Case briefing
The working hypothesis is that the client, Shamil, is experiencing a significant mood disturbance characterized by depressive symptoms, anxiety, and sleep disruption. Key reported features include hopelessness, avolition, and a lack of interest in living. The most critical diagnostic question is to differentiate a unipolar depressive episode from a bipolar disorder, given the client's report of cyclical mood patterns including periods of being 'very bright'. More data is needed to characterize these elevated mood states, clarify the nature of his anxiety, and conduct a thorough risk assessment regarding his passive suicidal ideation.
6A61 Bipolar type II disorder · working (40%)
Safety — severity high
suicidal ideation. No safety plan on file.
Still to find out · 21 (questions to answer at the next visit)
Complete a safety plan with the client
Crisis indicators are present and no safety plan is on file.
Administer PHQ-9 + GAD-7 to set a baseline
Progress can only be measured against a starting point.
You mentioned times when you feel 'very bright'. Can you describe what that is like for you? What is your energy, sleep, and thinking like during those times?
To gather specific evidence for or against a hypomanic episode, which is critical for differentiating Bipolar II from a depressive disorder.
You said you have 'no interest in living at all'. Thank you for sharing that. Can you tell me more about that feeling? Have you had thoughts about ending your life?
To directly assess the severity of suicidal ideation, including intent and plan, as part of a necessary and immediate risk assessment.
You also mentioned having a lot of anxiety. What kinds of things do you find yourself worrying about, and how much of your day does this worry take up?
To characterize the nature of the anxiety and determine if it meets criteria for a separate anxiety disorder like GAD.
These symptoms started about two months ago. Can you walk me through what was happening in your life around that time? Has anything like this, either the lows or the 'bright' periods, ever happened before in your life?
To identify potential triggers and establish a longitudinal history of mood episodes, which is essential for diagnosis.
How have these feelings and mood changes affected your daily life—for example, your relationships, your work or studies, and your ability to take care of daily tasks?
To assess the level of functional impairment, a key diagnostic criterion for mood disorders.
You mentioned sometimes behaving 'out of control' with people. Could you give me an example of what that looks like?
To explore potential symptoms of irritability or impulsivity, which can be features of a mood episode (depressive or hypomanic).
Do you ever use alcohol, tobacco, or any other substances to manage your mood or feelings?
To screen for substance use and rule out a substance-induced mood disorder.
Characterize the 'bright' periods: duration, energy levels, sleep needs, thought speed, and mood.
Tests 6A61 Bipolar type II disorder.
Assess for associated features of hypomania (e.g., increased goal-directed activity, impulsivity, grandiosity).
Tests 6A61 Bipolar type II disorder.
Establish a clear longitudinal history of distinct mood episodes.
Tests 6A61 Bipolar type II disorder.
Determine if these episodes cause functional impairment or a marked change from usual self.
Tests 6A61 Bipolar type II disorder.
Systematically assess for all diagnostic criteria for a depressive episode (e.g., concentration, guilt, psychomotor changes).
Tests 6A70 Single episode depressive disorder.
Thoroughly rule out any lifetime history of manic or hypomanic episodes.
Tests 6A70 Single episode depressive disorder.
Quantify the severity and functional impairment caused by the depressive symptoms.
Tests 6A70 Single episode depressive disorder.
Clarify the exact duration of the current episode.
Tests 6A70 Single episode depressive disorder.
Explore the content and focus of the anxiety/worry.
Tests 6B00 Generalized anxiety disorder.
Determine if the anxiety is persistent and occurs independently of the mood episodes.
Tests 6B00 Generalized anxiety disorder.
Assess for physical symptoms of anxiety (e.g., restlessness, muscle tension).
Tests 6B00 Generalized anxiety disorder.
Establish the chronicity of the anxiety symptoms.
Tests 6B00 Generalized anxiety disorder.
Do next
1.Address the active crisis flag
This sessionCrisis indicators (suicidal ideation) are present. Complete a safety plan this session.
Why: Risk takes precedence over all other clinical work.
2.Set a baseline — administer PHQ-9 + GAD-7
This sessionAdminister the recommended screeners so every later session measures change.
Why: You can only show progress against a starting point.
Administer now3.Next session — close an open diagnostic question
Next sessionAsk: "Characterize the 'bright' periods: duration, energy levels, sleep needs, thought speed, and mood."
Why: Tests 6A61 Bipolar type II disorder.
Next session: in ~7 days
Weekly during assessment keeps the differential narrowing.
A structured second opinion when you’re stuck — what’s been tried, what the data shows, options to consider, and questions to bring to supervision. Therapist-facing only.
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