Treatment Plan
Agencies Involved: Psychiatrist and nurses
Diagnoses
Axis I: Major Depressive Disorder with Suicidal Attempt
Axis II: Substance and Alcohol Use
Axis III: No diagnosis
Axis IV: Problems with family
Justification of diagnosis
The patient has more than six symptoms that fit the criteria for major depressive disorder. These include weight loss, feeling depressed most of the day, and almost all the time for more than six months, suicidal ideation and attempts, lack of interest in pleasurable activities once enjoyed, a sense of guilt and worthlessness as well as having problems with thinking and making decisions.
Medications
Prozac 20mg once daily for depression
Amitriptyline 25 mg nocte for depression
Diazepam 5mg daily for alcohol withdrawal
Response to Medication
D.M has responded well to the medicines. He reports feeling less depressed and is no longer irritable. He also says not feeling the need to take alcohol and has stopped suicidal ideation and now has a positive outlook on life. The psychiatrist has indicated that he plans to withdraw the benzodiazepine and amitriptyline and let D.M continue with Prozac.
Long Term Goal
The long term goal is to relieve D.M of the symptoms of depression and allow him to continue with his daily activities without any challenge. Anticipated completion of therapy is within two weeks.
Short term goals
D.M and his family will develop a no-self harm contract
He will get involved in football as an extracurricular activity
He will not have any suicidal ideation for the next month
D.M will get to learn the various coping skills such as problem-solving and how to regulate his emotions to avoid resorting to alcohol and drug use.
Interventions
Family therapy to help both the patient and family understand the dynamics leading to depression. It will also help explore negative patterns and problems that arise within the family structure and help both parties learn to use communication and conflict resolution skills
Individual therapy will be used to explore D.M’s issues and his feelings about his wife and family rules within the society and at the workplace and to allow him use communication and coping skills. It will also help him learn conflict resolution skills