mental health case study vignettes

Case Vignette Slides and Sample Cases

Through the use of case vignettes, students can engage in conversations and discussions of clinical and ethical considerations that come up in practice as well as discussions on various substance use treatment modalities and what treatment planning may look like.

These slides and sample case vignettes provide discussion prompts for faculty to use in small group sessions or can be used as part of a written assignment.

Related Resources

Oct 29, 2021

Clinical Practice Guideline for the Treatment of Posttraumatic Stress Disorder (PTSD)

Case Examples

Strongly Recommended Treatments

Jill, a 32-year-old Afghanistan War veteran

Jill had been experiencing PTSD symptoms for more than five years. She consistently avoided thoughts and images related to witnessing her fellow service members being hit by an improvised explosive device. This case example explains how Jill's therapist used a cognitive worksheet as a starting point for engaging in Socratic dialogue.

Tom, a 23-year-old Iraq War veteran

Several published CPT case examples exist in the literature but many find the one in this chapter to be especially helpful:

Monson, C.M., Resick, P.A., & Rizvi, S.L. (2014). Posttraumatic stress disorder. In D.H. Barlow (Ed.), Clinical handbook of psychological disorders (5th ed., pp. 80-113). New York, NY: Guilford Press.

Philip, a 60-year-old who was in a traffic accident (PDF, 294KB)

This case example from the European Journal of Psychotraumatology details an assisted self-study application of cognitive therapy for PTSD. Philip developed PTSD and comorbid major depression following a traffic accident. He was treated in six sessions of cognitive therapy with self-study modules completed in between sessions.

Terry, a 42-year-old earthquake survivor

Terry consistently avoided thoughts and images related to witnessing the injuries and deaths of others during an earthquake. He began spending more time at work and filling his days with hobbies and activities. However, whenever he had free time, he would have unwanted intrusive thoughts about the earthquake. In addition, he was having increasingly distressing nightmares. This case example is followed by an excerpt from an in-session imaginal exposure with a different client.

Conditionally Recommended Treatments

Mike, a 32-year-old Iraq War veteran

Mike was a 32-year-old flight medic who had completed two tours in Iraq and discharged from the Army due to his posttraumatic stress disorder.

Eric, a 24-year-old Rwandan refugee living in Uganda (PDF, 28KB)

This document from the Common Language for Psychotherapy Procedures summarizes narrative exposure therapy and includes a case example about a Rwandan civil war refugee living in a Ugandan settlement. Eric had recurring intrusive images and nightmares of seeing his family be shot by armed rebels.

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DSM-5 Clinical Cases

Rachel A. Davis , M.D.

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DSM-5 Clinical Cases makes the rather overwhelming DSM-5 much more accessible to mental health clinicians by using clinical examples—the way many clinicians learn best—to illustrate the changes in diagnostic criteria from DSM-IV-TR to DSM-5. More than 100 authors contributed to the 103 case vignettes and discussions in this book. Each case is concise but not oversimplified. The cases range from straightforward and typical to complicated and unusual, providing a nice repertoire of clinical material. The cases are realistic in that many portray scenarios that are complicated by confounding factors or in which not all information needed to make a diagnosis is available. The authors are candid in their discussions of difficulties arriving at the correct diagnoses, and they acknowledge the limitations of DSM-5 when appropriate.

The book is conveniently organized in a manner similar to DSM-5. The 19 chapters in DSM-5 Clinical Cases correspond to the first 19 chapters in section 2 of DSM-5. As in DSM-5, DSM-5 Clinical Cases begins with diagnoses that tend to manifest earlier in life and advances to diagnoses that usually occur later in life. Each chapter begins with a discussion of changes from DSM-IV. These changes are further explored in the cases that follow.

•.	Autism spectrum disorder is used to describe symptoms previously broken into separate categories.
•.	The age limit prior to which attention deficit hyperactivity disorder symptoms must be present has been changed from 7 to 12 years, and adults must only meet five criteria from each dimension rather than six.
•.	Schizophrenia subtypes have been eliminated.
•.	“Other specified” is used for those patients who have symptoms in a particular diagnostic category but do not meet full criteria (e.g., other specified bipolar and related disorder).
•.	“Unspecified” is used for those patients who have significant symptoms consistent with a particular diagnostic category but in whom adequate history cannot be obtained (e.g., unspecified schizophrenia spectrum and other psychotic disorder).
•.	Disruptive mood dysregulation disorder is a new diagnosis for children in the depressive disorders diagnostic category.
•.	Bereavement is no longer an exclusion to the diagnosis of major depressive disorder.
•.	Obsessive-compulsive disorder (OCD) and posttraumatic stress disorder are now considered in their own sections rather than grouped with anxiety disorders.
•.	Hoarding disorder is new.
•.	Hypochondriasis has been eliminated and replaced by two separate disorders, somatic symptom disorder and illness anxiety disorder.
•.	Avoidant/restrictive food intake disorder is a new diagnosis to describe people with symptoms of restricting or avoiding food in a manner that leads to impairment but do not meet criteria for anorexia nervosa.
•.	Gender identity disorder has been eliminated and replaced with gender dysphoria.
•.	Substance use disorders are no longer split into abuse and dependence but rather are specified by course and severity.

Each case vignette is titled with the presenting problem. The cases are formatted similarly throughout and include history of present illness, collateral information, past psychiatric history, social history, examination, any laboratory findings, any neurocognitive testing, and family history. This is followed by the diagnosis or diagnoses and the case discussion. In the discussions, the authors highlight the key symptoms relevant to DSM-5 criteria. They explore the differential diagnosis and explain their rational for arriving at their selected diagnoses versus others they considered as well. In addition, they discuss complicating factors that make the diagnoses less clear and often mention what additional information they would like to have. Each case is followed by a list of suggested readings.

As an example, case 6.1 is titled Depression. This case describes a 52-year-old man, “Mr. King,” presenting with the chief complaint of depressive symptoms for years, with minimal response to medication trials. The case goes on to describe that Mr. King had many anxieties with related compulsions. For example, he worried about contracting diseases such as HIV and would wash his hands repeatedly with bleach. He was able to function at work as a janitor by using gloves but otherwise lived a mostly isolative life. Examination was positive for a strong odor of bleach, an anxious, constricted affect, and insight that his fears and behaviors were “kinda crazy.” No laboratory findings or neurocognitive testing is mentioned.

The diagnoses given for this case are “OCD, with good or fair insight,” and “major depressive disorder.” The discussants acknowledge that evaluation for OCD can be difficult because most patients are not so forthcoming with their symptoms. DSM-5 definitions of obsessions and compulsions are reviewed, and the changes to the description of obsessions are highlighted: the term urge is used instead of impulse so as to minimize confusion with impulse-control disorders; the term unwanted instead of inappropriate is used; and obsessions are noted to generally (rather than always) cause marked anxiety or distress to reflect the research that not all obsessions result in marked anxiety or distress. The authors review the remaining DSM-5 criteria, that OCD symptoms must cause distress or impairment and must not be attributable to a substance use disorder, a medical condition, or another mental disorder. They discuss the two specifiers: degree of insight and current or past history of a tic disorder. They briefly explore the differential diagnosis, noting the importance of considering anxiety disorders and distinguishing the obsessions of OCD from the ruminations of major depressive disorder. They also point out the importance of looking for comorbid diagnoses, for example, body dysmorphic disorder and hoarding disorder.

This brief case, presented and discussed in less than three pages, leaves the reader with an overall understanding of the diagnostic criteria for OCD, as well as a good sense of the changes in DSM-5.

DSM-5 Clinical Cases is easy to read, interesting, and clinically relevant. It will improve the reader’s ability to apply the DSM-5 diagnostic classification system to real-life practice and highlights many nuances to DSM-5 that one might otherwise miss. This book will serve as a valuable supplementary manual for clinicians across many different stages and settings of practice. It may well be a more practical and efficient way to learn the DSM changes than the DSM-5 itself.

