Family Medicine · Year 3 · from Family Medicine

Case 1: Major Depressive Disorder

Patient Demographics

  • Age: 42 years old
  • Sex: Female
  • Occupation: Accountant

Chief Complaint

"I've been feeling down and have no energy. I can't seem to enjoy anything anymore."

History of Present Illness

Ms. Sarah Mitchell is a 42-year-old woman presenting with depressed mood and fatigue for the past 3 months. She reports persistent sadness "almost every day," loss of interest in activities she previously enjoyed (reading, spending time with friends), fatigue despite adequate sleep, difficulty concentrating at work, and feeling "worthless." She has gained 12 pounds over 3 months due to "eating for comfort." She reports initial insomnia (difficulty falling asleep) and early morning awakening. She denies suicidal ideation, stating "I would never do that to my kids."

The symptoms began insidiously after her divorce was finalized 4 months ago. She has two children (ages 10 and 14) who live with her. She is managing work but feels she is "just going through the motions."

Past Medical History

  • Hypothyroidism on levothyroxine
  • Migraine headaches
  • Prior episode of depression 8 years ago, treated with sertraline for 1 year, resolved

Family History

  • Mother: Depression, anxiety
  • Father: Alcohol use disorder
  • Maternal aunt: Bipolar disorder

Social History

  • Non-smoker
  • Occasional wine (1-2 glasses on weekends)
  • Recently divorced, single mother of two
  • Limited social support (moved to new city 2 years ago)
  • No current exercise (previously walked regularly)

Mental Status Examination

  • Appearance: Appropriately dressed, appears fatigued
  • Behavior: Cooperative, psychomotor slowing noted
  • Speech: Normal rate, soft volume
  • Mood: "Sad" (patient's words)
  • Affect: Constricted, tearful at times
  • Thought process: Linear, goal-directed
  • Thought content: No suicidal or homicidal ideation, no delusions
  • Perception: No hallucinations
  • Cognition: Alert, oriented x4, concentration mildly impaired
  • Insight/Judgment: Good

Screening Tools

  • PHQ-9 Score: 18 (moderately severe depression)
  • Little interest: 3
  • Feeling down: 3
  • Sleep problems: 2
  • Tired/no energy: 3
  • Appetite changes: 2
  • Feeling bad about self: 2
  • Trouble concentrating: 2
  • Psychomotor changes: 1
  • Suicidal thoughts: 0
  • GAD-7: 8 (mild anxiety)

Clinical Image

Image: A healthcare provider engaging in a patient consultation, demonstrating the therapeutic relationship essential to primary care management of mental health conditions including depression.

Image Source: Wikimedia Commons Attribution: National Cancer Institute, Public Domain URL: https://commons.wikimedia.org/wiki/File:Doctor_and_patient.jpg

Outpatient Workup

  • TSH: Normal (1.8 mIU/L) - rules out hypothyroidism contribution
  • CBC: Normal
  • Complete metabolic panel: Normal
  • Vitamin B12 and folate: Normal

Assessment and Diagnosis

  1. Major depressive disorder, recurrent episode, moderate - Meets DSM-5 criteria (depressed mood, anhedonia, fatigue, concentration difficulty, worthlessness, weight gain, sleep disturbance for >2 weeks)
  2. Mild generalized anxiety symptoms - Common comorbidity
  3. Situational stressor: Divorce - Contributing factor but symptoms meet criteria for MDD

Management Plan

Psychotherapy:

  • Referral to therapist for cognitive-behavioral therapy (CBT) or interpersonal therapy
  • Both evidence-based for moderate depression
  • Can be combined with medication for better outcomes

Pharmacotherapy:

  • Given prior positive response to sertraline, restart sertraline
  • Sertraline 50 mg daily, may increase to 100 mg after 2-4 weeks if tolerated
  • Discuss:
  • Takes 2-4 weeks to see initial effect, 6-8 weeks for full effect
  • Common side effects: GI upset, headache, sexual dysfunction
  • Not habit-forming
  • Plan for at least 6-12 months of treatment after remission to prevent relapse

Lifestyle Recommendations:

  • Regular exercise: 30 minutes most days (equivalent efficacy to antidepressants for mild-moderate depression)
  • Sleep hygiene: Regular sleep schedule, limit screen time before bed
  • Social connection: Encourage reaching out to friends/family
  • Reduce alcohol (can worsen depression)

Safety Planning:

  • Direct questioning about suicidal ideation (she denies)
  • Provide crisis hotline number: 988 (Suicide and Crisis Lifeline)
  • Discuss warning signs to watch for
  • Involve family support if appropriate

Follow-Up

  • Phone check in 1-2 weeks to assess medication tolerance
  • Return visit in 4 weeks to assess response (repeat PHQ-9)
  • Earlier if symptoms worsen or suicidal thoughts develop
  • Target PHQ-9 <5 (remission)

Teaching Points

  1. PHQ-9 for depression screening and monitoring:
  • 0-4: Minimal depression
  • 5-9: Mild depression
  • 10-14: Moderate depression
  • 15-19: Moderately severe depression
  • 20-27: Severe depression
  • Item 9 asks specifically about suicidal ideation
  1. DSM-5 criteria for MDD: ≥5 symptoms for ≥2 weeks, including depressed mood OR anhedonia. (SIG E CAPS: Sleep, Interest, Guilt, Energy, Concentration, Appetite, Psychomotor, Suicidal ideation)
  1. Treatment approach by severity:
  • Mild: Psychotherapy alone may be sufficient; watchful waiting acceptable
  • Moderate: Pharmacotherapy and/or psychotherapy
  • Severe: Combination therapy (medication + psychotherapy), consider psychiatry referral
  1. SSRI selection: SSRIs are first-line for MDD. Choice based on prior response, side effect profile, drug interactions. Sertraline and escitalopram have favorable tolerability.

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