depression case study questions

Mental Health Case Study: Understanding Depression through a Real-life Example

Through the lens of a gripping real-life case study, we delve into the depths of depression, unraveling its complexities and shedding light on the power of understanding mental health through individual experiences. Mental health case studies serve as invaluable tools in our quest to comprehend the intricate workings of the human mind and the various conditions that can affect it. By examining real-life examples, we gain profound insights into the lived experiences of individuals grappling with mental health challenges, allowing us to develop more effective strategies for diagnosis, treatment, and support.

The Importance of Case Studies in Understanding Mental Health

Case studies play a crucial role in the field of mental health research and practice. They provide a unique window into the personal narratives of individuals facing mental health challenges, offering a level of detail and context that is often missing from broader statistical analyses. By focusing on specific cases, researchers and clinicians can gain a deeper understanding of the complex interplay between biological, psychological, and social factors that contribute to mental health conditions.

One of the primary benefits of using real-life examples in mental health case studies is the ability to humanize the experience of mental illness. These narratives help to break down stigma and misconceptions surrounding mental health conditions, fostering empathy and understanding among both professionals and the general public. By sharing the stories of individuals who have faced and overcome mental health challenges, case studies can also provide hope and inspiration to those currently struggling with similar issues.

Depression, in particular, is a common mental health condition that affects millions of people worldwide. Disability Function Report Example Answers for Depression and Bipolar: A Comprehensive Guide offers valuable insights into how depression can impact daily functioning and the importance of accurate reporting in disability assessments. By examining depression through the lens of a case study, we can gain a more nuanced understanding of its manifestations, challenges, and potential treatment approaches.

Understanding Depression

Before delving into our case study, it’s essential to establish a clear understanding of depression and its impact on individuals and society. Depression is a complex mental health disorder characterized by persistent feelings of sadness, hopelessness, and loss of interest in activities. It can affect a person’s thoughts, emotions, behaviors, and overall well-being.

Some common symptoms of depression include:

– Persistent sad, anxious, or “empty” mood – Feelings of hopelessness or pessimism – Irritability – Loss of interest or pleasure in hobbies and activities – Decreased energy or fatigue – Difficulty concentrating, remembering, or making decisions – Sleep disturbances (insomnia or oversleeping) – Appetite and weight changes – Physical aches or pains without clear physical causes – Thoughts of death or suicide

The prevalence of depression worldwide is staggering. According to the World Health Organization, more than 264 million people of all ages suffer from depression globally. It is a leading cause of disability and contributes significantly to the overall global burden of disease. The impact of depression extends far beyond the individual, affecting families, communities, and economies.

Depression can have profound consequences on an individual’s quality of life, relationships, and ability to function in daily activities. It can lead to decreased productivity at work or school, strained personal relationships, and increased risk of other health problems. The economic burden of depression is also substantial, with costs associated with healthcare, lost productivity, and disability.

The Significance of Case Studies in Mental Health Research

Case studies serve as powerful tools in mental health research, offering unique insights that complement broader statistical analyses and controlled experiments. They allow researchers and clinicians to explore the nuances of individual experiences, providing a rich tapestry of information that can inform our understanding of mental health conditions and guide the development of more effective treatment strategies.

One of the key advantages of case studies is their ability to capture the complexity of mental health conditions. Unlike standardized questionnaires or diagnostic criteria, case studies can reveal the intricate interplay between biological, psychological, and social factors that contribute to an individual’s mental health. This holistic approach is particularly valuable in understanding conditions like depression, which often have multifaceted causes and manifestations.

Case studies also play a crucial role in the development of treatment strategies. By examining the detailed accounts of individuals who have undergone various interventions, researchers and clinicians can identify patterns of effectiveness and potential barriers to treatment. This information can then be used to refine existing approaches or develop new, more targeted interventions.

Moreover, case studies contribute to the advancement of mental health research by generating hypotheses and identifying areas for further investigation. They can highlight unique aspects of a condition or treatment that may not be apparent in larger-scale studies, prompting researchers to explore new avenues of inquiry.

Examining a Real-life Case Study of Depression

To illustrate the power of case studies in understanding depression, let’s examine the story of Sarah, a 32-year-old marketing executive who sought help for persistent feelings of sadness and loss of interest in her once-beloved activities. Sarah’s case provides a compelling example of how depression can manifest in high-functioning individuals and the challenges they face in seeking and receiving appropriate treatment.

Background: Sarah had always been an ambitious and driven individual, excelling in her career and maintaining an active social life. However, over the past year, she began to experience a gradual decline in her mood and energy levels. Initially, she attributed these changes to work stress and the demands of her busy lifestyle. As time went on, Sarah found herself increasingly isolated, withdrawing from friends and family, and struggling to find joy in activities she once loved.

Presentation of Symptoms: When Sarah finally sought help from a mental health professional, she presented with the following symptoms:

– Persistent feelings of sadness and emptiness – Loss of interest in hobbies and social activities – Difficulty concentrating at work – Insomnia and daytime fatigue – Unexplained physical aches and pains – Feelings of worthlessness and guilt – Occasional thoughts of death, though no active suicidal ideation

Initial Diagnosis: Based on Sarah’s symptoms and their duration, her therapist diagnosed her with Major Depressive Disorder (MDD). This diagnosis was supported by the presence of multiple core symptoms of depression that had persisted for more than two weeks and significantly impacted her daily functioning.

The Treatment Journey

Sarah’s case study provides an opportunity to explore the various treatment options available for depression and examine their effectiveness in a real-world context. Supporting a Caseworker’s Client Who Struggles with Depression offers valuable insights into the role of support systems in managing depression, which can complement professional treatment approaches.

Overview of Treatment Options: There are several evidence-based treatments available for depression, including:

1. Psychotherapy: Various forms of talk therapy, such as Cognitive Behavioral Therapy (CBT) and Interpersonal Therapy (IPT), can help individuals identify and change negative thought patterns and behaviors associated with depression.

2. Medication: Antidepressants, such as Selective Serotonin Reuptake Inhibitors (SSRIs), can help regulate brain chemistry and alleviate symptoms of depression.

3. Combination Therapy: Many individuals benefit from a combination of psychotherapy and medication.

4. Lifestyle Changes: Exercise, improved sleep habits, and stress reduction techniques can complement other treatments.

5. Alternative Therapies: Some individuals find relief through approaches like mindfulness meditation, acupuncture, or light therapy.

Treatment Plan for Sarah: After careful consideration of Sarah’s symptoms, preferences, and lifestyle, her treatment team developed a comprehensive plan that included:

1. Weekly Cognitive Behavioral Therapy sessions to address negative thought patterns and develop coping strategies.

2. Prescription of an SSRI antidepressant to help alleviate her symptoms.

3. Recommendations for lifestyle changes, including regular exercise and improved sleep hygiene.

4. Gradual reintroduction of social activities and hobbies to combat isolation.

Effectiveness of the Treatment Approach: Sarah’s response to treatment was monitored closely over the following months. Initially, she experienced some side effects from the medication, including mild nausea and headaches, which subsided after a few weeks. As she continued with therapy and medication, Sarah began to notice gradual improvements in her mood and energy levels.

The CBT sessions proved particularly helpful in challenging Sarah’s negative self-perceptions and developing more balanced thinking patterns. She learned to recognize and reframe her automatic negative thoughts, which had been contributing to her feelings of worthlessness and guilt.

