This document provides a summary of a psychiatric case study of a 15-year-old Caucasian female patient admitted to Belmont Pines psychiatric facility in March 2021. She has a history of trauma including sexual abuse, self-harm behaviors, suicide attempts, and family discord. Her diagnoses include major depressive disorder, generalized anxiety disorder, social anxiety disorder, and psychotic disorder. She is being treated with medication and therapies like CBT. Safety protocols are in place due to her history of self-harm. Her Christian faith both discourages suicide but also provides her some spiritual support.
This document provides a summary of a psychiatric case study of a 15-year-old Caucasian female patient admitted to Belmont Pines psychiatric facility in March 2021. She has a history of trauma including sexual abuse, self-harm behaviors, suicide attempts, and family discord. Her diagnoses include major depressive disorder, generalized anxiety disorder, social anxiety disorder, and psychotic disorder. She is being treated with medication and therapies like CBT. Safety protocols are in place due to her history of self-harm. Her Christian faith both discourages suicide but also provides her some spiritual support.
This document provides a summary of a psychiatric case study of a 15-year-old Caucasian female patient admitted to Belmont Pines psychiatric facility in March 2021. She has a history of trauma including sexual abuse, self-harm behaviors, suicide attempts, and family discord. Her diagnoses include major depressive disorder, generalized anxiety disorder, social anxiety disorder, and psychotic disorder. She is being treated with medication and therapies like CBT. Safety protocols are in place due to her history of self-harm. Her Christian faith both discourages suicide but also provides her some spiritual support.
This document provides a summary of a psychiatric case study of a 15-year-old Caucasian female patient admitted to Belmont Pines psychiatric facility in March 2021. She has a history of trauma including sexual abuse, self-harm behaviors, suicide attempts, and family discord. Her diagnoses include major depressive disorder, generalized anxiety disorder, social anxiety disorder, and psychotic disorder. She is being treated with medication and therapies like CBT. Safety protocols are in place due to her history of self-harm. Her Christian faith both discourages suicide but also provides her some spiritual support.
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Psychiatric Mental Health Case Study
Mental Health Comprehensive Case Study
Layne Black
3/15/2021 2 Psychiatric Mental Health Case Study Abstract
Depression is one of the most diagnosed mental disorders in the United States. It is
also one of the many reasons a person can be placed into a psychiatric facility. This is
the diagnosis of one particular patient at Belmont Pines in March 2021. This patient
experienced many traumas that got her to this point in her life. Throughout this paper,
the patient’s diagnosis, objective data and many other things will be discussed to show
the patient’s current situation.
3 Psychiatric Mental Health Case Study Objective Data
This patient was admitted to Belmont Pines of March 6 th, 2021 and the data used
is from March 9th, 2021. The patient was diagnosed with Major Depressive Disorder,
General Anxiety Disorder, social anxiety disorder and psychotic disorder. The patient
had no lab results that were recorded on this day of care. Upon admission, the charts
stated that she was very aggressive. She has a history of violent outbursts towards her
mother and would punch holes in the wall. It was also stated that she had been yelling a
lot and tore down light fixtures. She came in voluntarily. On the day of care, the patient
was not aggressive. She seemed restless, constantly rocking back and forth or shaking
her leg. She was very eager to talk. She talked openly about her past experiences, as
well as her other admission to Belmont Pines in 2018.
The patient has been diagnosed with PTSD, ADHD and sleep disturbances. To
treat the PTSD, the patient has therapy to discuss her feelings towards her traumas.
She was prescribed Intuniv to help with her ADHD. The patient has been prescribed
Melatonin to help with her sleep issues. The medication has been working, with the
patient now averaging around 6-8 hours of sleep per night. The patient is currently on
self-harm precautions. She has a history of self-harming and has even been taken to
the Emergency Department by the police several times due to her cutting herself. She
had all of her jewelry taken away from her upon admission in order to avoid any self-
harming or suicide attempts while in the hospital.
The patient is currently on a few medications. She is taking Intuniv for her ADHD.
