Clinical Vignette

Clinical Vignette
Below is a case example, with scores for both the BDI-II and BAI. Read the case, and in a paragraph (1/2 page or less) answer the three questions, explaining the scores and treatment considerations.
Clinical Vignette
Robert is a 28 year old single, black male, who is a government employee referred by his family physician for evaluation. He reports a 3 month history of worsening anxiety that is especially bad early in the morning. “I wake up at 3 in the morning and I can’t get back to sleep. My thoughts torment me.” He also reports decreased energy, inability to concentrate at his job, decreased appetite with a 10 pound weight loss, and suicidal ideation. “I feel so hopeless that suicide seems like an option.” He also states, “There is nothing in my life that I enjoy.”
Robert is tearful during the evaluation. He lacks animation and his mood is quite depressed. He denies prior hypomanic or manic episodes. A Mental Health Status Exam reveals slowed thinking but with no evidence of psychosis. He does report 2 pervious depressive periods, one in late adolescence and another during his senior year at college. During the latter episode, his symptoms were severe enough that he was unable to attend class. He reports, “I almost failed that semester.” Both depressive episodes remitted in a few months without treatment; he “felt normal” during remission. He denies using illegal substances and has no significant medical problems other than seasonal allergies. The family history is positive for depression in a paternal grandfather, and in his father, and he reports that a depressed uncle committed suicide about 10 years ago.
Robert’s BDI-II score was 46, including a score of 2 on item #2 and a score of 1 on item #9. On item #9, he originally endorsed a score of 2, and then scratched it out.
On Robert’s BAI, he marked “not at all” for every item except 5 (fear of the worst happening), and “fear of dying,” both of which he reported feeling “mildly.”
1. What is your evaluation of Robert’s depression and anxiety?
2. What questions would you ask him after analyzing the results?
3. What recommendations (if any) would be warranted at this time?
THE OTHER HALF OF THE PAGE
( other client )
did both BAI and BDI-II
her total score on the BAI = 7 in the ( MILDLY )
her total score on the BDI-II = 8
I attached Inventory – Scoring & Interpreting for both BAI and BDI-II
to help with both cases ALSO the instruments for BAI and BDI-II of the client
Report the scores, and make sure to briefly comment on the scores for items 2 (pessimism/hopelessness) her score on the BDI-II. on item 2 was ( 1 ) and 9 (suicidal thoughts) on the BDI-II was ( 0 )
Even if the scores were not high, say so, to make it clear you checked. If a client scored 2 or 3 on either of these, you would need to do a further assessment for risk to self, and take appropriate action based on that assessment .
4. Write a short paragraph interpreting the results, from the perspective of a counselor/psychologist explaining these scores to your client (you can make up a client such as a child, adolescent, college student or middle-aged adult). This should be in lay terms.

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