The author reports no financial relationships with commercial interests.

Cited by None

She has been treated for years with various antidepressants and mood stabilizers but has had only two short inpatient admissions. She has seen numerous therapists since childhood and, for the past five years, has been treated by a respected psychiatrist with a specialty in serious mental illness and psychopharmacology.

Symptoms are similar to most major depressions: hopelessness, helplessness, self-directed angry outbursts, worthlessness, poor self-esteem, feelings of guilt, lack of motivation, excessive sleeping, poor hygiene, and tearfulness.

She describes herself as a “terrible housekeeper.” She says she never cleans, never opens mail, and rarely eats at home. She once reported with sadness and disdain, “Sometimes, I make a bowl of cold cereal and milk, and I stand in the middle of the dining room and eat it. That’s so pitiful!”

Because she is an exceptionally intelligent and articulate person, these negative characterizations are painful to hear—for her therapist, her doctor, and for Taylor.

Taylor’s descriptions of her father have always been more detailed and scathing. She describes her father as harsh and hypercritical with a history of severe teasing. “He never had to raise a hand against me. He is an expert at punishing with words,” Taylor explains. She has reported being called derogatory names critical of her mental health problems and physical appearance. Taylor does understand the connection between these experiences and her problems with depression, self-image, and self-esteem, but this insight does not seem to produce improvement. Unfortunately, due to the repeated episodes of depression, Taylor has had to depend on her father in the past eight years for financial assistance, which she bitterly resents.

Periodically, Taylor had problems in school, especially high school. Eventually, her parents enrolled her in a private school that she loved and where she excelled. She was accepted into an Ivy League university but had difficulties due to a combination of social issues, an inability to organize her work, and a serious medical illness that led to a two-month hospitalization.

Although she did not finish college, she transferred to a university in France where she stayed for several years, happily studying and traveling to many different countries. One of her major pastimes was mountain climbing, and she has climbed mountains all over Europe, Africa, and the United States. She sometimes talks about living in Europe permanently but has not pursued this beyond the most preliminary steps. Beginning in her mid-40s, Taylor began to suffer multiple health problems, some of which continue but are not life threatening. She has become more hopeless over her impending 50th birthday. The life review that this often engenders in people has become a major crisis for her as she reviews a life she believes to be worthless.

She had an unexpected monetary windfall and decided to reward herself with a three-week trip to Europe. She felt exceptionally energetic and returned to an old love of mountain climbing. On her return to the United States, she resumed treatment. She was full of stories about her trip, quickly found a new job, and felt reasonably content even though she had taken a pay cut. She resumed seeing her friends and talked about returning abroad to live permanently.

This improvement was short lived. Over the next year and a half, the depression and its familiar distressing symptoms returned with increasing intensity. Taylor’s doctor actively managed her medications, but she continued to decline. During a session in my office one evening, she was so depressed that she sat practically mute with tears running down her face. She was still able to work but reported that her job was in jeopardy.

After much consideration, she decided to try ECT again. However, this trial was unsuccessful, and Taylor had an unfortunate reaction and needed to be hospitalized for a few days. Since her discharge, sessions are dominated by Taylor’s depressive symptoms, self-hatred, and anger. She is frustrated with her inability to manage her home and is increasingly gloomy about her future. During our most recent session, she reported that she had lost her job.

Taylor initially presented with a strong desire to get her life together, and she had two specific goals: to feel better about herself and to organize her home. “My doctor recommended you because he said you are a no-nonsense kind of person,” she told me. Taylor comes to therapy regularly, and she has been able to successfully discuss sensitive issues in her past such as a date rape in her late teens. Although she does not have an intimate relationship now and is not dating, she has several close friends with whom she sometimes goes out to dinner or to a movie when she agrees to call them. She often assumes it is their responsibility to call her.

She has developed a trusting relationship with me as her therapist and is able to follow some basic cognitive therapy techniques to examine her thinking and structure her day. However, all attempts at permanent change have been met with only temporary success. Homework assignments are done only for a few days, and physical activity has the same duration. Suggestions such as focusing on her beloved Siamese cats, connecting with friends, revisiting former interests, and learning to manage anger and the relationship with her father have all worked for a while but are never entirely successful.

There are times when she is able to draw on past accomplishments and see that she has some strengths and has done some positive things. Her life has been adventuresome and somewhat eccentric, but she resists seeing this as a genuine way to live and believes that she is a flawed person without a husband, children, a fine home, and living what she perceives to be a “normal” life.

Despite her severe bouts of depression, she does not want to die and firmly states that she would never harm herself. Taylor is wedded to the idea that psychopharmacology or some other yet undiscovered miracle medical procedure will be the answer to her difficulties. She reports that she is more willing to try any medication or procedure (after careful assessment) rather than having to go through the harder, slower process of therapy. Her mantra about any new therapeutic process is “What good will this do?”

Taylor seems to be a study in contradictions. She wants a quick fix for her problems but has stayed in this therapy for at least a year and a half. She shifts from positive to negative feelings about her intelligence, and she sees herself as flawed for not having a “normal” life, though she is quite disparaging of her normal parents. One explanation for these contradictions could be her attachment to her negative feelings about herself, which seem quite profound. Her ability to tolerate positive feelings appears limited, perhaps because it could endanger her negative, but reliable, identity.

Despite Taylor’s attachment to her negative persona, she has pursued this therapy, which suggests that there is a role for a therapist to play in helping her find a more self-accepting, positive identity. The key to working with Taylor could be helping her realize that someone understands how much she has suffered but is not empathically overwhelmed and/or emotionally harmed by the suffering she demonstrates in her sessions (i.e., mute despair with weeping and self-punitive comments).

Taylor seems to be unaware that the way she treats herself is similar to the way she describes her father treating her, but in an internalized, self-imposed manner. The therapist’s role at this point in the treatment seems to be witnessing Taylor’s intense suffering. The description Taylor was given of her current therapist as “no-nonsense” could be a clue to what she thinks she needs (i.e., a therapist who doesn’t get lost in Taylor’s misery). This could also mean a therapist who sees that the suffering is a crucial part of Taylor’s identity and acknowledges the importance it has to her without seeing it as the only identity she could have.

The therapist says, “Something very strong keeps her [Taylor] going in this world, helps her to survive.” I see this comment as encouraging Taylor to see herself as emotionally stronger than she feels, which could be overlooking how psychologically destroyed Taylor can feel at times during what sound like psychotic episodes. The desire to avoid these extremely painful episodes could be what leads Taylor to cling to her very difficult but reliable, negative self-images and to be financially dependent on her demeaning but reliable father. Over time, the therapeutic process could offer Taylor a different experience and new ways to avoid the experience of losing her identity in overwhelming depression.

Taylor seems to be nonverbally asking the therapist to take responsibility for her awful feelings, just as she wants her friends to be the ones to reach out to her. Seeing the therapeutic process as a way to begin to own and contain her painful feelings would be a necessary precursor to helping Taylor look at the identity she has constructed and maintains.

It would be a good idea for the therapist to explore Taylor’s question, “What good will this do?” and be clear that any change that comes from therapy will likely be a long process, as Taylor and the therapist build new ways for Taylor to own and contain her feelings. Empathizing with the frustration this is likely to cause Taylor would be an important part of building a therapeutic alliance. But simply tolerating the pain Taylor experiences and encouraging her to put it in words when she can, as the therapist seems to be doing, is also a crucial part of helping Taylor.

