MENTAL HEALTH ASSESSMENT TASK 2

MENTAL HEALTH ASSESSMENT
TASK 2
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PART 1: Holistic assessment and planning
1.a. The Mental Status Examination
 Appearance & behaviour
 Appearance
 Motor behaviour
 Attitude to situation and
interviewer
Mary is a 41year-old female, married with 3
children. At the time of assessment,(ATOA) she
appeared clean and tidy dressed in T-shirt, jeans
and sandals. Her hair was brushed but looking
unwashed, she was not wearing makeup.
She avoided eye contact and sat with her hands
clasped in her lap.
Mary was cooperative throughout the interview.
 Speech form
 Rate
 Volume
 Quantity of information
 Speech content
 Disturbance of meaning
 Disturbance of language
Mary responded in a monosyllabic and slow
rate.
On attempts to engage with Mary she gave brief
responses.
 Mood and Affect
 Mood
 Affect
 Congruency
Mary’s flat affect was congruent with her
depressed mood.
 Form of Thought
 Excess, absence, quality of
thought
 Continuity of ideas
Mary described moments of despair, tearful and
lack of energy. She exhibited loss of interest in
daily activities.
 Content of Thought
 Delusions
 Suicidal thoughts
 Other
Mary stated she is avoiding contact with friends
nor attended church due to her tiredness and
lack of pleasure. Diagnosed with depression 3
years ago and was hospitalized for this for 5
weeks was treated with Citalopram stopped 12
months ago as she felt she no longer needed
them. States has been well since that time.
Husband stated, Mary spoke of feeling
worthless and hopeless and had made
comments of not knowing how she would get
through the day with these thoughts occurring
more frequently. He also stated he has noticed
her disturbed sleep pattern.
 Perception Mary exhibits normal perception. Symptoms of
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 Hallucinations
 Illusions
 Depersonalisation/derealisation
illusions, derealisation, depersonalisation,
misinterpretations, were absent.
 Sensorium and Cognition
 Level of consciousness
 Memory:
 Orientation.
 Abstract thinking
Mary was alert and orientated to time, place and
people.
 Insight & Judgement
 Extent of individual’s awareness
of the problem
 Can they make rational decisions
When questioned about her condition, Mary
denies that she is unwell. She is adamant she is
needed at home to care for the family.
Risk Assessment
 Potential for harm to self
 Potential for harm to others
 Potential for absconding
No potential risk for self or others was detected
ATOA. Flight risk undetermined.
1.b. Clinical Formulation Table
Summarize the pertinent information from case study
Presenting
factors
 Presented exhibiting symptoms of depression.
 Impaired function,(#12) currently on sick leave from work.
 Fatigue, loss of interest in activities. (#11)
 Lacks motivation for daily activities, e.g., eating, dressing.
 Personal hygiene has deteriorated
 Feelings of worthlessness, feeling of burden to family.
 Recent death of mother due to suicide.
 Non-adherence to antidepressant medication.
 Sleep disturbance with insomnia. (#2 p232)
Precipitating
factors
 Has a responsible position in a large firm.
 Family have noticed her negative thoughts and actions have become
more frequent.
 Added concerns due to previous admission to hospital.
 Possible grief due to history of mother’s depression and successful
suicide.
Predisposing
factors
 Past history of depression diagnosed 3 years post, hospitalised for 5
weeks at that time.
 Ceased antidepressant medication 12 months ago believing she no
longer needed them.
 Family history, Mother suffered depression for 35 years and suicided 9
months post.
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Perpetuating
factors
 Denial of being unwell.
 Past history of depression.
 Non-adherence to medication.
 Recent death of depressive mother due to successful suicide
 Risk of malnutrition due to poor diet.
 Sleep disturbance (#2),
Protective
factors
 Has strong family support from her husband of 20 years and teenage
children.
 Has job she loves.
 Financially sound with a good home.
 Husband has good employment.
 Good church/spiritual family.
 Does not drink alcohol, smoke or use illicit drugs.
 Has regular health checks with her GP.
 Her need to care for her family.
 Well educated and intelligent.
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