The combination of medication and therapy allowed Sarah to regain the motivation to engage in physical exercise and social activities. As she reintegrated these positive habits into her life, she experienced further improvements in her mood and overall well-being.

The Outcome and Lessons Learned

Sarah’s journey through depression and treatment offers valuable insights into the complexities of mental health and the effectiveness of various interventions. Understanding the Link Between Sapolsky and Depression provides additional context on the biological underpinnings of depression, which can complement the insights gained from individual case studies.

Progress and Challenges: Over the course of six months, Sarah made significant progress in managing her depression. Her mood stabilized, and she regained interest in her work and social life. She reported feeling more energetic and optimistic about the future. However, her journey was not without challenges. Sarah experienced setbacks during particularly stressful periods at work and struggled with the stigma associated with taking medication for mental health.

One of the most significant challenges Sarah faced was learning to prioritize her mental health in a high-pressure work environment. She had to develop new boundaries and communication strategies to manage her workload effectively without compromising her well-being.

Key Lessons Learned: Sarah’s case study highlights several important lessons about depression and its treatment:

1. Early intervention is crucial: Sarah’s initial reluctance to seek help led to a prolongation of her symptoms. Recognizing and addressing mental health concerns early can prevent the condition from worsening.

2. Treatment is often multifaceted: The combination of medication, therapy, and lifestyle changes proved most effective for Sarah, underscoring the importance of a comprehensive treatment approach.

3. Recovery is a process: Sarah’s improvement was gradual and non-linear, with setbacks along the way. This emphasizes the need for patience and persistence in mental health treatment.

4. Social support is vital: Reintegrating social activities and maintaining connections with friends and family played a crucial role in Sarah’s recovery.

5. Workplace mental health awareness is essential: Sarah’s experience highlights the need for greater understanding and support for mental health issues in professional settings.

6. Stigma remains a significant barrier: Despite her progress, Sarah struggled with feelings of shame and fear of judgment related to her depression diagnosis and treatment.

Sarah’s case study provides a vivid illustration of the complexities of depression and the power of comprehensive, individualized treatment approaches. By examining her journey, we gain valuable insights into the lived experience of depression, the challenges of seeking and maintaining treatment, and the potential for recovery.

The significance of case studies in understanding and treating mental health conditions cannot be overstated. They offer a level of detail and nuance that complements broader research methodologies, providing clinicians and researchers with invaluable insights into the diverse manifestations of mental health disorders and the effectiveness of various interventions.

As we continue to explore mental health through case studies, it’s important to recognize the diversity of experiences within conditions like depression. Personal Bipolar Psychosis Stories: Understanding Bipolar Disorder Through Real Experiences offers insights into another complex mental health condition, illustrating the range of experiences individuals may face.

Furthermore, it’s crucial to consider how mental health issues are portrayed in popular culture, as these representations can shape public perceptions. Understanding Mental Disorders in Winnie the Pooh: Exploring the Depiction of Depression provides an interesting perspective on how mental health themes can be embedded in seemingly lighthearted stories.

The field of mental health research and treatment continues to evolve, driven by the insights gained from individual experiences and comprehensive studies. By combining the rich, detailed narratives provided by case studies with broader research methodologies, we can develop more effective, personalized approaches to mental health care. As we move forward, it is essential to continue exploring and sharing these stories, fostering greater understanding, empathy, and support for those facing mental health challenges.

References:

1. World Health Organization. (2021). Depression. Retrieved from https://www.who.int/news-room/fact-sheets/detail/depression

2. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

3. Beck, A. T., & Alford, B. A. (2009). Depression: Causes and treatment. University of Pennsylvania Press.

4. Cuijpers, P., Quero, S., Dowrick, C., & Arroll, B. (2019). Psychological treatment of depression in primary care: Recent developments. Current Psychiatry Reports, 21(12), 129.

5. Malhi, G. S., & Mann, J. J. (2018). Depression. The Lancet, 392(10161), 2299-2312.

6. Otte, C., Gold, S. M., Penninx, B. W., Pariante, C. M., Etkin, A., Fava, M., … & Schatzberg, A. F. (2016). Major depressive disorder. Nature Reviews Disease Primers, 2(1), 1-20.

7. Sapolsky, R. M. (2004). Why zebras don’t get ulcers: The acclaimed guide to stress, stress-related diseases, and coping. Holt paperbacks.

8. Yin, R. K. (2017). Case study research and applications: Design and methods. Sage publications.

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Module 7: Mood Disorders

Case studies: mood disorders, learning objectives.

• Identify mood disorders in case studies

Let’s use the information we’ve learned in this module to examine a few fictional characters.

Case Study: A.J. from The Sopranos

We’ll start with the case study of Anthony Soprano, Jr. (referred to as A.J.) from  The Sopranos (a HBO television series, 1999–2005). A.J. started a new job working construction and was getting more stable in his life following dropping out of community college. He met a girl named Blanca at the construction site and they started dating.

Figure 1 . A.J. became sad and irritable following his failed engagement.

The two became really close, and A. J. eventually proposed to Blanca. After some reconsideration, she decided that A.J. was not right for her and broke up with him. Following the breakup, A.J. is sad and lethargic. A.J. continued to work at the construction site for some time, but the sight of Blanca talking to other men becomes too much for him, so he eventually quits. After the breakup with Blanca, A.J. started sleeping all the time and would not come out of his room. He had a decreased appetite and anhedonia. He seemed to lack energy for quite some time. There were no suicidal ideations initially. Though his symptoms seemed to be improving slightly, after an incident with another student, he again confined himself to his room. He attempted to kill himself by jumping into a pool with a cinderblock around his leg while his parents were out of the house. Luckily, his father came home and saved him prior to there being any significant damage. A.J. was admitted to an inpatient psychiatric facility and received the therapy he needed.

Proper treatment of A.J.’s diagnosis would, given his severe symptom levels, include beginning with antidepressant medication. Psychotherapy, specifically CBT (which has shown great success with a combination of antidepressant medication), DBT, CT-SP, or BCBT, may also prove helpful.

Case Study: Eeyore from Winnie the Pooh

Background information.

Figure 2 . Eeyore.

Eeyore is an older gray donkey. There are no documents indicating the exact age.  Eeyore does not have an occupation. One main difficulty Eeyore has elaborated on is his detachable tail, which seems to cause him several problems. He has indicated that his goals are to remain strong for his friends despite his lack of self-confidence, and as a result, he often feels lonely without support from others that he is close to. Some forms of coping mechanisms include trying to feel useful in the presence of others and also trying his best to find pleasure in life.

Description of the Problem

Eeyore constantly insists that his tail falls off rather frequently. Eeyore’s posture typically involves a slumped head and droopy eyes, and he commonly says, “thanks for noticing me.” Sluggish movement is also apparent, without any physical cause for movement delay. He seems to step on his tail often and fall down. Eeyore indicates that sometimes it seems that even his close friends do not need him. Around friends, he typically makes comments about his relative unimportance and travels near the back of the pack. He also stated that although he tries to force a smile, a real smile has not existed in a long time, even though others try to cheer him up. He often feels empty even when accompanied by friends. Eeyore also seems to experience a loss of energy throughout the day, although sleeping habits are not explicitly expressed.

Eeyore met criteria including depressed mood most of the day, markedly diminished interest or pleasure in activities, fatigue or loss of energy nearly every day, feelings of worthlessness, and diminished ability to think or concentrate.