Taylor appears to have built her identity on primarily negative images of herself, her mother, and her father, with little capacity to question the way she now projects these images onto herself and others. Despite her conscious wish to be different from her parents, who she felt were cruel and/or neglectful, Taylor nonetheless continues to expect to be treated in these hurtful ways. In the absence of others doing so, she treats herself cruelly. Her ability to form a connection to the therapist is a good sign, but the miserable internal world she has lived in needs to be identified and discussed, particularly the way it is expressed in the therapy.

Managing the feelings Taylor stirs up in the therapist would be a major part of the therapist’s work. My primary goals for working with a patient like Taylor would be to look at her self-punitive comments as a way of avoiding critical comments about the therapist, helping her put her nonverbal anguish into words, and letting her know that this is a difficult process for both Taylor and the therapist but one that can be successful if Taylor is willing to work toward changing her self-punitive identity with the therapist’s help.

I utilize a biopsychosocial/spiritual perspective with most clients. As I explore developmental history, I focus on temperament and particularly on early personality development. Personality begins to show itself around the age of 3 and is thought to be malleable until somewhere in the third decade of life. I am most interested in attachment and bonding dynamics. From my vantage point, Taylor has introjected a “sterile” mother and a “dysfunctional” father in response to the early psychosocial climate and environment during her youth. So her “self” and “other” split object relations are negatively distorted.

Through the lens of Erik Erikson, I look at the stages of psychosocial development: trust/mistrust, autonomy/shame or doubt, initiative/guilt, industry/inferiority, and identity and role integration/confusion or what I refer to as diffusion. Taylor has not mastered these opportunities. Drawing from John Bowlby, I look at the common reactions to as serious disruptions or fractures of significant relationships: shock, protest, despair, reattachment, or detachment. I see plenty of evidence of these dynamics, which Taylor projects onto current and future relationships.

Taylor shows an insecure attachment with both aggressive/ambivalent and avoidant features. Globally, I consider her to show an “asocial” personality orientation. She likely feels vulnerable and fragile in close, intimate relationships.

In my clinical experience, an early childhood onset of depression has been rare. We know that in adolescence and adulthood, women are at great risk of major depression. I am struck by Taylor’s suicide attempt during the latency period. I wonder if the presentation of puberty was a potential trigger. In terms of suicide, women are more likely the attempters and men the completers. What method did she use? I always explore the meaning of these incidents, questioning the client’s reaction to them then and now. I find it remarkable, considering her overall suffering, that she has not attempted again.

I am very concerned about her degree of hopelessness. Aaron T. Beck and Judith S. Beck indicate this to be a high risk factor for suicide. I would also examine the degree of helplessness and worthlessness, as I have found this “suicidal triad” to be more predictive of risk. Taylor displays what the Becks refer to as the cognitive triad: negative view of past, self, and future. In addition, she clearly displays an external locus of control that leaves her vulnerable in facing psychosocial stressors.

I would like to know more about her sibling position and her current and former connections to her sisters. I am curious about any dynamics related to having a father with no sons. I suspect that her siblings also feel vulnerable about intimacy.

With all clients, I conduct a protection/risk inventory. Here is my assessment of Taylor’s: Her intellect and articulate qualities are assets. She has some friends. She used to really enjoy mountain climbing. Her therapy attendance is consistent. She showed a very positive response to her first series of ECT. Her risk factors include the degree of hopelessness she feels, her detachment from others, her persistent dysthymia, her marginal or poor response to appropriate psychotropic medication, and her long-standing negatively distorted self-concept.

I am curious about her experiences with previous therapists, and I am especially interested in her transference to her present one. I would like to know more about the clinician’s countertransference to this client.

My diagnosis is recurrent major depression with persisting dysthymia. When they occur together, some refer to this as double depression. In fact, some evidence shows that nine of 10 persons with dysthymia experience a major depressive episode. I also see Taylor as evidencing a mixed personality disorder in the “wary cluster (Cluster C), with avoidant and dependent features.” In my experience, persons with disordered personality respond marginally to the use of psychotropics.

A course of cognitive behavioral therapy is appropriate for her. I also would consider a course of interpersonal therapy. Both approaches are known to be effective in treating major depression. More importantly for Taylor, I recommend a movement away from individual to group psychotherapy. In group therapy, clinicians have access to various therapeutic factors unique to group, which give them additional leverage to be useful to our clients. I think that it will be important to see her through menopause and beyond.

Finally, I inquire about each person’s spiritual beliefs in terms of the meaning it gives to their life in times of suffering and in times of relative well-being. In summary, I see Taylor’s prognosis as guarded with continuing treatment and poor without it.

Social Work Today magazine

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Suicide Risk: Case Studies and Vignettes

Identifying warning signs case study.

Taken from Patterson, C. W. (1981). Suicide. In Basic Psychopathology: A Programmed Text.

Instructions: Underline all words and phrases in the following case history that are related to INCREASED suicidal risk. Then answer the questions at the end of the exercise.

History of Present Illness

A heavy drinker, he has been unemployed from his janitorial job for the past three months because of his drinking. He acknowledges feeling increasingly depressed since being fired, and for the past two weeks has had insomnia, anorexia, and a ten pound weight loss. He indicates he wanted to die, had been thinking of suicide for the past week, planned the overdose, but had to “get drunk” because “I didn’t have the guts” [to kill myself]. He is unhappy that the attempt failed, states that, “nobody can help me” and he sees no way to help himself. He denies having any close relationships or caring how others would feel if he committed suicide (“who is there who cares?”). He views death as a “relief.” His use of alcohol has increased considerably in the past month. He denies having any hobbies or activities, “just drinking.”

Past Psychiatric History

Hospitalized in 1985 at Pleasantview Psychiatric Hospital for three months following a suicide attempt after his fourth wife left him. Treated with ECT, he did “pretty good, but only for about two years” thereafter.

Social History

An only child, his parents are deceased (father died by suicide when client was eight years old; mother died of “old age” two years ago). Raised in Boston, he moved to Los Angeles at twenty-one and has lived here since. Completed eighth grade (without any repeat) but quit to go to work (family needed money). Has never held a job longer than two years, usually quitting or being fired because of “my temper.” Usually worked as a laborer. Denies any physical problems other than feeling “tired all the time.” Currently living on Social Security income, he has no other financial resources. He received a bad conduct discharge from the army after three months for “disobeying an order and punching the officer.” He has had no legal problems other than several arrests in the past two years for public intoxication. Married and divorced four times, he has no children or close friends.

Mental Status Examination

Thought processes were logical and coherent, and no delusions or hallucinations were noted. Theme of talk centered around how hopeless the future was and his wishes to be dead. There were no thoughts about wishing to harm others.

Mood was one of depression. He was oriented to person, place, and time, and recent and remote memory was intact. He could perform simple calculations and his general fund of knowledge was fair. His intelligence was judged average.

Diagnostic Impression

drug overdose (Valium and alcohol)
Dysthymic Disorder (depression)
Substance Use Disorder (alcohol)

Questions for Exercise

You have interviewed the client, obtained the above history, and now have to make some decisions about the client. He wants to leave the hospital.

Is he a significant risk for suicide?
discharging him as he wishes and with your concurrence?
discharging him against medical advice (A.M.A.)?
discharging him if he promises to see a therapist at a nearby mental health center within the next few days?
holding him for purposes of getting his psychiatric in-client care even though he objects?
Discuss briefly why you would not have chosen the other alternatives in question #2.

Identifying Warning Signs Case Study: Feedback/Answers

The client is a 65-year-old white male , divorced , living alone , admitted to the hospital in a near comatose condition yesterday because of an overdose of approximately thirty tablets of Valium, 5 mgm, combined with alcoholic intoxication. The client was given supportive care and is alert at the present time. A heavy drinker , he has been unemployed from his janitorial job for the past three months because of his drinking. He acknowledges feeling increasingly depressed since being fired, and for the past two weeks has had insomnia and a ten pound weight loss . He indicates he wanted to die, had been thinking of suicide for the past week, planned the overdose, but had to “get drunk” because “I didn’t have the guts” [to kill myself]. He is unhappy that the attempt failed , states that, “ nobody can help me ” and he sees no way to help himself. He denies having any close relationships or caring how others would feel if he committed suicide (“who is there who cares?”). He views death as a “relief.” His use of alcohol has increased considerably in the past month. He denies having any hobbies or activities , “just drinking.”

