Psychiatry · Year 3 · from Psychiatry
Case 1: First Episode Depression - Comprehensive Psychiatric Assessment
Patient Demographics
- Age: 32 years old
- Sex: Female
- Occupation: Marketing manager
Chief Complaint
"I can't stop crying and I don't know why. I feel empty inside."
History of Present Illness
The patient presents to outpatient psychiatry with a 6-week history of persistent low mood, tearfulness, and loss of interest in activities she previously enjoyed. She reports difficulty concentrating at work, leading to performance issues that have been noticed by her supervisor. She has been withdrawing from friends and family, canceling social plans, and spending weekends alone in her apartment. She endorses poor appetite with 10-pound weight loss over the past month, initial and middle insomnia (difficulty falling asleep and waking at 3 AM), and profound fatigue despite sleeping 10-11 hours when she can sleep through the night. She denies suicidal ideation, intent, or plan. She denies any history of manic or hypomanic symptoms.
Mental Status Examination
Appearance: Woman appearing stated age, casually dressed in dark clothing, poor grooming (hair unwashed), slumped posture, poor eye contact
Behavior: Psychomotor retardation noted with slowed movements, minimal gesturing, limited facial expressions
Speech: Decreased rate, decreased volume, increased latency to respond, normal articulation
Mood: "Empty" and "hopeless"
Affect: Constricted range, depressed, congruent with stated mood, tearful at times
Thought Process: Linear and goal-directed but slowed; no loosening of associations
Thought Content: Preoccupation with feelings of worthlessness and guilt about work performance; denies suicidal ideation, homicidal ideation, delusions, or obsessions
Perceptions: Denies auditory or visual hallucinations; no illusions
Cognition: Alert and oriented x4; attention mildly impaired (required repetition of questions); concentration decreased; memory grossly intact for recent and remote events
Insight: Fair - recognizes something is wrong and that she may be depressed
Judgment: Fair - sought help appropriately, able to identify that isolating is not helpful
Psychiatric Workup
Screening Tools:
- PHQ-9 score: 21 (severe depression)
- GAD-7 score: 8 (mild anxiety)
- Columbia Suicide Severity Rating Scale: Negative for suicidal ideation
Laboratory Studies to Rule Out Medical Causes:
- TSH: 2.4 mIU/L (normal)
- CBC: Within normal limits
- CMP: Within normal limits
- Vitamin B12: 450 pg/mL (normal)
- Folate: 12 ng/mL (normal)
Diagnosis
Major Depressive Disorder, Single Episode, Severe without Psychotic Features (F32.2)
DSM-5 Criteria Met:
- Depressed mood most of the day, nearly every day (crying, feeling empty)
- Markedly diminished interest or pleasure in activities (anhedonia)
- Significant weight loss (10 lbs/5% body weight in one month)
- Insomnia (initial and middle)
- Fatigue or loss of energy
- Feelings of worthlessness and excessive guilt
- Diminished ability to concentrate
- Duration >2 weeks
- Causes clinically significant distress and functional impairment
- Not attributable to substance use or medical condition
- No history of manic or hypomanic episodes
Treatment Plan
Pharmacotherapy:
- Start sertraline 50 mg daily, titrate to 100 mg after 1 week if tolerated
- Discussed expected timeline for medication effect (2-4 weeks for initial response)
Psychotherapy:
- Refer for Cognitive Behavioral Therapy (CBT), weekly sessions
- Focus on behavioral activation and cognitive restructuring
Safety:
- No current suicidal ideation; safety plan reviewed
- Crisis resources provided (988 Suicide & Crisis Lifeline)
- Return precautions discussed
Follow-up:
- Return in 2 weeks to assess tolerability and early response
- PHQ-9 at each visit for measurement-based care