Case Study: Ashlynn

Ashlynn is a 21-year-old college student and political science major who has struggled with depression on and off since beginning college. She was picked up by campus police after being caught vandalizing a man’s apartment and was recommended to a psychiatrist after exhibiting erratic behavior. She explained that she was only at the man’s apartment because he was a classmate and she wanted to prove to him how much she liked him. She spoke about how that, even though he didn’t know it yet, they were destined to be together and that they would someday run for office together and be the first-ever married president and vice president. She was irritable and argumentative, and defensive about her behavior. She indicated that she didn’t care about her finals anymore (though she had consistently good grades in the past), she had been pulling all-nighters to research politicians, and had been experimenting with illicit drugs.

• Major Depressive Disorder Case Studies. Authored by : Bill Pelz. Provided by : Lumen. Located at : https://courses.lumenlearning.com/suny-hccc-abnormalpsych/chapter/major-depressive-disorder/ . License : CC BY-SA: Attribution-ShareAlike
• Engagement ring. Located at : https://www.pxfuel.com/en/free-photo-qfvpb . License : Public Domain: No Known Copyright
• Eeyore. Located at : https://pixy.org/852182/ . License : CC BY-NC-ND: Attribution-NonCommercial-NoDerivatives

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Case scenario: Management of major depressive disorder in primary care based on the updated Malaysian clinical practice guidelines

Uma visvalingam.

MBBS (MAHE), Master of Medicine (Psychiatry) (UKM), Department of Psychiatry and Mental Health, Hospital Putrajaya, Putrajaya, Malaysia

Umi Adzlin Silim

MD (UKM), M. Med (Psychiatry) (UKM), Department of Psychiatry and Mental Health, Hospital Serdang, Serdang, Selangor, Malaysia

Ahmad Zahari Muhammad Muhsin

MB., BCh., BAO (UCD, Ireland), M. Psych Med (Malaya), Department of Psychological Medicine, Faculty of Medicine Universiti Malaya, Kuala Lumpur, Malaysia

Firdaus Abdul Gani

MBBS (Malaya) M.Med (Psy) (USM) CMIA (NIOSH), Department of Psychiatry and Mental Health, Hospital Sultan Haji Ahmad Shah, Temerloh, Pahang, Malaysia

Noormazita Mislan

MB, BCh, BAO (Ireland), M Med. (Psychiatry) (UKM), Department of Psychiatry and Mental Health, Hospital Tuanku Ja'afar, Seremban, Negeri Sembilan, Malaysia

Noor Izuana Redzuan

MBBS (Malaya), Dr in Psychiatry (UKM), Department of Psychiatry and Mental Health, Hospital Raja Permaisuri Bainun, Ipoh, Perak, Malaysia

Peter Kuan Hoe Low

MB, BCh, BAO (Ireland), M.Psych Med (UM), Department of Psychiatry and Mental Health, Hospital Kuala Lumpur, Kuala Lumpur, Malaysia

Sing Yee Tan

MBBS (Malaya), M.Med (Family Med) (UM), Klinik Kesihatan Jenjarom, Jenjarom Selangor, Malaysia

Masseni Abd Aziz

MD (USM) M Med (Fammed) USM, Klinik Kesihatan Umbai, Merlimau, Melaka, Malaysia

Aida Syarinaz Ahmad Adlan

MBBS (Malaya), M. Psych Med (UM), PostGrad. Dip. (Dynamic Psychotherapy) (Mcgill University), Department of Psychological Medicine, Faculty of Medicine, Universiti Malaya Kuala, Lumpur, Malaysia

Suzaily Wahab

MD (UKM), MMed Psych (UKM), Hospital Canselor Tuanku Muhriz UKM, Kuala Lumpur, Malaysia

Aida Farhana Suhaimi

B. Psych (Adelaide), M. Psych (Clin. Psych) (Tasmania), PhD (Psychological Medicine) (UPM), Department of Psychiatry and Mental Health, Hospital Putrajaya, Putrajaya, Malaysia

Nurul Syakilah Embok Raub

BPharm (Hons) (CUCMS), MPH (Malaya), Pharmacy Enforcement Branch, Selangor Health State Department, Shah Alam, Selangor, Malaysia

Siti Mariam Mohtar

BPharm (UniSA), Malaysian Health Technology Assessment Section (MaHTAS), Ministry of Health Malaysia, Putrajaya, Malaysia

Mohd Aminuddin Mohd Yusof

MD (UKM), MPH (Epidemiology) (Malaya), Malaysian Health Technology Assessment Section (MaHTAS), Ministry of Health Malaysia, Putrajaya, Malaysia, Email: moc.oohay@rd2ma

Major depressive disorder (MDD) is a common but complex illness that is frequently presented in the primary care setting. Managing this disorder in primary care can be difficult, and many patients are underdiagnosed and/or undertreated. The Malaysian Clinical Practice Guidelines (CPG) on the Management of Major Depressive Disorder (MDD) (2nd ed.), published in 2019, covers screening, diagnosis, treatment and referral (which frequently pose a challenge in the primary care setting) while minimising variation in clinical practice.

Introduction

MDD is one of the most common mental illnesses encountered in primary care. It presents with a combination of symptoms that may complicate its management.

This mental disorder requires specific treatment approaches and is projected to be the leading cause of the disease burden in 2030. 1 Patients experiencing this ailment are at elevated risk for early mortality from physical disorders and suicide. 2 In Malaysia in particular, MDD contributes to 6.9% of total Years Living with Disability. 3

Ensuring full functional recovery and prevention of relapse makes remission the targeted outcome for treatment of MDD. In contrast, nonremission of depressive symptoms in MDD can impact functionality 4 and subsequently amplify the economic burden that the illness imposes.

About the new edition

The highlights of the updated CPG MDD (2nd ed.) are as follows:

• emphasis on psychosocial and psychological interventions, particularly for mild to moderate MDD
• inclusion of all second-generation antidepressants as the first-line pharmacotherapy
• introduction of new emerging treatments, ie. intravenous ketamine for acute phase and intranasal esketamine for next-step treatment/treatment-resistant MDD
• improvement in pre-treatment screening and monitoring of treatment
• integration of mental health into other health services with emphasis on collaborative care
• addition of 2 new chapters on special populations (pregnancy and postpartum, chronic medical illness) and table on safety profile of pharmacotherapy in pregnancy and breastfeeding
• comprehensive, holistic biopsychosocial-spiritual approaches addressing psychospirituality

Details of the evidence supporting the above statements can be found in Clinical Practice Guidelines on the Management of Major Depressive Disorder (2nd ed.) 2019, available on the following websites: http://www.moh.gov.my (Ministry of Health Malaysia) and http://www.acadmed.org.my (Academy of Medicine). Corresponding organisation: CPG Secretariat, Health Technology Assessment Section, Medical Development Division, Ministry of Health Malaysia; contactable at ym.vog.hom@aisyalamath .

Statement of intent

This is a support tool for implementation of CPG Management of Major Depressive Disorder (2nd ed.).

Healthcare providers are advised of their responsibility to implement this evidence-based CPG in their local context. Such implementation will lead to capacity building to ensure better accessibility of psychosocial and psychological services. More options in pharmacotherapy facilitate flexibility in prescribing antidepressants among clinicians. Further integration of mental health into other health services, upscaling of mental health service development in perinatal and medical services, and enhancement of collaborative care will incorporate holistic approaches into care.