Hospitalized in 1985 at Pleasantview Psychiatric Hospital for three months following a suicide attempt after his fourth wife left him . Treated with ECT, he did “pretty good, but only for about two years” thereafter.

An only child, his parents are deceased ( father died by suicide when client was eight years old; mother died of “old age” two years ago). Raised in Boston, he moved to Los Angeles at twenty-one and has lived here since. Completed eighth grade (without any repeat) but quit to go to work (family needed money). Has never held a job longer than two years , usually quitting or being fired because of “ my temper .” Usually worked as a laborer. Denies any physical problems other than feeling “tired all the time.” Currently living on Social Security income, he has no other financial resources . He received a bad conduct discharge from the army after three months for “disobeying an order and punching the officer.” He has had no legal problems other than several arrests in the past two years for public intoxication. Married and divorced four times , he has no children or close friends .

65 y.o. W/M, short, thin, grey-haired, unkempt, with 2-3 day-old beard, lying passively in bed and avoiding eye contact. His speech was slow and he did not spontaneously offer information . Passively cooperative. Little movement of his extremities. His facial expression was sad and immobile. Thought processes were logical and coherent, and no delusions or hallucinations were noted. Theme of talk centered around how hopeless the future was and his wishes to be dead . There were no thoughts about wishing to harm others. Mood was one of depression . He was oriented to person, place, and time, and recent and remote memory was intact. He could perform simple calculations and his general fund of knowledge was fair. His intelligence was judged average.

Is he a significant risk for suicide? Yes. The client presents a considerable suicidal risk, with respect to demographic characteristics, psychiatric diagnosis and mental status findings.
Discuss briefly why you would not have chosen the other alternatives in question #2. The client appears to be actively suicidal at the present time,and may act upon his feelings. Nothing about his life has changed because of his attempt. He still is lonely, with limited social resources. He feels no remorse for his suicidal behavior and his future remains unaltered. He must be hospitalized until some therapeutic progress can be made.

Short-Term Suicide Risk Vignettes

*Case study vignettes taken from Maris, R. W., Berman, A. L., Maltsberger, J. T., & Yufit, R. I. (Eds), (1992). Assessment and prediction of suicide. New York: Guilford. And originally cited in Stelmachers, Z. T., & Sherman, R. E. (1990). Use of case vignettes in suicide risk assessment. Suicide and Life-Threatening Behavior, 20, 65-84.

The assessment of suicide risk is a complicated process. The following vignettes are provided to promote discussion of suicide risk factors, assessment procedures, and intervention strategies. The “answers” are not provided, rather students are encouraged to discuss cases with each other and faculty. Two examples of how discussions may be facilitated are provided.

37-year-old white female, self-referred. Stated plan is to drive her car off a bridge. Precipitant seems to be verbal abuse by her boss; after talking to her nightly for hours, he suddenly refused to talk to her. As a result, patient feels angry and hurt, threatened to kill herself. She is also angry at her mother, who will not let patient smoke or bring men to their home. Current alcohol level is .15; patient is confused, repetitive, and ataxic. History reveals a previous suicide attempt (overdose) 7 years ago, which resulted in hospitalization. After spending the night at CIC and sobering, patient denies further suicidal intent.

16-year-old Native American female, self-referred following an overdose of 12 aspirins. Precipitant: could not tolerate rumors at school that she and another girl are sharing the same boyfriend. Denies being suicidal at this time (“I won’t do it again; I learned my lesson”). Reports that she has always had difficulty expressing her feelings. In the interview, is quiet, guarded, and initially quite reluctant to talk. Diagnostic impression: adjustment disorder.

49-year-old white female brought by police on a transportation hold following threats to overdose on aspirin (initially telephoned CIC and was willing to give her address). Patient feels trapped and abused, can’t cope at home with her schizophrenic sister. Wants to be in the hospital and continues to feel like killing herself. Husband indicates that the patient has been threatening to shoot him and her daughter but probably has no gun. Recent arrest for disorderly conduct (threatened police with a butcher knife). History of aspirin overdose 3 years ago. In the interview, patient is cooperative; appears depressed, anxious, helpless, and hopeless. Appetite and sleep are down, and so is her self-esteem. Is described as “anhedonic.” Alcohol level: .12.

23-year-od white male, self-referred. Patient bought a gun 2 months ago to kill himself and claims to have the gun and four shells in his car (police found the gun but no shells). Patient reports having planned time and place for suicide several times in the past. States that he cannot live any more with his “emotional pain” since his wife left him3 years ago. This pain has increased during the last week, but the patient cannot pinpoint any precipitant. Patient has a history of chemical dependency, but has been sober for 20 months and currently goes to AA.

22-year-old black male referred to CIC from the Emergency Room on a transportation hold. He referred himself to the Emergency Room after making fairly deep cuts on his wrists requiring nine stitches. Current stress is recent breakup with his girlfriend and loss of job. Has developed depressive symptoms for the last 2 months, including social withdrawal, insomnia, anhedonia, and decreased appetite. Blames his sister for the breakup with girlfriend. Makes threats to sister (“I will slice up that bitch, she is dead when I get out”). Patient is an alcoholic who just completed court-ordered chemical dependency treatment lasting 3 weeks. He is also on parole for attempted rape. There is a history of previous suicide attempts and assaultive behavior, which led to the patient being jailed. In the interview, patient is vague regarding recent events and history. He denies intent to kill himself but admits to still being quite ambivalent about it. Diagnostic impression: antisocial personality.

19-year-old white male found by roommate in a “sluggish” state following the ingestion of 10 sleeping pills (Sominex) and one bottle of whiskey. Recently has been giving away his possessions and has written a suicide note. After being brought to the Emergency Room, declares that he will do it again. Blood alcohol level: .23. For the last 3 or 4 weeks there has been sleep and appetite disturbance, with a 15-pound weight loss and subjective feelings of depression. Diagnostic impression: adjustment disorder with depressed mood versus major depressive episode. Patient refused hospitalization.

30-year-old white male brought from his place of employment by a personnel representative. Patient has been thinking of suicide “all the time” because he “can’t cope.” Has a knot in his stomach; sleep and appetite are down (sleeps only 3 hours per night); and plans either to shoot himself, jump off a bridge, or drive recklessly. Precipitant: constant fighting with his wife leading to a recent breakup (there is a long history of mutual verbal/physical abuse). There is a history of a serious suicide attempt: patient jumped off a ledge and fractured both legs; the precipitant for that attempt was a previous divorce. There is a history of chemical dependency with two courses of treatment. There is no current problem with alcohol or drugs. Patient is tearful, shaking, frightened, feeling hopeless, and at high risk for impulsive acting out. He states that life isn’t worthwhile.

Vignette Discussion Examples

Vignette example 1.

Twenty-six year old white female phoned her counselor, stated that she might take pills, and then hung up and kept the phone off the hook. The counselor called the police and the patient was brought to the crisis intervention center on a transportation hold. Patient was angry, denied suicidal attempt, and refused evaluation; described as selectively mute, which means she wouldn’t answer any of the questions she didn’t like.

