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Psychological Report Sample Depression

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Vrunda Bhikadiya
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152 views2 pages

Psychological Report Sample Depression

Uploaded by

Vrunda Bhikadiya
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Psychological Report Sample

Depression

Client Information:
Name: Alex Johnson
Date of Birth: MM/DD/YYYY
Age: 30
Gender: Male
Date of Evaluation: MM/DD/YYYY
Evaluator: Dr. Emily Clarke, Clinical Psychologist

Referral Reason:
Alex was referred for psychological evaluation due to persistent feelings of sadness,
lack of energy, and difficulty concentrating, which have been impacting his daily
functioning and quality of life.

Background Information:
Alex is a 30-year-old male who has been experiencing a significant decline in mood
over the past six months. He reports a loss of interest in previously enjoyed activities,
increased sleep disturbances, and feelings of worthlessness. Alex has a history of
depression in his family and mentions a stressful work environment as a contributing
factor to his current state.

Assessment Methods:

● Clinical Interview
● Beck Depression Inventory (BDI-II)
● Hamilton Depression Rating Scale (HDRS)
● Observations during the evaluation

Behavioral Observations:
Alex appeared neatly dressed but looked tired. He made minimal eye contact and spoke
in a low, monotone voice. His responses were coherent but required prompts for
elaboration. Alex showed signs of psychomotor retardation.

Clinical Findings:
Beck Depression Inventory (BDI-II): Alex scored a 35, indicating severe depression. He
endorsed items related to pessimism, feelings of failure, and dissatisfaction with life.

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Hamilton Depression Rating Scale (HDRS): Alex's score of 24 suggests a moderate
to severe level of depression, with significant symptoms such as weight loss, sleep
disturbance, and psychomotor agitation being reported.

Diagnosis:
Based on the DSM-5 criteria and the findings from the assessment, Alex meets the
criteria for Major Depressive Disorder, Single Episode, Severe Without Psychotic
Features.

Treatment Recommendations:

Psychotherapy: Initiating Cognitive Behavioral Therapy (CBT) to address negative


thought patterns, improve mood, and develop coping strategies for stress
management.
Medication: A referral to a psychiatrist for evaluation and consideration of
antidepressant medication may be beneficial in conjunction with psychotherapy.
Lifestyle Modifications: Encourage regular physical activity, a healthy diet, and
adequate sleep to support overall mental health.
Support System: Engage family and friends in Alex's treatment process for additional
support and to facilitate a supportive environment.

Conclusion:
Alex is currently experiencing severe depression, significantly impacting his daily life. A
combination of psychotherapy, potential pharmacotherapy, and lifestyle changes are
recommended for the treatment of his depression. It is crucial to monitor Alex's progress
closely and adjust the treatment plan as necessary to ensure the most effective care
and support.

Confidentiality Notice:
This psychological evaluation report is confidential and intended solely for the use of the
individual or entity to whom it is addressed. Unauthorized use, disclosure, or duplication
is prohibited.

Evaluator's Signature:
Dr. Emily Clarke, Clinical Psychologist
[Date]

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