Case Scenario

Tini is a female college student aged 24 years old. She comes to the health clinic accompanied by a friend and complains of several symptoms that she has experienced over the past 4 weeks. She reports:

• difficulty falling asleep, feeling tired after waking up in the morning and experiencing headaches
• difficulty staying focused during classes. These symptoms have led to deterioration in her study and prompted her to seek advice from the doctor.

Will you screen her for depression?

Yes, because the patient presents with multiple vague symptoms and sleep disturbance. 5 (Refer to Subchapter 2.1, page 3 in CPG.)

What tools are used to screen for depression?

Screening tools for depression are:

• Beck Depression Inventory (BDI)
• Depression Anxiety and Stress Scale (DASS)
• Patient Health Questionnaire-9 (PHQ-9)
• Hospital Anxiety and Depression Scale (HADS)
• Whooley Questions

Screening for depression using Whooley Questions in primary care may be considered in people at risk. 5

( Refer to Subchapter 2.1, pages 3 and 4 in CPG. )

• “During the past month, have you often been bothered by feeling down, depressed or hopeless?”
• “During the past month, have you often been bothered by having little interest or pleasure in doing things?

The doctor decides to use Whooley Questions, and Tini answers “yes” to both questions.

How would you proceed from here to further assess for depression?

Assessment of depression consists of:

• detailed history taking (Refer to Subchapter 2.2, page 4 in CPG.)
• mental state examination (MSE), including evaluation of symptom severity, presence of psychotic symptoms and risk of harm to self and others
• physical examination to rule out organic causes
• investigations where indicated — biological and psychosocial investigations

Upon further assessment, Tini reveals that she feels overwhelmingly sad. She is frequently tearful and reports feeling excessively guilty, blaming herself for not performing well enough in her studies. Her postings on social media have been revolving around themes of self-defeat. Despite feeling low, she still strives to attend classes and complete her assignments. However, her academic performance has exhibited a marked deterioration. There is no history to suggest hypomanic, manic or psychotic symptoms. She denies using any illicit substances or alcohol. Her menstrual cycle is normal and does not correspond to her mood changes.

MSE reveals a young lady who appears to be in distress. Rapport is easily established, but her eyes are downcast. Her speech is relevant, with low tone. She describes her mood as sad; she is tearful while talking about her poor results, with appropriate affect. She harbours multiple unhelpful thoughts, eg. “I’m a failure” and “I’m useless”. She exhibits no suicidal ideations, delusions or hallucinations. Her concentration is poor, and insight is partial.

Physical examination reveals no recent selfharm scars, and examination of other systems is unremarkable. Biological investigations such as full blood count and thyroid function test are within normal range. Corroborative history is taken from accompanying person to verify the symptoms.

How would you arrive at the diagnosis and severity?

Diagnosis of depression can be made using the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) or the 10th revision of the International Statistical Classification of Disease and Related Health Problems (ICD-10). 5 (Refer to Appendix 3 and 4, pages 73-76 in CPG.) 6 , 7

In the last 2 weeks, Tini has been experiencing:

• poor concentration
• excessive guilt

These symptoms have caused marked impairment in her academic functioning. Thus, she is diagnosed as having MDD with mild to moderate severity in acute phase and can be treated in primary care.

Severity according to DSM-5

• Five or more symptoms are present, which cause distress but are manageable
• Result in minor impairment in social or occupational functioning
• Symptom presentation and functional impairment between 2 severities
• Most of the symptoms are present with marked impairment in functioning

What can be offered to this patient?

Psychosocial interventions and psychotherapy with or without pharmacotherapy. 5 (Refer to Algorithm 1. Treatment of Major Depressive Disorder, page xii in CPG)

ALGORITHM 1. TREATMENT OF MAJOR DEPRESSIVE DISORDER

Psychosocial interventions include the following:

• symptoms and course of depression
• biopsychosocial model of aetiology
• pharmacotherapy for acute phase and maintenance
• drug side effects and complications
• importance of medication adherence
• early signs of recurrence
• management of relapse and recurrence
• counselling/non-directive supportive therapy - aims to guide the person in decision-making and allow to ventilate their emotions
• relaxation - a method to help a person attain a state of calmness, eg. breathing exercise, progressive muscle relaxation, relaxation imagery
• peer intervention - eg. peer support group
• exercise - activity of 45-60 minutes per session, up to 3 times per week, and prescribed for 10-12 weeks

(Refer to subchapter 4.1.1, pages 9-12 in CPG.)

However, the doctor may choose to start antidepressant medication as an initial measure in some situations, for example:

• past history of moderate to severe depression
• patient’s preference
• previous response to antidepressants
• lack of response to non-pharmacotherapy interventions

What are the types of psychotherapy that can be offered in mild to moderate MDD, and what factors should be considered before starting psychotherapy?

Psychotherapy for the treatment of MDD has been shown to reduce psychological distress and improve recovery through the therapeutic relationship between the therapist and the patient.

In mild to moderate MDD, psychosocial intervention and psychotherapy should be offered, based on resource availability, and may include but are not restricted to the following 5 :

• Cognitive behavioural therapy (CBT)
• Interpersonal therapy
• Problem-solving therapy
• Behavioural therapy
• Internet-based CBT

The type of psychotherapy offered to the patient will depend on various factors, including 5 :

• patient preference and attitude
• nature of depression
• availability of trained therapist
• therapeutic alliance
• availability of therapy

(Refer to Subchapter 4.1.1, page 17 in CPG.)

After shared-decision making, Tini receives psychosocial intervention, that includes:

• psychoeducation
• non-directive supportive therapy
• lifestyle modification, e.g. restoring healthy sleep hygiene and adopting healthy eating habits
• relaxation, e.g. progressive muscle relaxation, imagery and breathing technique

Tini will benefit from CBT due to her multiple unhelpful thoughts, for example, “I’m a failure” and “I’m useless”.

CBT helps improve understanding of the impact of a person’s unhelpful thoughts on current behaviour and functioning through cognitive restructuring and a behavioural approach. By learning to correctly identify these negative thinking patterns, Tini can then challenge such thoughts repeatedly to replace disordered thinking with more rational, balanced and healthy thinking. However, she is not able to commit to regular sessions of CBT due to a demanding academic schedule and upcoming final examination. After further discussion, Tini opts for pharmacotherapy.

What are the options for pharmacotherapy?

The choice of antidepressant medication will depend on various factors, including efficacy and tolerability, patient profile and comorbidities, concomitant medications and drug-drug interactions, cost and availability, as well as the patient’s preference. Taking into account efficacy and side effect profiles, most second-generation antidepressants, namely selective serotonin reuptake inhibitors (SSRIs), serotonin noradrenaline reuptake inhibitors (SNRIs), noradrenergic and specific serotonergic antidepressants (NaSSAs), melatonergic agonist and serotonergic antagonist, noradrenaline/dopamine-reuptake inhibitors (NDRIs) and a multimodal antidepressants may be considered as the initial treatment medication, while the older antidepressants such as tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs) may be subsequently considered for a later choice. 5 (Refer to Subchapter 4.1.2, page 18 in CPG.)