Facilitator: How high a risk is this person for committing suicide? Low, moderate or high? Student Answer 1: Maybe moderate because the person is warning somebody, basically a plea for help. Facilitator: Okay, so we have suicidal talk. That’s one of our red flags. What else? She said she might take pills, so we didn’t know if she does have the pills. So she has a plan. The plan would be to take pills, but we don’t know if we have means. Student Answer 2: High. She’s also angry. I don’t know if she’s angry often. Facilitator: A person in this situation who is really thinking about killing themselves tends not to deny it. They tend not to deny it. There are exceptions to everything, but most of the time, for some reason, this is one of the things where people tend to mostly tell you the truth. If you ask people, they tend to tell you the truth. It’s a very funny thing about suicide that way. That’s certainly not true about most things. If you ask people how much they drink…But, “Are you thinking about killing yourself?” “Well, yes.” If you ask a question, you tend to get a more or less accurate, straight answer. Student question: Is that because it doesn’t matter anymore? If they’re going to die anyway, who’s going to care about what anybody thinks or what happens? Facilitator: My hypothesis would be, when someone is at that point, they’re talking about real, true things. They’re not into play. This is where they are. If they’re really looking at it, then they’re just at that place. What’s to hide at that point? You don’t have anything to lose. It’s a state of mind. And then if you’re not in that place—it’s like, how close are you to the edge of that cliff? “I’m not there. I know where that is, and I’m not there.” “If you get there, will you tell me?” “Yeah, I’m not there.” So, people have a sense—if they’ve gotten that close, they know where that line is, and they know about where they stand in regard to it, because it’s a very hard-edged, true thing.

Twenty-three year old white male, self-referred. Patient bought a gun two months ago to kill himself and claims to have the gun and four shells in his car. Police found the gun but no shells. Patient reports having planned time and place for suicide several times in the past. States that he cannot live anymore with his emotional pain since his wife left him three years ago. This pain has increased during the last week, but the patient cannot pinpoint any precipitant. Patient has a history of chemical dependency but has been sober for 20 months and currently goes to AA.

Facilitator: How high a risk is this person for committing suicide? Low, moderate or high? On a scale from 0 to 7 (7 being very high). Student Answer 1: High. On a scale of 0 to 7? Student Answer: Six. Student Answer 2: I would say three. I think it would be lower because if he’s already bought the gun two months ago and he’s self-referring himself to get help, he wants to live. He has not made peace with whatever, and he’s more likely not give away his things, and he’s going to AA meetings. I think it’s lower than really an extreme…I would say a three or four. Student Answer 3: I would say a four or five, moderate. Student Answer 4: About a five..several times and hasn’t followed through, tells me he doesn’t really want to follow through with it. Facilitator: And there are no shells, right? So we can see some of the red flags are there, but some of them aren’t. He’s still sober… Student: He has a support group. Student: He’s not using, though he bought a gun—so that’s a concern. There is a lot there. Student: He may not have the shells so he doesn’t have the opportunity to. So does that make him more…? Student 2: Think I’ll change mine to a five. Facilitator: So the mean was 4.68, so 5 was the mode. If we’re saying this is a moderate risk, what things would we look for that would make this a high risk? Student: Take away AA. Student: If he falls off the wagon, he goes right to the top. Student: And if he finds the shells. Facilitator: Because it probably is not that hard to find shells. All these stores around here, you can get shells quicker than you can get a gun, so he’s only a five-minute purchase away from having lethal—in contrast to not having the gun. Student: Could there be a difference in the time? Let’s say his wife left him just four to six months ago rather than three years. Would that be something that would be more serious? Facilitator: Yes, or if his wife just left him. So, say his wife left him a month ago that would bump it up. So that’s unresolved. That’s taking a person that was worried and that’s pushing him higher. Student: It also raises the homicide rate. Facilitator: Yes, because these tend to be murder-suicides. How often have we seen that? Murder-suicide is a big deal. If she won’t be with me, she won’t be with anybody.

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June 01, 2024 | VOL. 75, NO. 6 CURRENT ISSUE pp.513-612
May 01, 2024 | VOL. 75, NO. 5 pp.401-509
April 01, 2024 | VOL. 75, NO. 4 pp.307-398
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January 01, 2024 | VOL. 75, NO. 1 pp.1-71

Best Practices: Using Case Vignettes to Train Clinicians and Utilization Reviewers to Make Level-of-Care Decisions

Peter B. Rosenquist , M.D. ,
Christopher C. Colenda , M.D., M.P.H. ,
Judy Briggs , R.N. ,
Stephen I. Kramer , M.D. , and
Michael Lancaster , M.D.

Search for more papers by this author

Note from the column editor: Dr. Rosenquist and his colleagues describe how their academically based health maintenance organization joined in training for level-of-care decision making with the external managed behavioral health organization that was providing utilization review and case management decisions. The academic department later took over its own utilization review and in so doing internalized the utilization review function.This development, which is beginning to occur in several states, is an important solution to the "assault" that many providers of care have experienced as a result of the utilization review process. Having taken this step to deal with the realities of 21st-century health care, the authors then seize the opportunity to use their own data to improve decision making within the clinic. This process is how we get to best practices.

Medical necessity has emerged as the de facto standard for decisions about payment for behavioral health services, despite criticisms leveled from theoretical ( 1 , 2 ) and practical ( 3 ) perspectives. Moreover, it has been difficult to define best practices within the current framework of medical necessity, largely because of the many sources of variation in decisions about appropriate levels of care.

In practice, when clinicians and clinical case managers—that is, utilization reviewers—communicate information about a patient, usually by telephone, they use a narrative case presentation. Discussion is focused on assessment of necessity criteria, such as symptom severity, dangerousness, social support, and resource availability, that would support a higher level of care, such as inpatient hospitalization. Unfortunately, the dialogue may break down without resolution of differences, and with considerable residual ill will between parties ( 4 ).

In this column we report on our use of case vignettes as a training device to help clinicians and clinical case managers make consistent decisions about appropriate levels of care and to develop best practices.

Development and use of case vignettes

Partly because of their research and teaching missions, academic centers have been slow to react to changes in health care financing and have a reputation of inefficiency and overuse of intensive levels of care ( 5 ). In 1995 Wake Forest University established a health maintenance organization with about 50,000 enrollees. In the first year of operation, the university contracted with an outside, for-profit managed behavioral health organization to provide behavioral health utilization review and case management. Eventually the department was able to establish its own internal managed behavioral health care organization ( 6 ).

Initially, however, the department struggled to meet the demands of managed care, working with the outside organization. To promote greater uniformity in decision making, we designed four case vignettes and used them in joint training with our clinicians and the clinical case managers from the outside organization.

Case vignettes have been used previously to compare decision-making strategies of different groups ( 7 ). Because use of vignettes limits variation in how people perceive a case by providing all persons with the same information, vignettes offer training advantages over real-life patients. Case vignettes are ideal when the primary objective is to identify conflicts in judgment ( 8 ).

Each vignette developed by the department is a typical narrative case presentation and includes details about the patient's history and mental status. Each patient has a different diagnosis—delirium, comorbid depression and substance abuse, chronic depression, and schizophrenia. In two vignettes, the patient presents as an outpatient. In another, the setting is an emergency room. In the fourth case, the patient has been referred for a consultation to an inpatient general medical setting. The vignettes do not convey any expectations about case disposition or information about insurance status.

Thirty-one persons participated in the training—seven attending physicians, 16 house officers (psychiatric residents), and eight clinical case managers. After reading each vignette, respondents were prompted to choose the most appropriate treatment setting—inpatient care, partial hospitalization, or outpatient care. They provided up to five of their own reasons for each decision. In a translational process paralleling the interaction between clinician and reviewer, the reasons were examined to determine whether they referred to either of two common medical-necessity criteria: the patient's level of dangerousness and the patient's support system. These reasons were tallied separately and compared by group using Fisher's exact tests.

Results are summarized in Table 1 . All the respondents recommended that the patient with delirium receive inpatient care. Similarly, for the patient with comorbid depression and substance abuse, 94 percent recommended inpatient care, and only 6 percent recommended partial hospitalization.