She takes one mg daily. She is also currently taking Zoloft which is a SSRI
antidepressant drug. She is taking 50 mg of this daily for her anxiety and mood. This 4 Psychiatric Mental Health Case Study seems to be working effectively for her. The patient takes Melatonin as well. She takes
this due to her sleep disturbances. It has improved her sleep since she has started
taking it.
Psychiatric Diagnosis
The main psychiatric diagnosis for my patient on this day was depression.
Depression is one of the most commonly diagnosed disorders. Depression “…involves
2 weeks or more of a sad mood or lack of interest in life activities, with at least four
other symptoms of depression such as anhedonia and changes in weight, sleep,
energy, concentration, decision-making, self-esteem, and goals.” (Videback, 2020).
Some common behaviors that are associated with this diagnosis include depressed
mood most of the day (nearly every day), markedly diminished interest in all or almost
all activities, significant weight loss or gain, psychomotor agitation, fatigue, feelings of
worthlessness, diminished ability to think/concentrate and recurrent thoughts of death.
Environmental factors can play a large role in being diagnosed with depression. Sexual,
physical or emotional abuse are also major risk factors that can contribute to the
Prior to admission to the hospital, the patient tried to commit suicide. She took
seven of her 150 mg Seroquel medications. This medication is an antipsychotic. This
helped treat her depression and psychotic disorder. Upon admission, it was noted in her
chart to not give any Seroquel to her. The patient stated that her adopted father died of
a massive heart attack almost one year ago. She was thinking about him and wanted to 5 Psychiatric Mental Health Case Study be with him so she tried to commit suicide. She has had other previous suicide
attempts. One was when she tried to hang herself at age five, another in 2018 when she
tried to strangle herself with a belt and in 2020 when she tried to strangle herself with a
bathrobe.
This patient has previous sexual abuse. According to a study done in 2020, child
sexual abuse is “significantly related to an earlier onset of depression and that the
relationship between age at CSA (child sexual abuse) onset and depression is more
consistently found in studies with older females.” (Li, 2020). At the age of four, she was
raped by her dad’s friend in front of the friend’s girlfriend. Shortly after that she was
placed into foster care. She also stated to me that she was molested by her adopted
mother’s brother when she was placed in their care. There was nothing about this in the
chart though. She has a history of molesting cats and dogs and sending inappropriate
pictures to boys. She has previously ran away from home. Upon admission, her mother
told the hospital that her daughter had been in contact with older men from India and
has met up with other older men she has contacted on the internet. She has been sent
to the Emergency Department by police for self-harming.
The patient stated a few stressors in her life. One is her family discord. She
stated that her homelife is very messy at times. She has many foster siblings who she
does not get along with. Her mother has stated that she bullies them. The patient also
stated that a major stressor is her mother. She says that her mother yells at her and her
siblings for small things, like getting food out of the fridge after midnight if they are
hungry and not being allowed to have a cellphone. She argues with her mother a lot. 6 Psychiatric Mental Health Case Study Patient and Family History of Mental Illness
This patient did not have a lot in her chart regarding family history of mental
illness. The patient was put into foster care at the age of five, so not much was
discussed about her biological parents. The chart did state that she witnessed her father
physically abusing her mother on several occasions. It was stated that she saw her
father push her mother down concrete stairs. No other form of illnesses were
mentioned.
The patient has been hospitalized for her mental illness before. In 2018, she was
hospitalized for depression along with a suicide attempt. She tried to strangle herself
with a belt due to family discord. She was placed in Belmont Pines. She was discharged
back home afterwards. She also attempted suicide at the age of five after she was
placed into foster care. She attempted to hang herself. The patient has a history of
molesting cats and dogs. It did not state when the last time this occurred. The patient
also has a history of generalized anxiety. This could be the reason why she has stated
to do poorly in school. She would constantly skip or miss assignments and has been
kicked out of a school in the past for this reason. The patient is on the verge of being
kicked out of her current high school for the same reasons.