Since Tini is being seen at a health clinic, the widely available SSRIs are sertraline and fluvoxamine. Sertraline has fewer gastrointestinal side effects and drug interactions compared with fluvoxamine. TCAs are not the treatment of choice due to prominent side effects. Tini is put on tablet sertraline 50 mg daily and educated on the anticipated onset of response and possible side effects. Short-term and low dose benzodiazepine, eg. alprazolam or lorazepam, may be offered as an adjunct to treat her insomnia. (Refer to Subchapter 4.1.2, page 24 in CPG.) Tini is given tablet lorazepam 0.5 mg at night for 2 weeks. She is asked to come in for a follow-up.

What is her follow-up and monitoring plan?

The following should be done:

(Refer to Appendix 8, page 81 in CPG.)

• Titrate up by 50 mg within 1-2 weeks (but may be done earlier based on clinical judgement)
• Monitor biological parameters if indicated (Refer to Table 5. Ongoing monitoring during treatment of MDD, page 57 in CPG.)

During follow-up at 2 weeks, she is noted to show partial response despite being compliant with good tolerability. She is not experienceing nausea, diarrhoea, headache, constipation, dry mouth or somnolence. She reports being less tearful. Her sleep and ability to focus have improved. Tini has started engaging in regular exercise and practises relaxation, especially before sleep. Tablet sertraline is optimised to 100 mg daily, while tablet lorazepam is reduced to 0.5 mg PRN.

Tini is reviewed again within 4 weeks; during this subsequent follow-up, she achieves full remission. Tablet lorazepam is stopped. She is then advised to continue tablet sertraline for at least 6-9 months in maintenance phase. The aim in this phase is to prevent relapse and recurrence of MDD. In view of her young age, no comorbidities and good tolerability, repeated electrolyte monitoring is not indicated.

(Refer to Algorithm 2. Pharmacotherapy for Major Depressive Disorder, page xiii in CPG.)

ALGORITHM 2. PHARMACOTHERAPY FOR MAJOR DEPRESSIVE DISORDER

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Patient case navigator: major depressive disorder.

Introduction

Learning Objectives

• How to perform a structured psychiatric interview
• Standardized psychiatric rating scales appropriate for patients with depressive symptoms
• Common barriers to adequate treatment response
• How to assess and monitor patients for treatment side effects and adequate treatment response

Watch the video:

History and Examination

Medical History

Examination

History of Present Illness

Eric is a 60-year-old man who presents to his primary care nurse practitioner, Tina, with irritability, excessive sleeping, and a lack of interest in his usual hobbies, such as attending baseball games and going to the movies with his wife. He also has been spending much time at home alone, watching television, rather than spending time with his friends or wife, as he usually does. Eric recently retired from his job as a general contractor remodeling people’s kitchens and bathrooms. He enjoyed his job very much and felt a sense of pride in helping people make their homes more functional and attractive. However, his job was very physical, and at times stressful, so Eric felt it was time to retire and find something new with which to occupy his time.

Eric was diagnosed with hypothyroidism 5 years ago and has been on medication ever since. Annual lab tests indicate his thyroid levels have remained within the normal range for the past few years. He also has mild hypertension, which is well-controlled at an adequate dose.

Psychosocial History

Eric reports that he has several close friends and that he got along well with people at work. He denies a history of substance misuse and reports that he occasionally drinks a glass of wine with dinner. He does not smoke. Eric describes his marriage as “very good.” He is also close with his adult daughter and enjoys spending time with his 2 grandchildren.

At age 33, Eric experienced a period of depressed mood after losing his job. During that time, he had problems getting out of bed in the morning because he felt hopeless and sad, stopped socializing with friends, and lost about 4 lbs of body weight in 4 weeks without intentionally dieting. He sought treatment from his primary care physician, who referred him to a psychiatrist for medication and a psychologist for outpatient cognitive-behavioral therapy (CBT). Eric worked with his psychiatrist and tried 4 different selective serotonin reuptake inhibitors (SSRIs) before he ultimately found one that seemed to work for him. He and his psychiatrist decided together that he could stop taking the medication after 1 year because his mood had improved and stabilized. He saw his therapist once weekly for approximately 2.5 years and reports that CBT also helped improve his mood and functioning.

Family History

Eric reports that, throughout his life, his mother had “very low periods” when she seemed extremely sad and had trouble functioning. However, she never sought treatment for these episodes.

Eric’s physical examination indicates he is generally healthy for his age. His vital signs are all within the normal range, and the mental status examination indicates he is fully oriented and alert. Eric’s appearance is that of an older man. His affect is flat, and he has trouble making eye contact, often staring at the floor instead.

Patient Interview

Quiz #1: initial presentation and diagnosis, dsm-5 diagnostic criteria for mdd.

MDE Diagnostic Criteria

Safety Plan

Major Depressive Episode (MDE)

A. Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous function; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.

• Depressed mood most of the day, nearly every day, as indicated by either subjective report or observation made by others
• Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day
• Significant weight loss when not dieting or weight gain, or decrease or increase in appetite nearly every day
• Insomnia or hypersomnia nearly every day
• Psychomotor agitation or retardation nearly every day
• Fatigue or loss of energy nearly every day
• Feelings of worthlessness or excessive or inappropriate guilt nearly every day
• Diminished ability to think or concentrate, or indecisiveness, nearly every day
• Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide

B. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of function

C. The episode is not attributable to the physiological effects of a substance or another medical condition

Diagnostic and Statistical Manual of Mental Disorders. 5th ed. American Psychiatric Association; 2013.

• It is important to thoroughly review each of these 9 symptoms with your patients when assessing them for MDD.
• Clinical rating scales can help identify which patients require more in-depth screening for depression.

Quiz #2: DSM-5 Diagnostic Criteria for MDD

Scales for mdd.

PHQ-9 Scale Scoring

QIDS Scale Scoring

Patient Health Questionnaire-9 (PHQ-9)

This scale was developed by Drs Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke, and colleagues with an educational grant from Pfizer inc. No permission required.

Scoring Criteria

Kroenke K, Spitzer RL. Psychiatric Annals. 2002;32:509-521.

The Quick Inventory of Depressive Symptomatology (QIDS)

• The QIDS is a 16-item, multiple-choice questionnaire in which depressive symptoms are rated on a 0-3 scale according to severity
• Items are derived from the 9 diagnostic criteria for major depressive disorder used in the Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV), including sadness, loss of interest or pleasure, poor concentration or decision-making, self-outlook, suicidal ideation, lack of energy, sleep disturbance, appetite change, and psychomotor agitation
• Although the QIDS was initially developed based on DSM-IV criteria, the scale is also compatible with the DSM-5. The core criteria for MDD are consistent across these editions

Rush AJ, et al. Biol Psychiatry. 2003;54(5):573-583.

Bernstein IH, et al. Int J Methods Psychiatr Res. 2009;18(2):138-146.

Quiz #3: Scales for MDD

Treatment initiation and monitoring.

APA Guidelines

Eric's PHQ-9 Score

Treatment Options

American Psychiatric Association (APA) Guidelines for Treatment of MDD

1-2 weeks: Improvement from pharmacologic therapy can be seen as early as 1-2 weeks after starting treatment

2-4 weeks: Some patients may achieve improvement in 2-4 weeks

4-6 weeks: Short-term efficacy trials show antidepressant therapy appears to require 4-6 weeks to achieve maximum therapeutic effects

4-8 weeks: The APA recommends 4-8 weeks of adequate* treatment is needed before concluding that a patient is partially responsive or unresponsive to treatment *Adequate dose and duration Practice Guideline for the Treatment of Patients With Major Depressive Disorder. 3rd ed. American Psychiatric Association; 2010.