For the patient with schizophrenia who was experiencing negative symptoms, 52 percent of respondents recommended outpatient services, 36 percent recommended partial hospitalization, and 13 percent recommended inpatient care. For the patient with chronic depression, 39 percent recommended outpatient services, 26 percent recommended partial hospitalization, and 36 percent recommended inpatient care.

No significant differences were found between attending physicians and clinical case managers on any of the four level-of-care decisions. Only house officers selected inpatient treatment for the patient with schizophrenia. Compared with attending physicians and case managers, house officers selected higher levels of care for this patient; however, the difference was not significant.

Compared with attending physicians and case managers, house officers were significantly less likely to take into account the patient's support system as a factor in decision making in two cases—the patient with schizophrenia (Fisher's exact test, p=.09) and the patient with chronic depression (p=.09). Attending physicians were less likely than house officers and case managers to take into account the patient's level of dangerousness in their decision about the patient with chronic depression (Fisher's exact test, p=.06).

Our study failed to demonstrate significant differences between groups of clinicians and utilization reviewers in level-of-care decisions for any of four common psychiatric presentations. Similarly, we identified very few differences between groups in their use of particular criteria as a rationale for their decisions.

Both the clinicians and the utilization reviewers in our setting have expressed surprise at these findings, because they run counter to the expectation that level-of-care decisions and decision rules used by each group would be quite different. In a study of implementation of a managed care plan during the course of which use of inpatient services markedly declined, it was shown that over time clinical case managers rated fewer patients as severely disturbed while ratings by clinicians remained unchanged ( 8 ).

Use of the vignettes has effectively demystified the process of utilization review for clinicians in our department. Two vignettes engendered strong agreement by all respondents. The others revealed more variation in decisions about the most appropriate level of care, both across all respondents and within respondent groups. This finding raises the question of how we can increase the level of agreement for more equivocal cases. Level-of-care decisions must be reliable—that is, care managers must make similar decisions in similar cases across time. Without some degree of reliability, a meaningful best practice is unlikely to emerge.

First, we must develop meaningful and reliable criteria. Some progress has been made. In one study, when clinicians were presented with a broad and unstructured list of variables, they were unable to achieve an acceptable level of agreement about indicators for hospitalization ( 9 ). On the other hand, expert panels using modified Delphi techniques have achieved high levels of agreement in decisions about levels of care for both hypothetical and actual cases, and in the process they have identified and developed anchored ratings for a number of key variables ( 10 , 11 ).

Second, level-of-care decision criteria must not remain the sole province of health services researchers and clinical case managers. Instead, they should be widely disseminated to the network of providers. At our facility, the outside managed behavioral health care organization shared its criteria with clinicians from the outset. When the department took over care management, this practice was continued. Also, medical-necessity criteria have been incorporated into the admission forms, admitting orders, and computerized treatment planning documentation of the inpatient and partial hospital unit ( 12 ).

Experience and training would seem to be likely sources of variation in decision making in clinical and managed care settings. Although our study was limited by its small sample size, the results suggest that house officers may differ from more experienced psychiatrists and clinical case managers in their decisions and approach. By ensuring that the house officers encounter the decision criteria in the course of their daily work and by providing them with training material on managed care principles, we hope to create a working model of best practices against which they can compare their decisions. Senior residents may also participate in an elective rotation in managed care during which they can review cases and make interpretations of medical necessity.

Criterion-based admission policies and procedures clearly narrow the range of variables used in level-of-care decisions. However, we will continue to encounter equivocal cases. One approach to improving the reliability of decisions would be to conduct field tests to systematically identify sources of variation in decision making. Once we know the sources, we may more clearly define what constitutes best practice. In a study using videotaped interviews conducted in an emergency room, agreement between raters was low for recommended disposition, psychopathology, impulse control problems, ability to care for self, and danger to self ( 13 ). A somewhat higher level of agreement was reached for psychosis and substance abuse.

Clinical case managers and medical directors continue to oversee care management in our system through traditional review processes. Every three months appeals are presented for discussion and comment before a quality improvement committee composed of a rotating group of network clinicians. Level-of-care criteria are reviewed and amended annually. This body recently voted to begin using the Criteria for Short-Term Treatment of Acute Psychiatric Illness, jointly published by the American Academy of Child and Adolescent Psychiatry and the American Psychiatric Association ( 15 ).

As practice guidelines become more detailed, and more reflective of best practices, we anticipate an eventual eclipse of more generic level-of-care criteria. For example, the use of the Clinical Institute Withdrawal Assessment protocol ( 16 ) in our facility has supplanted the need for concurrent review of necessity and intensity of service for alcohol detoxification because such a review is part of the protocol. The measure of our success will be how well we work collectively to meet the needs of patients as we develop our mental maps, whether they are vignettes, criteria, practice guidelines, or protocols.

Dr. Rosenquist is assistant professor and Dr. Kramer is associate professor in the department of psychiatry and behavioral medicine at Wake Forest University School of Medicine in Winston-Salem, North Carolina. Ms. Briggs is chief executive officer of Carolina Behavioral Health Alliance in Winston-Salem. Dr. Colenda is professor in the department of psychiatry at Michigan State University in East Lansing. Dr. Lancaster is regional medical director of Value Options in Raleigh, North Carolina. Send correspondence to Dr. Rosenquist at the Department of Psychiatry and Behavioral Medicine, Medical Center Boulevard, Winston-Salem, North Carolina 27157-1087 (e-mail, [email protected] ). William M. Glazer, M.D., is editor of this column.

Table 1. Level-of-care decisions made by seven attending physicians, 16 house officers, and eight case managers about patients described in four case vignettes

1. Asch D, Hershey J: Why some health policies don't make sense at the bedside. Annals of Internal Medicine 122:846-850, 1999 Crossref , Google Scholar

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8. Elstein AS, Kleinmuntz B, Rabinowitz M: Diagnostic reasoning of high- and low-domain-knowledge clinicians: a reanalysis. Medical Decision Making 13:21-29, 1993 Crossref , Medline , Google Scholar

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Case Vignettes

Start with:

McGraw-Hill Case Files: Basic Sciences Covering anatomy, biochemistry, microbiology, neuroscience, pathology, pharmacology, and physiology.
McGraw-Hill Case Files: Clinical Medicine Covering anesthesiology, emergency medicine, family medicine, internal medicine, neurology, obstetrics & gynecology, pediatrics, psychiatry, and surgery.
Symptom Media Symptom Media is a film library of 180 clinical training vignettes that serves as an integral educational tool for "symptom recognition." All films are produced with an experienced multi-disciplinary behavioral health team working in concert with professional scriptwriters, filmmakers and highly trained actors, facilitating a synergistic realism and clinical accuracy during the entire filmmaking process. Videos range in length from 30 seconds to 15 minutes.

Then try any of the following:

Basic sciences.

Clinical Neuroanatomy
MSU Neuropathology Navigator
Pathophysiology of Disease Cases
UPMC Anatomic Pathology Cases of the Month
University of Michigan Medical School BlueLink
Yale University School of Medicine Anatomy Clinic

Family Medicine Cases

Family Medicine Board Review

Geriatrics Cases

Age-Friendly Care and Education Collection

Internal Medicine Cases

Acid-Base Disturbances
Harrison's Fluid/Electrolyte & Acid-Base Cases
Kumar and Clark's Cases in Clinical Medicine
Medicine: A Competency-Based Companion
Resident Readiness: Internal Medicine
Vanderbilt Internal Medicine and Pediatrics Curriculum

Neurological Cases

Baylor College of Medicine Medical Center Dept of Neurology Case of the Month
University of Utah NeuroLogical Cases

OB/GYN Cases

McGraw-Hill Case Files: Obstetrics & Gynecology
Obstetrics and Gynecology: A Competency-Based Companion

Pediatric Cases

Pediatrics: A Competency-Based Companion

Surgery Cases

Surgery : a Case Based Clinical Review
Clinical Cases and OSCEs in Surgery
Toronto Video Atlas of Surgery

Also check out:

Aquifer Free Interdisciplinary Cases Aquifer is a non-profit organization dedicated to delivering evidence-based, peer-reviewed virtual learning to support best practices in clinical teaching and learning. Most content is available to subscribers only, but there are some interdisciplinary cases available for free.
MedEdPortal A peer-reviewed, open-access journal that promotes educational scholarship and dissemination of teaching and assessment resources in the health professions. MedEdPORTAL publications are stand-alone, complete teaching or learning modules that have been implemented and evaluated with medical or dental trainees or practitioners.
Virtual Interactive Case System Covers anesthesia, obstetrics, and rheumatology. Also has content specific to nurse practitioner and pharmacy programs.

