Psychiatry · Year 3 · from Psychiatry
Case 3: Major Depressive Disorder in Adolescence
Patient Demographics
- Age: 15 years old
- Sex: Female
- Grade: 10th grade
Chief Complaint
Per patient: "I don't know. My parents made me come." Per parents: "She's not herself. She's irritable, her grades dropped, and she stays in her room all the time."
History of Present Illness
The patient is a 15-year-old female brought by her parents for evaluation of mood and behavior changes over the past 4 months. Previously an honor roll student and varsity volleyball player, she has shown declining function across multiple domains. Her grades dropped from A's and B's to C's and D's. She quit the volleyball team, stating "I just don't care anymore." She has withdrawn from friends, rarely responding to texts and declining all social invitations. She spends most of her time in her room, often sleeping.
Parents describe her as increasingly irritable, "snapping" at family members over minor issues and frequently arguing. She has stopped activities she previously enjoyed, including drawing and playing guitar. She complains of frequent headaches and stomachaches, leading to multiple school absences.
When interviewed alone, the patient tearfully admits she feels "empty" and "worthless." She reports persistent sad mood for most of the day, nearly every day, for over 3 months. She has difficulty concentrating on schoolwork ("I read the same page over and over"). She sleeps 12+ hours on weekends but still feels tired. Her appetite is decreased, and she has lost 8 pounds. She has passive suicidal ideation, stating "Sometimes I think everyone would be better off without me" but denies any plan, intent, or access to means. She has not engaged in self-harm.
She identifies a specific trigger: her best friend moved away at the start of the school year, and she has struggled to adjust. She also reports increasing conflict with her parents about grades and extracurriculars.
Past Psychiatric History
- No prior psychiatric treatment
- No history of mania or hypomania
- No prior suicide attempts
- Positive family history: Mother treated for depression, maternal aunt with bipolar disorder
Mental Status Examination
Appearance: Adolescent female, minimal makeup, wearing dark hoodie with hood up, poor eye contact
Behavior: Slow to warm up, initially guarded with parents present, more open when alone; psychomotor retardation noted; tearful when discussing feelings
Speech: Decreased rate and volume, increased latency to respond
Mood: "Empty" and "nothing matters"
Affect: Depressed, constricted range, tearful, irritable when discussing school/parents
Thought Process: Linear, slowed, ruminative on negative themes
Thought Content:
- Feelings of worthlessness ("I'm a failure")
- Hopelessness ("Things will never get better")
- Passive suicidal ideation (wishes she didn't exist) without plan, intent, or means
- No homicidal ideation
- No psychotic symptoms
Perceptions: No hallucinations
Cognition: Alert, oriented; concentration impaired by interview
Insight: Fair - recognizes something is wrong but uncertain about cause
Judgment: Fair - agreed to come to appointment, willing to engage in treatment
Screening Measures
Patient Health Questionnaire - Adolescent (PHQ-A):
- Score: 18 (moderately severe depression)
Columbia Suicide Severity Rating Scale (C-SSRS):
- Passive ideation present
- No active ideation, plan, intent, or preparatory behaviors
- No lifetime history of attempts
Diagnosis
Major Depressive Disorder, Single Episode, Moderate (F32.1)
DSM-5 Criteria Met: A. Five or more symptoms during same 2-week period, representing change from baseline:
- Depressed mood most of the day, nearly every day (can be irritable in adolescents): YES
- Markedly diminished interest/pleasure: YES (quit volleyball, stopped hobbies)
- Weight loss when not dieting (>5% in month): YES (8 lbs)
- Insomnia or hypersomnia: YES (hypersomnia - 12+ hours)
- Psychomotor retardation: YES
- Fatigue: YES
- Feelings of worthlessness: YES
- Diminished ability to concentrate: YES
- Recurrent thoughts of death: YES (passive suicidal ideation)
B. Symptoms cause significant distress/impairment: YES (academic, social, family) C. Not attributable to substance/medical condition: YES D. Not better explained by other disorder: YES E. No history of manic/hypomanic episode: YES
Severity: Moderate (5+ symptoms with moderate impairment)
Treatment Plan
Safety Assessment and Planning:
- Currently at low-to-moderate risk
- Safety plan developed collaboratively:
- Warning signs (isolating more, feeling hopeless)
- Coping strategies (music, drawing, walking dog)
- People to contact (friend from volleyball, aunt)
- Crisis resources (988 Suicide & Crisis Lifeline)
- Means restriction: Parents to secure any medications in home
- Parents educated on warning signs and when to seek emergency care
Psychotherapy - First-Line Treatment:
- Cognitive Behavioral Therapy (CBT) for depression
- Weekly sessions x 12-16 weeks
- Focus on:
- Behavioral activation (re-engaging in activities)
- Cognitive restructuring (addressing negative thoughts)
- Problem-solving skills
- Interpersonal skills
Pharmacotherapy:
- Given moderate severity and patient/family agreement, start fluoxetine 10 mg daily
- Most evidence for fluoxetine in adolescent depression
- Increase to 20 mg after 1 week if tolerated
- Black Box Warning discussion: Risk of increased suicidal ideation in first weeks of treatment (monitor closely)
- Family education about activation side effects
School Support:
- Letter to school counselor regarding diagnosis and treatment
- May need academic accommodations during recovery
- Regular check-ins with school counselor
Family Involvement:
- Family psychoeducation about adolescent depression
- Address family conflict contributing to symptoms
- Supportive communication strategies
Follow-up:
- Weekly therapy sessions
- Psychiatry in 1 week (increased monitoring per Black Box Warning)
- Phone check-in at 72 hours
- Monthly psychiatry visits once stable
- PHQ-A at each visit for measurement-based care
Image Attribution
Image: Diagram showing developmental assessment domains in child and adolescent psychiatry including cognitive, social-emotional, language, and adaptive functioning. Source: Wikimedia Commons. Used for educational purposes under Creative Commons license.