Psychiatry · Year 2 · from Psychiatry
Case 1: Major Depressive Episode - Comprehensive MSE
Patient Presentation
Demographics: 45-year-old female
Chief Complaint: "I can't get out of bed anymore and I don't care about anything."
History of Present Illness: A 45-year-old married woman is brought to the outpatient psychiatry clinic by her husband who reports that she has been increasingly withdrawn over the past 6 weeks. She stopped going to work 2 weeks ago after being a reliable employee for 15 years. She has lost approximately 10 pounds due to poor appetite and wakes up at 4 AM daily unable to return to sleep. She admits to feeling "worthless" and having fleeting thoughts that "everyone would be better off without me," though she denies any specific plan or intent to harm herself. Her husband reports she barely speaks and shows little emotional response to anything, including visits from their grandchildren whom she previously adored.
Mental Status Examination:
- Appearance: Middle-aged woman appearing older than stated age, disheveled with unwashed hair, wearing wrinkled clothing, poor hygiene noted
- Behavior: Psychomotor retardation with slowed movements, minimal spontaneous gestures, poor eye contact
- Cooperation: Cooperative but minimally engaged
- Speech: Soft volume, slow rate, monotonous tone, increased latency, poverty of content
- Mood: "Empty... hopeless" (patient's words)
- Affect: Blunted range, unreactive, congruent with depressed mood
- Thought Process: Linear but impoverished, goal-directed with significant latency
- Thought Content: Passive suicidal ideation without plan or intent; no homicidal ideation; no delusions; pervasive guilt and worthlessness
- Perceptions: Denies hallucinations
- Cognition: Alert and oriented x4; attention mildly impaired (difficulty with serial 7s); memory intact
- Insight: Partial - acknowledges something is wrong but attributes it to personal failure
- Judgment: Impaired - stopped taking blood pressure medication, not attending to hygiene
Workup:
- PHQ-9: Score 24 (severe depression)
- Columbia Suicide Severity Rating Scale: Passive ideation without intent
- TSH: 2.4 mIU/L (normal)
- CBC, CMP: Within normal limits
- Urine drug screen: Negative
- Vitamin B12, folate: Normal
Diagnosis: Major Depressive Disorder, single episode, severe, without psychotic features
Treatment:
- Started on sertraline 50 mg daily with plan to titrate to therapeutic dose
- Safety plan developed collaboratively with patient and husband
- Husband agreed to secure firearms and medications in the home
- Referral for cognitive behavioral therapy
- Weekly follow-up appointments initially to monitor suicidal ideation
- Discussed sleep hygiene and structured daily activities
Clinical Pearl: The mental status examination provides a cross-sectional snapshot of the patient's current mental state. The distinction between mood (subjective, patient-reported) and affect (objective, clinician-observed) is crucial. This patient demonstrates congruence between her depressed mood and blunted affect. The presence of passive suicidal ideation requires careful safety planning and close follow-up, even without active intent.