*Adequate dose and duration

Practice Guideline for the Treatment of Patients with Major Depressive Disorder. 3rd ed. American Psychiatric Association; 2010.

Quiz #4: Treatment Initiation and Monitoring

Assessing for treatment challenges.

Treatment Challenges

Eric's Updated PHQ-9 Score

Possible Challenges to Antidepressant Therapy

• Suboptimal efficacy due to the wrong dose, inadequate length of time on the medication, or the person's individual biology not being responsive to the medication
• Unpleasant side effects of antidepressants can occur, such as weight gain, insomnia, and sexual dysfunction
• Nonadherence to the antidepressant
• As a reminder, the American Psychiatric Association (APA) recommends 4-8 weeks of adequate* treatment is needed before concluding that a patient is partially responsive or unresponsive to treatment

Practice Guideline for the Treatment of Patients With Major Depressive Disorder. 3rd ed. American Psychiatric Association; 2010.

MDD Diagnosis

Clinical Probes

Treatment Assessment

Monitoring Considerations

Factors to Consider When Making a MDD Diagnosis

• Take a thorough patient history
• Previous or current depressive episodes
• Previous or current manic or hypomanic episodes
• Family history of MDD, bipolar disorder
• Medical comorbidities
• Consider a broad differential diagnosis

Clinical Queries That Aid in Diagnosing Major Depressive Episodes

1. Diagnostic and Statistical Manual of Mental Disorders, 5th Edition. American Psychiatric Association; 2013. 2. Kroenke K, et al. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16(9):606-613.

APA Practice Guidelines on Treatment Assessment

• Wait 4 to 8 weeks to assess treatment response to antidepressants
• In patients without adequate response, clinicians can consider changing or augmenting with a second medication
• Changes to treatment plans, such as augmenting with a second-generation antipsychotic medication, are reasonable if a patient does not have adequate improvement in 6 weeks
• Consistently follow-up with patients to assess treatment effects, adverse medication effects, and risk of self-harm

APA Practice Guidelines note that the frequency of monitoring should be based on:

• Symptom severity (including suicidal ideation)
• Co-occurring disorders (including general medical conditions)
• Treatment adherence
• Availability of social supports
• Frequency and severity of side effects with medication

Tina Matthews-Hayes is a paid consultant for Abbvie Medical Affairs and was compensated for her time.

American Psychiatric Association. Practice Guideline for the Treatment of Patients with Major Depressive Disorder. 3rd ed. American Psychiatric Association; 2010.​

• American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders . 5th ed. American Psychiatric Association; 2013. ​
• Kapfhammer HP. Somatic symptoms in depression. Dialogues Clin Neurosci . 2006;8(2):227-239.​
• Bobo WV. The diagnosis and management of bipolar I and II disorders: clinical practice update. Mayo Clin Proc . 2017;92(10):1532-1551.​
• Kroenke K, Spitzer RL, Williams JBW. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med . 2001;16:606-613.​
• Smarr KL, Keefer AL. Measures of depression and depressive symptoms. Arthritis Care Res . 2011;63(S11):S454-S466. doi:10.1002/acr.20556​
• Rush AJ, Trivedi MH, Ibrahim HM, et al. The 16-Item Quick Inventory of Depressive Symptomatology (QIDS), Clinician Rating (QIDS-C), and Self-Report (QIDS-SR): a psychometric evaluation in patients with chronic major depression. Biol Psychiatry. 2003;54:573-583.​
• Brown ES, Murray M, Carmody TJ, et al. The Quick Inventory of Depressive Symptomatology–Self-report: a psychometric evaluation in patients with asthma and major depressive disorder. Ann Allergy Asthma Immunol. 2008;100(5):433-438. doi:10.1016/S1081-1206(10)60467-X​
• Liu R, Wang F, Liu S, et al. Reliability and validity of the Quick Inventory of Depressive Symptomatology-Self-Report Scale in older adults with depressive symptoms. Front Psychiatry . 2021;12:686711. doi:10.3389/fpsyt.2021.686711 ​
• Bernstein IH, Rush AJ, Suppes T, et al. A psychometric evaluation of the clinician-rated Quick Inventory of Depressive Symptomatology (QIDS-C16) in patients with bipolar disorder. Int J Methods Psychiatr Res . 2009;18(2):138-146. doi:10.1002/mpr.2855​
• Bernstein IH, Rush AJ, Trivedi MH, et al. Psychometric properties of the Quick Inventory of Depressive Symptomatology in adolescents. Int J Methods Psychiatr Res. 2010;19(4):185-194. doi:10.1002/mpr.321 ​
• Kroenke K. Enhancing the clinical utility of depression screening. CMAJ . 2012;184(3):281-282.doi:10.1503/cmaj.112004 ​
• Levinstein MR, Samuels BA. Mechanisms underlying the antidepressant response and treatment resistance. Front Behav Neurosci . 2014;8:208. doi:10.3389/fnbeh.2014.00208​
• Haddad PM, Talbot PS, Anderson IM, McAllister-Williams RH. Managing inadequate antidepressant response in depressive illness. Br Med Bull. 2015;115(1):183-201. doi:10.1093/bmb/ldv03​

This resource is intended for educational purposes only and is intended for US healthcare professionals. Healthcare professionals should use independent medical judgment. All decisions regarding patient care must be handled by a healthcare professional and be made based on the unique needs of each patient.

This is not a diagnostic tool and is not intended to replace a clinical evaluation by a healthcare provider.

Reach out to your family or friends for help if you have thoughts of harming yourself or others, or call the National Suicide Prevention Helpline for information at 800-273-8255.

ABBV-US-00976-MC, V1.0 Approved 12/2023 AbbVie Medical Affairs

Recommended on NP Psych Navigator

Disease Primer

Major depressive disorder (MDD) is one of the most recognized mental disorders in the United States. Learn more about the prevalence, pathophysiology, diagnosis, and management of MDD here.

Clinical Article

State-Dependent Differences in Emotion Regulation Between Unmedicated Bipolar Disorder and Major Depressive Disorder

Rive et al use functional MRI to look at some of the differences between patients with bipolar depression and major depressive disorder.

Unrecognized Bipolar Disorder in Patients With Depression Managed in Primary Care: A Systematic Review and Meta-Analysis

Daveney et al explore the characteristics of patients with mixed symptoms, as compared to those without mixed symptoms, in both bipolar disorder and major depressive disorder.

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Pathophysiology

Normal Physiology

Normal physiology of patient’s mood, perception, emotion and behavior focuses majorly on neurotransmitters in the brain. There are over 46 neurotransmitters in the brain and many have more than one function. Neurotransmitters are chemical messengers that are released and received by synapses of neurons to mediate intracellular communication in the nervous system. They use electrical signals to stimulate messages along the neurons where it affects ion channels and eventually performs a specific mechanism at a site of action (McCance & Huether, 2014).

Serotonin is involved with mood, happiness, anxiety, and sleep induction. Raphe-Serotonin System normally modulates homeostasis, emotionality, and tolerance to aversive experiences. Norepinephrine in the brain helps regulate alertness, mood, functions in dream sleep, and maintains arousal. It also can help in the response to stressful situations. The locus ceruleus has a group of norepinephrine containing cells implicated in global psychologic processes including attention, vigilance and orientation to stimuli. Dopamine in the brain regulates reward and motivation which could explain the loss of interest in patients with depression. Dopamine motivates people to take action toward goals, desires, and needs, and issues a surge of reinforcing pleasure once they’ve been accomplished (Garcia-Arocena). Sufficient levels are needed for the brain to function properly and decreased levels have been found in patients with depression (McCance & Huether, 2014).

