Psychiatry · Year 3 · from Psychiatry
Case 1: Major Depressive Disorder - Classic Presentation
Patient Demographics
- Age: 28 years old
- Sex: Female
- Occupation: Elementary school teacher
Chief Complaint
"I feel like I'm drowning and can't come up for air."
History of Present Illness
The patient presents to her primary care physician with an 8-week history of depressed mood, loss of energy, and difficulty functioning at work. She describes feeling persistently sad, with crying spells occurring daily, often without identifiable triggers. She has lost interest in activities she previously enjoyed, including running (she was training for a half-marathon before symptoms began), seeing friends, and reading. She reports initial insomnia with racing thoughts about work and relationships, sleeping only 4-5 hours per night, and feeling exhausted despite coffee consumption. Her appetite has decreased significantly, and she has lost 12 pounds over the past two months. She finds it difficult to concentrate at work and has been making "careless mistakes" in her lesson plans. She feels guilty about "letting down" her students. She endorses passive suicidal ideation, stating "Sometimes I wish I wouldn't wake up," but denies any plan, intent, or history of suicide attempts. She denies any history of manic or hypomanic symptoms.
Mental Status Examination
Appearance: Well-groomed woman appearing stated age, dressed appropriately but wearing dark colors, fatigued appearance with dark circles under eyes
Behavior: Cooperative, psychomotor retardation with slowed movements, frequent sighing, tearful at multiple points during interview
Speech: Soft volume, slow rate, normal rhythm and articulation
Mood: "Hopeless" and "empty"
Affect: Depressed, constricted, tearful, congruent
Thought Process: Linear but slowed, goal-directed
Thought Content: Themes of worthlessness, guilt about work performance, passive suicidal ideation without plan or intent, no homicidal ideation, no delusions
Perceptions: Denies hallucinations
Cognition: Alert and oriented x4, attention intact, concentration impaired (difficulty with serial 7s)
Insight: Good - recognizes she is depressed and needs help
Judgment: Good - seeking help, able to contract for safety
Psychiatric Workup
Screening Tools:
- PHQ-9: 22/27 (severe depression)
- Depressed mood: 3
- Anhedonia: 3
- Sleep disturbance: 3
- Fatigue: 3
- Appetite change: 2
- Feelings of worthlessness: 3
- Concentration difficulty: 3
- Psychomotor changes: 1
- Suicidal ideation: 1
- GAD-7: 12/21 (moderate anxiety)
- Columbia-Suicide Severity Rating Scale: Passive ideation present, no plan/intent
Laboratory Studies:
- TSH: 2.1 mIU/L (normal)
- CBC: Normal
- CMP: Normal
- Vitamin D: 18 ng/mL (insufficient - may contribute to symptoms)
Diagnosis
Major Depressive Disorder, Single Episode, Severe without Psychotic Features (F32.2)
DSM-5 Criteria - SIG E CAPS Mnemonic:
- Sleep disturbance (insomnia) - present
- Interest diminished (anhedonia) - present
- Guilt and worthlessness - present
- Energy decreased (fatigue) - present
- Concentration impaired - present
- Appetite change with weight loss - present
- Psychomotor retardation - present
- Suicidal ideation (passive) - present
8/9 criteria met, duration >2 weeks, functional impairment present
Treatment Plan
Pharmacotherapy:
- Start escitalopram 10 mg daily
- Increase to 20 mg after 2 weeks if tolerated
- Discussed side effects: GI upset, headache initially; sexual dysfunction possible
- Discussed 2-4 week onset for initial response, 6-8 weeks for full effect
Psychotherapy:
- Refer to CBT therapist for weekly sessions
- Initial focus on behavioral activation (scheduling pleasant activities)
- Cognitive restructuring for negative automatic thoughts
Lifestyle Interventions:
- Sleep hygiene counseling
- Encourage gradual return to exercise (known to improve depression)
- Vitamin D supplementation: 2000 IU daily
Safety:
- Safety plan developed and documented
- 988 Suicide & Crisis Lifeline number provided
- Emergency contact identified (sister)
- Instructed to go to ED or call if suicidal thoughts worsen
Follow-up:
- Return in 2 weeks for medication check
- PHQ-9 monitoring at each visit