Vignette 5: Assessing for Depression in a Mental Health Appointment

In Vignette 3, Tony has been referred to a mental health provider to assess for depression. This vignette (5) shows a mental health provider assessing Tony for depression and suicidality. The provider must find a way to get beyond female–oriented ways of asking about depression to help Tony talk about his feelings. Adolescent males often do not endorse sadness, depression, crying, or hopelessness. They may experience frustration, anxiety, irritability, and anger, and may have somatic concerns. Asking about these symptoms often provides a pathway for boys to talk more about their feelings, or to at least indicate their level of distress. Being able to assess adolescent boys for depression and suicidality is vital, given the rate of completed suicides among males.

In this vignette:

The positive elements in this vignette are:

The negative elements in this vignette are:

Patient Case #1: 27-Year-Old Woman With Bipolar Disorder

Theresa Cerulli, MD
Tina Matthews-Hayes, DNP, FNP, PMHNP

Custom Around the Practice Video Series

Experts in psychiatry review the case of a 27-year-old woman who presents for evaluation of a complex depressive disorder.

EP: 1 . Patient Case #1: 27-Year-Old Woman With Bipolar Disorder

Ep: 2 . clinical significance of bipolar disorder, ep: 3 . clinical impressions from patient case #1, ep: 4 . diagnosis of bipolar disorder, ep: 5 . treatment options for bipolar disorder, ep: 6 . patient case #2: 47-year-old man with treatment resistant depression (trd), ep: 7 . patient case #2 continued: novel second-generation antipsychotics, ep: 8 . role of telemedicine in bipolar disorder.

Michael E. Thase, MD : Hello and welcome to this Psychiatric Times™ Around the Practice , “Identification and Management of Bipolar Disorder. ”I’m Michael Thase, professor of psychiatry at the Perelman School of Medicine at the University of Pennsylvania in Philadelphia, Pennsylvania.

Joining me today are: Dr Gustavo Alva, the medical director of ATP Clinical Research in Costa Mesa, California; Dr Theresa Cerulli, the medical director of Cerulli and Associates in North Andover, Massachusetts; and Dr Tina Matthew-Hayes, a dual-certified nurse practitioner at Western PA Behavioral Health Resources in West Mifflin, Pennsylvania.

Today we are going to highlight challenges with identifying bipolar disorder, discuss strategies for optimizing treatment, comment on telehealth utilization, and walk through 2 interesting patient cases. We’ll also involve our audience by using several polling questions, and these results will be shared after the program.

Without further ado, welcome and let’s begin. Here’s our first polling question. What percentage of your patients with bipolar disorder have 1 or more co-occurring psychiatric condition? a. 10%, b. 10%-30%, c. 30%-50%, d. 50%-70%, or e. more than 70%.

Now, here’s our second polling question. What percentage of your referred patients with bipolar disorder were initially misdiagnosed? Would you say a. less than 10%, b. 10%-30%, c. 30%-50%, d. more than 50%, up to 70%, or e. greater than 70%.

We’re going to go ahead to patient case No. 1. This is a 27-year-old woman who’s presented for evaluation of a complex depressive syndrome. She has not benefitted from 2 recent trials of antidepressants—sertraline and escitalopram. This is her third lifetime depressive episode. It began back in the fall, and she described the episode as occurring right “out of the blue.” Further discussion revealed, however, that she had talked with several confidantes about her problems and that she realized she had been disappointed and frustrated for being passed over unfairly for a promotion at work. She had also been saddened by the unusually early death of her favorite aunt.

Now, our patient has a past history of ADHD [attention-deficit/hyperactivity disorder], which was recognized when she was in middle school and for which she took methylphenidate for adolescence and much of her young adult life. As she was wrapping up with college, she decided that this medication sometimes disrupted her sleep and gave her an irritable edge, and decided that she might be better off not taking it. Her medical history was unremarkable. She is taking escitalopram at the time of our initial evaluation, and the dose was just reduced by her PCP [primary care physician]from 20 mg to 10 mg because she subjectively thought the medicine might actually be making her worse.

On the day of her first visit, we get a PHQ-9 [9-item Patient Health Questionnaire]. The score is 16, which is in the moderate depression range. She filled out the MDQ [Mood Disorder Questionnaire] and scored a whopping 10, which is not the highest possible score but it is higher than 95% of people who take this inventory.

At the time of our interview, our patient tells us that her No. 1 symptom is her low mood and her ease to tears. In fact, she was tearful during the interview. She also reports that her normal trouble concentrating, attributable to the ADHD, is actually substantially worse. Additionally, in contrast to her usual diet, she has a tendency to overeat and may have gained as much as 5 kg over the last 4 months. She reports an irregular sleep cycle and tends to have periods of hypersomnolence, especially on the weekends, and then days on end where she might sleep only 4 hours a night despite feeling tired.

Upon examination, her mood is positively reactive, and by that I mean she can lift her spirits in conversation, show some preserved sense of humor, and does not appear as severely depressed as she subjectively describes. Furthermore, she would say that in contrast to other times in her life when she’s been depressed, that she’s actually had no loss of libido, and in fact her libido might even be somewhat increased. Over the last month or so, she’s had several uncharacteristic casual hook-ups.

So the differential diagnosis for this patient included major depressive disorder, recurrent unipolar with mixed features, versus bipolar II disorder, with an antecedent history of ADHD. I think the high MDQ score and recurrent threshold level of mixed symptoms within a diagnosable depressive episode certainly increase the chances that this patient’s illness should be thought of on the bipolar spectrum. Of course, this formulation is strengthened by the fact that she has an early age of onset of recurrent depression, that her current episode, despite having mixed features, has reverse vegetative features as well. We also have the observation that antidepressant therapy has seemed to make her condition worse, not better.

Transcript Edited for Clarity

Dr. Thase is a professor of psychiatry at the Perelman School of Medicine at the University of Pennsylvania in Philadelphia, Pennsylvania.

Dr. Alva is the medical director of ATP Clinical Research in Costa Mesa, California.

Dr. Cerulli is the medical director of Cerulli and Associates in Andover, Massachusetts.

Dr. Tina Matthew-Hayes is a dual certified nurse practitioner at Western PA Behavioral Health Resources in West Mifflin, Pennsylvania.

Evaluating the Efficacy of Lumateperone for MDD and Bipolar Depression With Mixed Features

Blue Light, Depression, and Bipolar Disorder

An expert discusses the role of cognition in bipolar disorder and the potential of modafinil as a treatment for it at the 2024 ASCP Annual Meeting.

Efficacy of Modafinil for Treatment of Neurocognitive Impairment in Bipolar Disorder

Four Myths About Lamotrigine

How can we enhance our lithium research?

Securing the Future of Lithium Research

An expert shares some clinical pearls from his lecture at the recent American Psychiatric Association Annual Meeting.