Major Depressive Disorder

Major depression is classified as a unipolar mood disorder. Further, major depression can be classified as when an emotional state, such as sadness, becomes chronic and uncontrollable. It is the most common mood disorder (McCance & Huether, 2014). Mood disorders are still being studied due to the unclear nature of how they occur due to the difficult availability of human brain tissue for neurochemical measurement until patients are post-mortem. Each of the dysfunctions below focuses on what are thought to be the causes of major depressive disorder.

Pathophysiology: Genetic Predisposition and Environmental Influences

There is a genetic predisposition in major depression that runs in families. However, due to the large variance in symptoms, developmental and environmental factors also must be evaluated in the contributing factors to major depression. One view of mood disorders includes the connection between susceptible genes and environmental influence. The combination of life stressors and a potentially dysfunctional serotonin (5-HT) system. The serotonin transporter serves in the reuptake of serotonin at the synapse and may moderate the serotonergic response to stress. Individuals with 2 copies of the s allele were more likely to develop major depression and have suicidal thoughts in response to stressors than individuals homozygous for the l allele. As well as, individuals with 2 s alleles increased their risk for major depression episodes by twofold after experiencing 4 or more stressful events (McCance & Huether, 2014).

Pathophysiology: Neurochemical dysregulation

There are antidepressant drugs that can increase neurotransmitters in the body leading to another theory called the monoamine hypothesis of depression. In this hypothesis, there is a deficit in the concentration of the brain norepinephrine, dopamine, and/or serotonin resulting in depression. Antidepressant therapies focus on increasing the monoamine neurotransmitter levels within the synapses (McCance & Huether, 2014).

Pathophysiology: Neuroendocrine Dysregulation

There are 2 theories in the pathophysiology of depression that involve dysregulation of the neuroendocrine system. The first one focuses on stress and the hypothalamic-Pituitary-Adrenal system. The hypothalamic-pituitary-adrenal system (HPA) plays an essential role in an individual’s ability to cope with stress. Chronic activation of the HPA system and chronic glucocorticoid secretion are found in 30-70% of individuals with major depression suggesting the correlation between the dysfunctional system and depression. Chronic cortisol release in the body results in secretion of pro-inflammatory cytokines which causes immunosuppression and inflammation. Also, there is a Neurotrophic Hypothesis of depression. It is thought to focus on neuronal atrophy of the hippocampus resulting in no cell growth consequently causing in a reduction of the hippocampal brain derived neurotrophic factor (BDNF) and has been proposed as an extension of the monoamine hypothesis of depression.

The second neuroendocrine dysregulation is in the hypothalamic-pituitary-thyroid system. While this dysfunction is not completely understood, 20-30% cases of major depression have shown to have an altered hypothalamic-pituitary-thyroid (HPT) system. There is an increase in thyrotropin releasing hormone, blunted thyroid stimulating hormone in response to TRH challenge and decreased nocturnal rise in TSH level that normally occur. This all increases risk for relapse (McCance & Huether, 2014).

Pathophysiology: Neuroanatomic and Function Abnormalities

Depressed individuals post-mortem brains have shown widespread decrease in serotonin 5-HT1a receptor subtype binding in the frontal, temporal, and limbic cortex as well as serotonin transporter binding in the cerebral cortex and hippocampus, reflecting a dysfunction in the raphe-serotonin system. The activation of the locus ceruleus-norepinephrine system is capable of inhibiting the raphe-serotonin system. This suggests an indirect role in the modulation of serotonin function. Norepinephrine receptor alterations are found in the frontal cortex of some suicide victims with depression. Alterations in norepinephrine systems may be linked to attention or concentration difficulties as well as sleep and arousal disturbances in depression

Alterations in frontal and limbic regions (such as the amygdala) have shown a decreased number of glial cells in people with unipolar disorders. As well as, a decreased prefrontal cortex functioning and decreased frontal lobe volume.

Depressed individuals have also been found to have abnormalities in Cerebral blood flow and glucose metabolism. Dorsolateral prefrontal abnormalities in depression may be responsible for the retardation in cognitive processing and speech deficits similar to those found in schizophrenia. Dorsomedial frontal dysfunction may be associated with mnemonic and attentional impairments that accompany mood disorders. The frontal brain has increased blood flow and metabolism. It is positively related to negative affect in depressed individuals (McCance & Huether, 2014).

Clinical Manifestations/Diagnostic Criteria

To diagnosis depression, symptoms must be present for at least two weeks. There are unremitting feelings of sadness and despair. Depressive episodes may occur or recur suddenly, gradually or continue from a few weeks to months. Twenty percent of all people with depression exhibit chronic forms of depression. Symptoms vary widely depending on the individual. The timing and length of the depression also varies.

To be diagnosed with Major Depressive Disorder, patients have to have several, usually five or more, symptoms including low mood that is present for at least two weeks (Depression, 2018). Other symptoms of major depressive disorder include:

• Depressed or irritable mood
• Loss of interests and pleasures – this includes interpersonal relationships
• Significant weight gain or loss (5%) in a month
• Sleep Disturbances: Insomnia/Hypersomnia
• Psychomotor agitation or retardation: Restlessness or agitation can occur
• Fatigue or loss of energy
• Feelings of worthlessness or excessive guilt: Pessimistic/Negative outcomes are perceived
• Poor concentration or indecisiveness
• Recent thoughts of suicide/death: Suicidal risk increases with depression

Garcia-Arocena, D. (n.d.). Happy or SAD: The chemistry behind depression. Retrieved October 29, 2018, from https://www.jax.org/news-and-insights/jax-blog/2015/december/happy-or-sad-the-chemistry-behind-depression

LA NEUROSCIENZA DEL CERVELLO CON ADHD. (2018, September 17). Retrieved from https://mondoadhd.blog/2018/09/17/la-neuroscienza-del-cervello-adhd/

(n.d.). Retrieved October 29, 2018, from https://www.nature.com/articles/nrdp201665/figures/3

What are neurotransmitters? (2017, November 09). Retrieved from https://qbi.uq.edu.au/brain/brain-physiology/what-are-neurotransmitters

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.

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Leanne: A Case Study in Major Depressive Disorder, Recurrent

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Counseling Across the Lifespan: Prevention and Treatment

Student resources, case study questions.

CASE EXAMPLE

Allen is a 65-year-old who retired as a history teacher 10 years ago. He is coming to counseling at the insistence of his wife and adult children, although he states that he doesn’t think counseling can help him. He reports that his wife says he repeats things “constantly” and although he shares that he may say things “a few times” because she didn’t hear him, he does not believe that he does this “constantly” and does not really think it is a big problem. He also shares that his wife tells him he is very impatient, although he is dismissive of this concern, again saying he thinks he is “not that bad.” He does admit that he has been depressed in the past and that he has been having a difficult time more recently feeling any motivation or interest to do anything.