Psychiatric Evidence Based Nursing Care Provided
Evidenced based practice is important in nursing to implement the highest quality
of care and promote service delivery change. These types of practices generally work
because they have been proven to before. Some people are now using psychiatric
rehabilitation as a form of care. This “offers structured interventions, defined by
7 Psychiatric Mental Health Case Study approved procedures and accurate assessment tools and measures, with clear target,
in order to achieve specific outcomes in patients.” (Vita, 2019). One of these
rehabilitation interventions that were used on my patient was cognitive behavioral
therapy. This tries to improve mood and social functioning. Another care that was
provided to my patient is safety protocols in the facility. The facility did a good job at
implementing and enforcing this practice within its walls.
The patients go through several milieu activities throughout the day. They have
at least one group therapy every day. This helps them in several ways. It helps to
improve their social skills, improves problem solving skills and gives support to one
another. Another is keeping the patients on a tight schedule. This helps the patients to
not have time to think of unfriendly thoughts.
Ethnic, Spiritual and Cultural Influences
The patient is a fifteen year old, Caucasian girl. She has stated that she is
Christian. She wears a cross necklace typically, but was unable to while in the facility.
Traditionally, Christian beliefs discourage suicide. In the year 1983, suicide was
removed from the list of mortal sins by the Roman Catholic Church. It is said now that
Christians try not to blame the person who has died by suicide, but try to provide
resources and care for those who are at risk and for the families. Even still, there is
some stigma in the Christian faith in regards to suicide and the afterlife.
Patient Outcomes
Patient outcomes refer to the results of the nursing care that the patient receives
in the hospital. While talking to the patient, she verbalized a long term plan about her 8 Psychiatric Mental Health Case Study future to me. She planned to move into a place with her friend and boyfriend when she
turns 18. This is a positive for this patient. She has depression, setting realistic goals
and thinking about the future are positive actions. I believe she has met this outcome.
Another outcome that is important for depression is discussing a loss with staff or family
members. The patient discussed the passing of her adoptive father with me, and with
other staff throughout her stay. She was able to verbalize her fears and concerns. A
major nursing care outcome for this patient is also patient safety. The hospital put this
patient on self-harm precautions. The patient was able to verbalize all her thoughts and
feelings, so I believe this outcome was also met.
Discharge Planning
Upon discharge, the patient is to report back home with her mother and siblings.
The date of discharge is Friday March 12th. Patient seemed torn to go home. She stated
that she enjoyed being at the hospital because it was more fun than her house. She
likes to talk to the other patients and has more to do. She stated that her mother owns a
lot of land and they have a lot of animals, so she always has something to do.
Prioritized List of Actual Diagnoses
A diagnosis for this patient is hopelessness related to stressors as evidenced by
suicide attempt. Interventions could be to allow the expression of feelings and
collaborate with patient to figure out which aspects of life the patient can control. A
second diagnosis is ineffective coping related to loss as evidenced by suicidal
ideation/attempt due to father passing away. Interventions for this diagnosis could be to
let the patient encourage her feelings and to monitor the patient closely throughout care. 9 Psychiatric Mental Health Case Study Another diagnosis is grieving related to actual loss as evidenced by depression. The
interventions that can be used to help this patient could be to allow the patient to
recognize and express feelings and to assist the patient to determine, recognize and
address the problem.
List of Potential Nursing Diagnoses
This patient is at risk for self-harm related to suicidal ideation as evidenced by
history of self-harm. A few interventions that can be implemented for this patient are
distract the patient with things such as therapy and to give alternatives to harming with
education on techniques to develop coping skills to help the patient handle stressful
situations. Another potential diagnosis could be risk for self-care deficit related to
anxiety as evidenced by persistent insomnia. This patient was prescribed Melatonin
because she was unable to get more than a couple hours of sleep any night. Some
interventions for this could be to encourage relaxation measures in the evenings and to
reduce environmental and physical stimulants in the evenings.
Conclusion
Depression is a very serious issue that many people deal with every single day.
My patient had a lot of trauma that had previously occurred in her life that led her to the
point of being in Belmont Pines. With the group and individual therapies given at
Belmont Pines, the hope is for the patient to be able to function everyday life with her
depression. 10 Psychiatric Mental Health Case Study Works Cited
Li. (2020, February). A developmental perspective on the relationship between child
sexual abuse and depression. Retrieved from https://web-b-ebscohost-
