Patient Intake Notes
November 28th, 1990

IDENTIFYING INFORMATION: Thie 17-year old boy was referred by J B, Director of ABC Family Services and his family physician DT, M.D. From Prineville for evaluation of increasing depression refractory to individual treatment and medications.

NATURE OF CURRENT PROBLEM: The patient was interviewed for approximately one hour on November 28, 1990. He was first seen for 20 minutes with his mother for gathering of individual history. His mother reported that she was first aware of his depressive symptoms about a year ago when he began to become increasingly quiet and withdrawn. He tended to become increasingly angry with other family members. About three or four months ago she noticed he had a fairly marked weight loss and loss of appetite and started having significant sleeping difficulty. He states that he has had problems sleeping off and on for two to three years but that the problems have been worse in the last year and describes times when he simply could not turn his mind off before going to bed. About eight weeks ago, he started seeing an individual counselor at P.C. Center in Bend. He had told him mothers he wished to have a religious counselor and was referred there by their pastor at the ABC church in Prineville. At the present time, the patient does not feel that the counseling is going well and does not wish to continue with his counselor. He commented that he felt he was probably an atheist now and did not have any faith.

Approximately three weeks ago, he was started on Prozac 20 mg in the morning by Dr. T. When he was initially started on Prozac, he showed marked improvement although the overall level of depression continued to be discouraging for him and some suicidal thoughts persisted. About a week after taking the medication, it stopped working essentially and he apparently went off it for a period of time and then was restarted. I was contacted about one week ago by Dr. T and because I was not able to see the patient at that time, recommended that his Prozac be increased to 2 – 20mg capsules on even days continuing 1 capsule on odd days. The patient noted that he again experienced some relief of his depression the first few days after the dosage was increased.

At the present time, the patient describes himself as miserable and discouraged in school. He used to be a straight A student but he no longer can maintain grades and does not feel interested in most classes. About two weeks ago he had a period of improvement which coincided not only with him being started on Prozac but also participating in a school play which he really liked. Since then his mood has fallen off again.

He has been going with the same girlfriend for about 14 months. His mother states that she is closer to him than anybody else in the family and he admits that he has discussed his suicidal feelings with her and that she is an important support system for him. He does not describe any relationship problems with his girlfriend at this time, or difficulty in physical attraction.

SIGNIFICANT PAST HISTORY: He was born in Australia while his parents were doing a four year rotation as teachers in the State of Victoria. The patient's mother was also from Victoria. The patient has a 24-year old half-sister by his father's previous marriage and a 14-year old brother. The 14 year old brother lives in the house and his 24-year old sister lived with them from the time his parents were married until she got married and left home. She is currently living in California. The patient's father is a 51-year old teacher at Prineville High School. His father is legally blind due to retinitus pigmentosa. His mother is a 43-year old teacher. She describes herself in good health except for obesity.

The patient's mother could not recall any significant problems occurring during his pregnancy or childbirth. Neither he or his mother recalled any significant physical, emotional or sexual traumas that occurred during his early or later childhood. He fell on some concrete and required sutures in his forehead at about the age of 5 but was not knocked out. The only other medical complication he had was appendicitis requiring an appendectomy when he was in the 7th grade. He recently apparently had a complete physical with Dr. T including lab tests, but I do not have the results of those available.

SIGNIFICANT FAMILY HISTORY: His maternal grandmother reportedly suffered a depression as a young woman after a fiancé committed suicide. She again experienced periods of depression years later after the death of his grandfather, but was never treated with medication. She recently suffered a stroke and is going to be living with the family during her recuperation. There is some alcoholism known in the family on his father's side but back over three generations.

MENTAL STATUS EXAM: The patient is a 17-year old boy who looks his approximate age. He is fairly thin and tall. During most of the visit he looked at the floor quietly. His affect ranged from depressed to moderately angry and he was only noted to smile slightly once when discussing something humorous. His speech was generally of normal rate and tone, however with no unusual thought patterns or sentence structure noted. He did describ that sometimes his thoughts seem to be about two opposite things at once but that most of the time he just felt discouraged. As noted above, he has had frequent suicidal thoughts with plans that he might slash his wrists or hang himself or a number of other things, commenting that “there are all kinds of ways to kill yourself.” He also said that while at the time he did not think he would harm himself he was not certain he could prevent impulses in the future but did not protest my recommendation that family members not leave him alone.

There were no apparent hallucinations or delusions suggestions any form of thought disorder. At times he noted that television or radio programs seemed to have special meaning but he did not really feel that they were actual efforts to change his thinking or control his thoughts. Detailed cognitive testing was not done at this time. There was no evidence of significant memory impairment although concentration impairment appeared to be present based on his history of problems and academic functioning alone. Intelligence was estimated to be at average based on general knowledge and vocabulary.

IMPRESSION: Major depression. Single episode. Sever 296.23

The patient's symptoms are consistent with major depressive disorder at a severe level. At this point he has shown a partial response to Prozac in the past. Of concern is whether or not family can maintain supports for him while medications are given a chance to work. In addition, more information needs to be gathered from Dr. T with respect to his physical work-up and in particularly whether thyroid function tests were normal. Thus far he does not appear to have been very amenable to individual counseling and I think the severity of his depression may not allow progress along those lines at this time. AT the present, his family does appear to be able to provide close care and contact for him over the next several days. During this time, I am recommending that his Prozac be increased to a full 40 mg a day. Considerations if the Prozac does not have a fairly rapid effect would be to have him start on Lithium if the family feels they can maintain support systems as well. However, given the severity of the depression, if response is not reasonably rapid, I will recommend hospitalization. Hospitalization itself is somewhat difficult because there is no inpatient unit in this area and he would be separated from the people who are his primary support systems and in a sense might be even at more risk for suicidal behavior. I will attempt to confer with Dr. L, Child Psychiatrist, on his situation at this time as well as seek possible recommendations for hospitalization if that becomes absolutely necessary.

The Cheese Man, M.D.

Cc: Dr T
ABC Family Services