Practice

Renee is self-referred after her primary care provider suggested counseling. For about seven weeks she has felt "empty" most of the day, nearly every day. She has stopped running with her group and skipped Bible study, saying nothing feels worth the effort. She wakes at 3 a.m. and cannot fall back asleep, has lost 8 pounds without trying, feels exhausted, and has trouble concentrating on medication charts. She describes guilt over two patient deaths on her unit during a staffing shortage, though a review found no error. She reports thoughts that she "wouldn't mind not waking up" on several nights; she denies a plan, intent, or past attempts and names her daughter and her faith as reasons to live. She denies any period of elevated mood or reduced need for sleep. She drinks a glass of wine one or two nights a week. Her primary care provider found normal thyroid results last month. She works rotating 12-hour shifts and has called in sick four times this month. On mental status examination she is neatly dressed, with slowed speech and movement, flat affect, linear thought process, no psychotic features, and good insight. Her PHQ-9 score is 17. Twice she asks who will be able to see her chart, saying she is afraid her employer or the nursing board will learn she is in counseling. While reviewing her intake form, the counselor notices that Renee works on the same small unit as the counselor's spouse.