An Update on Early Intervention in Psychotic Disorders

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Case Study: Definition, Examples, Types, and How to Write
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Mental Health Case study Bunyoro Kitara Part 3 by Ms.Teddy Diana Kemirembe Abwooli
Mental Health Case Manager interview questions
Possible Mental Health Case w Cops 5/24/24
Take part in mental health research
A Deep Dive into Charlie Zelenoff eight and a half-Minute Mental Health Case Study
Using Case Studies

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PDF Case Vignette Discussion Slides and Case Examples
Directions for live session: Share a case with students in advance of the live session along with some discussion prompts to prepare them for the discussion. Build out slide deck to guide conversation during the live session to include setting, client, any additional clinical details and what questions you want to focus on.
Case Examples
Sara, a 35-year-old married female. Sara was referred to treatment after having a stillbirth. Sara showed symptoms of grief, or complicated bereavement, and was diagnosed with major depression, recurrent. The clinician recommended interpersonal psychotherapy (IPT) for a duration of 12 weeks. Bleiberg, K.L., & Markowitz, J.C. (2008).
Case Vignette Slides and Sample Cases
Download. Through the use of case vignettes, students can engage in conversations and discussions of clinical and ethical considerations that come up in practice as well as discussions on various substance use treatment modalities and what treatment planning may look like. These slides and sample case vignettes provide discussion prompts for ...
Clinical vignette of an adult psychiatric patient
Clinical vignette of an adult psychiatric patient. Google Classroom. Tim is a 24 year-old PhD candidate at a large university. Over the past six months, his behavior has changed and become increasingly bizarre. Though originally very enthusiastic about graduate school, he states that he is no longer interested in pursuing a degree and has no ...
SWK 225: Case Vignettes
SWK 225 Case Vignettes 1 . Case Vignettes . Adapted from Human Behavior and the Social Environment I (Tyler, 2019) Case Vignette 1: Infant . ... Foley's thoughts on connecting Monty to mental health service as a support which could be provided at school. Foley reports feeling some anxiety with this as she does not know much about mental health
PDF NCMHCE Sample Case Studies
NCMHCE Sample Case Study. You are a licensed mental health counselor working in a community agency. Your client self-referred for services because "my mother won't stop bugging me for staying in bed all day. I can't help it. I am in a rut and cannot find a way out.".
Case Examples in the Treatment of Posttraumatic Stress Disorder
Philip, a 60-year-old who was in a traffic accident (PDF, 294KB) This case example from the European Journal of Psychotraumatology details an assisted self-study application of cognitive therapy for PTSD. Philip developed PTSD and comorbid major depression following a traffic accident. He was treated in six sessions of cognitive therapy with ...
PDF List of Case Vignettes, 2016-191
Depressed; fearful and anxious; acculturation stress. M/67, Born in 1949, African American, Divorcee with one son (deceased). M/55, White, divorced with one son and one daughter. Met with drug cartel leader from Mexican for private interview about drug war policies. Paranoid that Mexican government blamed him for the drug cartel leader's capture.
DSM-5 Clinical Cases
DSM-5 Clinical Cases makes the rather overwhelming DSM-5 much more accessible to mental health clinicians by using clinical examples—the way many clinicians learn best—to illustrate the changes in diagnostic criteria from DSM-IV-TR to DSM-5. More than 100 authors contributed to the 103 case vignettes and discussions in this book. Each case is concise but not oversimplified.
PDF Case Vignettes: A Supplement to the Trauma Informed Handbooks
The purpose of these case vignettes is to illustrate examples of how the concepts in the Handbook can be implemented. The human experience means struggling with concepts that are new and considered out of the box. Learning new concepts can best by taught through story. Attaching real people to real concepts makes the learning curve easier.
Therapist's Notebook: Case of Taylor
July/August 2008 Issue. Therapist's Notebook: Case of Taylor Social Work Today Vol. 8 No. 4 P. 24. Social Work Today presents a case vignette with input from three social workers—a case presenter and two discussants who offer their insights on the presenting problem, background and family history, and the initial phase of treatment.. Case of Taylor
Suicide Risk: Case Studies and Vignettes
Use of case vignettes in suicide risk assessment. Suicide and Life-Threatening Behavior, 20, 65-84. The assessment of suicide risk is a complicated process. The following vignettes are provided to promote discussion of suicide risk factors, assessment procedures, and intervention strategies. The "answers" are not provided, rather students ...
Best Practices: Using Case Vignettes to Train Clinicians and
Development and use of case vignettes. Partly because of their research and teaching missions, academic centers have been slow to react to changes in health care financing and have a reputation of inefficiency and overuse of intensive levels of care ().In 1995 Wake Forest University established a health maintenance organization with about 50,000 enrollees.
Evidence-Based Clinical Vignettes from the Care Management Institute
Depressive syndromes are commonly seen in the primary care setting. Major depression affects 4.8% to 8.6% of the general US population in any given year; other types of depression affect an additional 3% to 8.4% of patients. Total costs of depression, including direct medical costs and indirect costs due to days lost from work, exceed $43 ...
My Psych Board
This vignette tells us he's been experiencing issues for the last year. This is important to know if the symptoms are a new, acute experience or something that has been persisting. It also helps as most diagnoses have requirements on how long symptoms must be present for. Then, look for the 4 D's: deviance, distress, dysfunction, and danger.
PDF Suicide Assessment Case Vignettes MYSPP Suicide Assessment for ...
Vignette #3. 33 y/o white male called crisis the previous night after reportedly ingesting 20 sleeping pills. He says he hung up the phone because he got scared and later induced vomiting and slept through the night. The man called crisis again the following morning reporting ongoing suicidal thoughts but refusing to give name or location.
Often Undiagnosed but Treatable: Case Vignettes and Clinical
Case Selection and Assessments. Case study participants described in the vignettes were selected because they had a range of clinically significant traditional and distinct anxiety manifestations determined from a modified parent interview approach using the ADIS-P/ASA and expert consensus, illustrated some of the more complex diagnostic ...
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McGraw-Hill Case Files: Clinical Medicine. Covering anesthesiology, emergency medicine, family medicine, internal medicine, neurology, obstetrics & gynecology, pediatrics, psychiatry, and surgery. Symptom Media. Symptom Media is a film library of 180 clinical training vignettes that serves as an integral educational tool for "symptom ...
Case vignette-based evaluation of psychiatric blended training program
One of such program is blended psychiatric training program developed at our center. Aim: Case vignette-based outcome evaluation of on-site section of blended psychiatric training of PCDs at the end of 2 weeks. Materials and Methods: Two qualified psychiatrists designed the ten case vignettes after pilot use. Data were collected at baseline and ...
Vignette 5: Assessing for Depression in a Mental Health Appointment
This vignette (5) shows a mental health provider assessing Tony for depression and suicidality. The provider must find a way to get beyond female-oriented ways of asking about depression to help Tony talk about his feelings. ... This is a standard opening mental health assessment question. As in this case, adolescent boys often present at ...
Patient Case #1: 27-Year-Old Woman With Bipolar Disorder
We're going to go ahead to patient case No. 1. This is a 27-year-old woman who's presented for evaluation of a complex depressive syndrome. She has not benefitted from 2 recent trials of antidepressants—sertraline and escitalopram. This is her third lifetime depressive episode.
Lessons from the Use of Vignettes in the Study of Mental Health Service
Data Source. Interviews with vignette developers and qualitative data from a novel mental health services disparities study that used vignettes in two samples: (1) predominantly low-income parents of children attending mental health specialty care who were Latino or non-Latino White and (2) Latino and non-Latino mental health clinicians who treat children in their practice.
Ethics and Psychology: Vignette Warehouse (39)
Vignette Warehouse (39) First, these vignettes are meant to be teaching tools. Next, most vignettes have more than one ethical issue that can be addressed. While confidentiality has been preserved, the dynamics of each case are isomorphic to a real clinical situation faced by a practicing psychologist.