Psychiatry · Year 2 · from Psychiatry
Case 1: Major Depressive Disorder with Melancholic Features
Patient Presentation
Demographics: 58-year-old male
Chief Complaint: "I wake up every morning feeling like there's a heavy weight on my chest. I can't feel anything anymore."
History of Present Illness: A 58-year-old retired accountant presents to his primary care physician with his wife, who is concerned about significant changes over the past 2 months. The patient reports waking at 3-4 AM daily, unable to return to sleep, with mood at its worst in the early morning hours. He describes a complete inability to experience pleasure - even visits from his grandchildren, which previously brought him great joy, now "mean nothing." He has lost 18 pounds due to complete loss of appetite; his wife reports he "pushes food around his plate." He moves and speaks slowly, sometimes sitting motionless for hours. He ruminates constantly about past business decisions, convinced he is a "failure" who "ruined the family." He denies active suicidal ideation but admits to passive wishes that he "wouldn't wake up tomorrow." No previous psychiatric history. His father completed suicide at age 62.
Physical Examination:
- Vital signs within normal limits
- General: Thin, elderly-appearing male with psychomotor retardation
- Neurological: Grossly intact
Mental Status Examination:
- Appearance: Disheveled, unshaven, appears older than stated age
- Behavior: Marked psychomotor retardation, minimal spontaneous movement
- Speech: Low volume, slow rate, prolonged latency
- Mood: "Hollow... empty"
- Affect: Blunted, unreactive even to positive topics
- Thought content: Excessive guilt, worthlessness, passive death wishes
- Cognition: Intact but effortful
Workup:
- PHQ-9: Score 26 (severe depression)
- TSH: 4.2 mIU/L (normal)
- Vitamin B12: 380 pg/mL (normal)
- CBC, CMP: Within normal limits
- Testosterone level: 180 ng/dL (low - may contribute to symptoms)
Diagnosis: Major Depressive Disorder, single episode, severe, with melancholic features
Treatment:
- Given severity, melancholic features, and family history of suicide, started on venlafaxine XR 75 mg daily (SNRI chosen for melancholic subtype)
- Discussed ECT as potential treatment given severity and melancholic features; patient prefers medication trial first
- Weekly monitoring with PHQ-9 and safety assessment
- Increased venlafaxine to 150 mg at week 2, then 225 mg at week 4
- Sleep hygiene education; trazodone 50 mg at bedtime for insomnia
- Referral for cognitive behavioral therapy once medication takes effect
- Discussed testosterone replacement with primary care
- At 6-week follow-up: significant improvement, PHQ-9 decreased to 12
- Continuation phase treatment planned for at least 9 months
Clinical Pearl: Melancholic features (profound anhedonia, depression worse in morning, early morning awakening, marked psychomotor changes, excessive guilt) may predict better response to SNRIs or TCAs compared to SSRIs. Family history of completed suicide significantly elevates patient risk and should prompt thorough safety assessment. The presence of melancholic features is also a predictor of good response to ECT if medication fails.