuclear family with his father and younger brother. His mother passed away in 2013 due to ill health. His younger brother is unmarried and runs the garment shop along with his father. The patient has cordial relations with his father and his brother. No consanguinity was present in the parents’ marriage and there is no history of mental illness in the family.

Personal history:

Birth and early development:
The history could not be elicited.
Childhood history:

Scholastic history:

The patient was good in academics and used to like going to school. He did not participate in extracurricular activities in school and he like to watch T.V in his free time. He had good relations with the teachers and had friends in school. He studied till 10th Std and there is no history of changing of school or repeating any class.

Work history:

The patient started working after he completed his schooling. He used to work as a helper in a garment shop. He worked there for about two years and he liked his job and the owner used to treat him well. After a few years he started to buy garments and sell them from home. Along with that he had started a business of dairy products along with his friend. He used to sell milk and butter. He made a lot of profit in the dairy business but since his friend’s brother did not like them working together, he started his own business. In 2001 his shop was destroyed in Godhra riots and he relied on his dairy business for earning money. Currently he owns a garment shop which is run by his father and his brother and handles the dairy.

Marital history:
The patient is unmarried. He liked a girl whom he wanted to marry but since there was no parental consent, he was unable to get married.

Premorbid personality:

General appearance and behaviour
Patient was well groomed and maintained personal hygiene. He was conscious and maintained proper eye contact.
Attitude towards the examiner
He was co-operative.
Psychomotor activity
Rate was normal and volume was low; prosody was present. It was goal directed, relevant and coherent.

Stream: Nil significant
Possession: Nil significant
Content: Nil significant
Form: Nil significant
No perceptual disturbances were observed.
Cognitive functions
Attention and concentration:
On the digits forward and backward his attention was aroused and sustained. He repeated up to 5 digits on digits forward test and three digits on digits backward. He was able to tell the days of the week in the reverse order.

Patient was well oriented to time, place and person.
Immediate: Intact; he repeated the digits forward correctly.
Recent: Intact; he was able to tell what he had for dinner the previous night and what he had for breakfast. The information was confirmed from other people in the ward.
Remote: Intact; he was able to tell his date of birth and his residential address.
General information: Good; he was able to name the current chief minister of Gujarat and the Prime Minister of India.
Intelligence: Average; he was able to solve simple word problems of addition, subtraction and multiplication accurately.
Abstract thinking:
Present at conceptual level; when asked to explain the meaning of the proverb ‘lohe ke chane chabana’, he said, ‘bahut mushkil me hona.”
Personal: Intact
Social: Intact
Test: Intact
Level 5: Intellectual insight


...., 50 years, male, studied till 10th, unmarried, belonging to middle SES, was presented with the chief complaints of low mood, death wishes, loss of interest, anxious thoughts about the future, feeling restless and disturbed sleep. These complaints were reported to be since the past one month with and insidious onset, continuous course and deteriorating progress. The patient used to take treatment for disturbed sleep and anxious thought since 2005. He was asymptomatic until then. In 2001 his shop was destroyed during the riots and he used to have disturbed sleep and anxious thoughts. He took treatment in 2005 from Dr. .... and his symptoms improved within 2 months. Since then he has continued his medications. He took treatment from several doctors and was given 6 ECTs in 2009 in ... because he was having thoughts of dying.

He was co-operative towards the examiner. His attention and concentration was aroused but could not be sustained. In thought content he had thoughts of getting better. His immediate and recent memories were intact but recent memories were impaired. His judgment was intact and insight was at level 3.

Diagnostic formulation:

..... was presented with the complaints of low mood, suicidal ideation, anhedonia, reduced concentration, restlessness, disturbed sleep and reduced appetite since the past 12 years. These symptoms were presented with an insidious onset, continuous course and deteriorating progress. There is history of suicidal attempts. There is lack of social support in his family including his parents and his wife. On the MSE, he appeared tearful and anxious. His attention was aroused but could not be sustained. In thought content he had thoughts of getting better. His recent memories were impaired. His insight was found to be at grade 3.


F.32.4 Severe depressive episode

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