He expresses unhappiness because his wife recently retired from her full-time corporate position, but she continues to be very busy, continuing to work as a consultant and engaging in many activities with her friends. Allen, by comparison, reports that “all my friends are gone” and shares that although they are not deceased, they are spread out across the country where he does not have contact with any of them. Allen had looked forward to the time when his wife would retire, as he had expected that the two of them would spend more time together, travel, and enjoy retirement together.

Allen has been spending his time busying himself with household jobs, working on his own art, assisting his wife with her work projects, and planning their vacations. He enjoys a glass or two of wine with dinner and states that he is just a “social drinker.” He has experienced some times with sadness in the period of time since he retired but got through those times by focusing on his future hope about his wife retiring. At several points in the interview, Allen sighs and states, “I just feel like a total nothing.” He reports increasing disinterest in his previous interests and hobbies and that “I just can’t get interested in anything anymore.”

He admits that he has had some thoughts of suicide but then feels both ashamed and horribly guilty for how that would affect his family, which then serves to make him feel very sad. Allen says he is coming to counseling to see if the mental health provider can figure out what is wrong with him and admits that he is afraid he is “crazy.” On collateral consultation with Allen’s wife, it is apparent that Allen has minimized the intensity of his angry outbursts, and she admits that she has felt frightened by Allen’s outbursts.

DISCUSSION QUESTIONS

• What are the prominent clinical issues?
• What provisional diagnoses would be important to consider?
• What models discussed in the text would be useful?
• What other professional, medical, and/or social services may be important in this case?

Website maintenance is scheduled for Saturday, September 7, and Sunday, September 8. Short disruptions may occur during these days.

IRIS R. MABRY-HERNANDEZ, MD, MPH, Medical Officer, U.S. Preventive Services Task Force Program, Agency for Healthcare Research and Quality

HELEN C. KOENIG, MD, MPH, Preventive Medicine Resident, Johns Hopkins Bloomberg School of Public Health

Am Fam Physician. 2010;82(2):185-186

See related U.S. Preventive Services Task Force Recommendation Statement on page 178 .

A woman brings her two children, a 14-year-old boy and a nine-year-old girl, to your office for a routine checkup. She tells you that her husband has major depression, and she wants to know whether her children should be checked for early signs of depression.

Case Study Questions

1. Based on recommendations from the U.S. Preventive Services Task Force (USPSTF), which one of the following is the appropriate next step for these patients?

A. Both children should be screened for major depressive disorder (MDD).

B. Both children should be screened for MDD only if they have demonstrated symptoms of depression, including social isolation, anger, and sleep disturbance.

C. The son should be screened for MDD if systems are in place to assure accurate diagnosis, treatment, and follow-up.

D. Neither child should be screened for MDD, because treatment for depression has not been found to be effective in children or adolescents.

E. The daughter should be screened for MDD, because the prevalence of MDD is higher in girls than boys.

2. Which one of the following statements about screening for MDD is correct?

A. Screening instruments developed for primary care, such as the Patient Health Questionnaire for Adolescents (PHQ-A) and the Beck Depression Inventory for Primary Care (BDI-PC), have been used successfully in adolescents.

B. Screening instruments have a 25 percent sensitivity in detecting MDD in children.

C. The USPSTF found evidence that screening for MDD in children and adolescents causes significant harms.

D. No screening instruments have been used successfully to diagnose MDD in children and adolescents in primary care settings.

3. Which of the following statements about treating MDD is/are correct?

A. The USPSTF found adequate evidence that treating adolescents with selective serotonin reuptake inhibitors (SSRIs) decreases MDD symptoms.

B. Although SSRIs have demonstrated harms in adults, such as increased risk of suicidality, there is no evidence to support these harms in children or adolescents.

C. Psychotherapy has been found to be effective in the treatment of MDD in adolescents only when combined with SSRIs.

D. Fluoxetine is the only drug approved by the U.S. Food and Drug Administration (FDA) for treating MDD in children and adolescents.

1. The correct answer is C. The USPSTF recommends screening adolescents 12 to 18 years of age for MDD when systems are in place to assure accurate diagnosis, treatment, and follow-up. There is adequate evidence that screening tests accurately identify MDD in adolescents and that treatment with SSRIs, psychotherapy, or combined therapy (SSRIs and psychotherapy) decreases MDD symptoms.

The USPSTF concluded that the evidence is insufficient to assess the balance of benefits and harms of screening children seven to 11 years of age for MDD. Although SSRIs have been found to be effective in treating MDD in children, there is inadequate evidence that screening tests accurately identify MDD in children.

2. The correct answer is A. Instruments developed for primary care, such as the PHQ-A and the BDI-PC, have been used successfully to detect MDD in adolescents. The sensitivity and specificity in primary care settings is 73 and 94 percent, respectively, for the PHQ-A, and 91 and 91 percent, respectively, for the BDI-PC. However, data about the accuracy of MDD screening instruments in children are limited.

The USPSTF found no evidence of harms of screening for MDD in youth. Most studies on screening instruments in primary care settings focused on adolescents 12 years or older, and the studies that involved younger children demonstrated poorer performance of the screening instruments.

3. The correct answers are A and D. The USPSTF found adequate evidence that treating adolescents 12 to 18 years of age with SSRIs, psychotherapy, or combined therapy (SSRIs and psychotherapy) decreases MDD symptoms. Fluoxetine and citalo-pram yielded statistically significant higher response rates than did other SSRIs. Currently, fluoxetine is the only drug approved by the FDA for treating MDD in children and adolescents.

The USPSTF found inadequate evidence to support the benefits of treatment in children seven to 11 years of age. SSRIs (fluoxetine) reduce symptoms of MDD in children; however, data are limited on the benefits of psychotherapy (or psychotherapy plus SSRIs) in this age group.

There is convincing evidence that SSRIs are associated with harms, such as an increase in the risk of suicidality (i.e., suicide ideation, preparatory acts, or suicide attempts) in adolescents. Evidence is limited on the harms of psychotherapy or combined therapy (SSRIs and psychotherapy) in adolescents and children.

The USPSTF concluded that, in adolescents, there is moderate certainty that the net benefit of psychotherapy is moderate. In children, the evidence is lacking, and the balance of benefits and harms of psychotherapy could not be determined.

U.S. Preventive Services Task Force. Screening and treatment for major depressive disorder in children and adolescents: U.S. Preventive Services Task Force Recommendation Statement [published correction appears in Pediatrics . 2009;123(6):1611]. Pediatrics. 2009;123(4):1223-1228.

Williams SB, O'Connor EA, Eder M, Whitlock EP. Screening for child and adolescent depression in primary care settings: a systematic evidence review for the U.S. Preventive Services Task Force. Pediatrics. 2009;123(4):e716-e735.

This series is coordinated by Joanna Drowos, DO, contributing editor.

A collection of Putting Prevention Into Practice published in AFP is available at https://www.aafp.org/afp/ppip.

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• NICE Guidance
• Conditions and diseases
• Mental health, behavioural and neurodevelopmental conditions

Common mental health problems: identification and pathways to care

Clinical guideline [CG123] Published: 25 May 2011

We withdrew this guideline in May 2024, because all of the recommendations are now covered in other NICE guidelines, or are out of date and no longer relevant to clinical practice.

For guidance on common mental health problems, see our guidelines on:

• Depression in adults
• Depression in adults with a chronic physical health problem
• Depression in children and young people
• Generalised anxiety disorder and panic disorder in adults
• Obsessive-compulsive disorder and body dysmorphic disorder
• Social anxiety disorder