1. PSYCHOTHERAPY 9
Case scenarioW S. is a 36-year-old African American male who presents to the clinic for
follow-up psychiatric evaluation and medication management with the diagnosis of
unspecified depressive disorder and Alcohol/Ecstasy use. Chief complaints: Im here for a
follow-up. The patient presents restless, with euthymic mood and affects. He presents with
fair insight and judgment. There was no display of psychosis. He reports no significant
issues with sleep, appetite, or energy levels. No display of emotional or perpetual
disturbance. The thought process is clear and coherent, and the content does not reveal
delusion, paranoia, or suicidal ideations. He reports, my anxiety is a bit worse; I just lost my
dad, and I am down a lot lately. He stated that his current psychotropic has been working
for him, but he needs some therapy/counseling due to the recent death in the family. The
patient reports having the urge to drink again since this past event in the family. The patient
is single but in a relationship. He lives with a friend and renting. Denies any past inpatient
or outpatient hospitalization. Denies any past history of family psychiatric illnesses or
substance abuse.Assessment diagnosis: Unspecified depressive disorder, substance abuse
disorder, Alcohol abuse, anxiety disorderMedication: Remeron 30mg PO QHS, Celexa 20 mg
PO Q AM, Zoloft 25 mg PO Q daily. Treatment Plan: The plan is to continue with the current
medications and referral for therapy.The next appointment is to be scheduled in 1
month.Classroom Productions Links to an external site.. (Producer). (2016). Impulse and
conduct disorders [Video]. Walden University.Professor Hartung. (2020). Multisystemic
therapy (MST) for at-risk youth and juveniles informational webinar Links to an external
site.[Video]. YouTube. https://www.youtube.com/watch?v=yHbTEWCDlpE
![PSYCHOTHERAPY 9
Case scenarioW S. is a 36-year-old African American male who presents to the clinic for
follow-up psychiatric evaluation and medication management with the diagnosis of
unspecified depressive disorder and Alcohol/Ecstasy use. Chief complaints: Im here for a
follow-up. The patient presents restless, with euthymic mood and affects. He presents with
fair insight and judgment. There was no display of psychosis. He reports no significant
issues with sleep, appetite, or energy levels. No display of emotional or perpetual
disturbance. The thought process is clear and coherent, and the content does not reveal
delusion, paranoia, or suicidal ideations. He reports, my anxiety is a bit worse; I just lost my
dad, and I am down a lot lately. He stated that his current psychotropic has been working
for him, but he needs some therapy/counseling due to the recent death in the family. The
patient reports having the urge to drink again since this past event in the family. The patient
is single but in a relationship. He lives with a friend and renting. Denies any past inpatient
or outpatient hospitalization. Denies any past history of family psychiatric illnesses or
substance abuse.Assessment diagnosis: Unspecified depressive disorder, substance abuse
disorder, Alcohol abuse, anxiety disorderMedication: Remeron 30mg PO QHS, Celexa 20 mg
PO Q AM, Zoloft 25 mg PO Q daily. Treatment Plan: The plan is to continue with the current
medications and referral for therapy.The next appointment is to be scheduled in 1
month.Classroom Productions Links to an external site.. (Producer). (2016). Impulse and
conduct disorders [Video]. Walden University.Professor Hartung. (2020). Multisystemic
therapy (MST) for at-risk youth and juveniles informational webinar Links to an external
site.[Video]. YouTube. https://www.youtube.com/watch?v=yHbTEWCDlpE](https://image.slidesharecdn.com/psychotherapy9-230526121826-ea5c986a/85/PSYCHOTHERAPY-9-docx-1-320.jpg)
