Marks has reported the following symptoms: feelings of hopelessness. “why am I s ll here”,
“what’s my purpose”, feeling very irritable and lack of sleep. Unable to sleep from thoughts of
depression and anxious as whats to come next. He struggles with nding pleasure in doing
things and going out feels there is no “purpose” which has resulted in excessive usage of alcohol
and vaping. Alcohol usage has turned into daily usage, repor ng self-coping skills since the age
of 18. Never a ended therapy or thought to seek any professional help mainly due to the lack
of resources, access and s gma surrounding mental health. Has had some suicidal idea on
without interven on. No actual plan in place and no history of any noted a empts.
Mark reports smoking marijuana occasionally unsure of when it started. Currently not smoking
marijuana but vaping and drinking daily. Mark reports drinking to numb the pain and to not
have to face reality in a sense. Daily drinking started about 3 years ago a er the loss of a dear
friend, unable to cope with the loss and struggling with mental health. The responsibili es and
the task of everyday life pushed for the drinking. Reports feeling a sense of calmness and
relaxa on when under the in uence also reports drinking consistently throughout the day and
night. No reports of any hard drugs currently
Mark is currently single as alcohol consump on and mental health status has taken a toll on
many personal rela onships within his life. He is currently living back home with his mother and
younger siblings. Mark is not really open to sharing more informa on about his family at this
me. However, he is not sure if his family has dealt with the same thing as he o en feels alone
and misunderstood. Overall the goal is to get back to his once happy outgoing self
Mark dropped out of school in high school and has not yet entered the work force as he is
unsure what he wants to do and unsure of what interests him anymore. Mark says before his
mental health became a problem, he could not visualize his self-working a regular job as he
would rather tap into his crea ve side and provide work for hisself. Mark reports no other
health issues outside of mental health.
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No criminal history
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Mark, 25 year old single black male, main problem is depression and anxiety. O en men ons
feelings of hopelessness and alone. Feels like the weight of the world falls upon his shoulders
Treatment recommenda ons include: Psych evalua on, individual therapy and counesling
substance abuse, as well as group therapy to gain a be er understanding of nding of self as
well as educa on on self harm.
Objec ves:
This week Mark and I have collaborated to “iden fy what triggers me before I fall to deep”.
Client will work on iden fying triggers that aid in his depression and anxiety and write them
down.
Client will also “start waking up at the same me every day to try and build more structure and
rou nes”
Client will wake up at 7am every morning star ng this week for one full week and note any
changes he no ces.
Goals:
Client will exercise for a minimum of 30 minutes everyday.
Client will have improved their mood by atleast 30% as evidenced by lowering their PHQ-9
score.
Client will have improved their sleep quality by atleast 45% as evidenced by lowering their
PHQ-9 score.
Client will have improved their anxiety by atleast 20% as evidenced by lowering their PHQ-9
score.
Interven ons:
Life skill services
Boost’s Mark’s quality of slumber. MDD pa ents frequently experience sleep di cul es, which
can be treated with a combina on of behavioral therapy for sleep disorders and appropriate
sleep hygiene habits.
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Boost interpersonal interac on. People who su er from major depressive mood disorder tend
to withdraw from others. Mark suggested a ending a support group for males who are
depressed and ge ng in touch with some of his old football teammates as ways to deal with
this.
Discharge Planning
Client will be comfortable terminating services when the client's sleep quality has improved by
at least 40% and, their mood and anxiety have improved by at least 15%.
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