# Clinical Cases: Depression

## 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:**
- **S**leep disturbance (insomnia) - present
- **I**nterest diminished (anhedonia) - present
- **G**uilt and worthlessness - present
- **E**nergy decreased (fatigue) - present
- **C**oncentration impaired - present
- **A**ppetite change with weight loss - present
- **P**sychomotor retardation - present
- **S**uicidal 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

---

## Case 2: Treatment-Resistant Depression

### Patient Demographics
- **Age:** 52 years old
- **Sex:** Male
- **Occupation:** Accountant (currently on medical leave)

### Chief Complaint
"Nothing has worked. I've tried everything and I'm still miserable."

### History of Present Illness
The patient is referred to a psychiatrist by his primary care physician for treatment-resistant depression. He has a 15-year history of recurrent major depressive disorder, with the current episode lasting 18 months despite multiple medication trials. His first depressive episode occurred at age 37 following a job loss, and he has had 4 subsequent episodes. The current episode began insidiously after his divorce finalized. He describes persistent depressed mood, profound anhedonia (hasn't enjoyed anything in over a year), hypersomnia (sleeping 12-14 hours but still exhausted), significant weight gain (40 lbs), decreased concentration, and feelings of hopelessness. He reports frequent thoughts that "everyone would be better off without me" but denies active suicidal planning, stating "I'm too much of a coward to do anything." He went on medical leave 3 months ago when he could no longer function at work.

**Previous Treatment Trials (Adequate dose and duration confirmed):**
1. Sertraline 200 mg x 12 weeks - minimal response
2. Fluoxetine 60 mg x 10 weeks - no response
3. Venlafaxine XR 225 mg x 12 weeks - partial response, discontinued due to elevated blood pressure
4. Bupropion XL 450 mg x 8 weeks - no response
5. Mirtazapine 45 mg x 8 weeks - weight gain without mood improvement
6. Sertraline + Aripiprazole augmentation - partial response

Current medications: Sertraline 200 mg daily, Aripiprazole 5 mg daily

### Mental Status Examination

**Appearance:** Overweight man appearing older than stated age, poorly groomed, dressed in rumpled clothing

**Behavior:** Psychomotor retardation marked, minimal eye contact, slumped posture, speaks only when spoken to

**Speech:** Markedly decreased rate and volume, monotone, long latencies

**Mood:** "Terrible, as always"

**Affect:** Flat, blunted, depressed

**Thought Process:** Impoverished, goal-directed when engaged

**Thought Content:** Hopelessness, helplessness, worthlessness, passive suicidal ideation without plan

**Perceptions:** Denies hallucinations

**Cognition:** Oriented x4, attention and concentration impaired, complaints of "brain fog"

**Insight:** Fair - understands he has depression, skeptical that anything will help

**Judgment:** Fair - continues to engage in treatment despite pessimism

### Psychiatric Workup

**Screening Tools:**
- PHQ-9: 24/27 (severe)
- MADRS (Montgomery-Asberg Depression Rating Scale): 38 (severe)
- Columbia-Suicide Severity Rating Scale: Passive ideation present

**Laboratory Studies:**
- TSH: 2.8 mIU/L (normal)
- Free T4: 1.2 ng/dL (normal)
- Testosterone: 280 ng/dL (low-normal, may contribute)
- Vitamin B12: 320 pg/mL (low-normal)
- Folate: 8 ng/mL (normal)
- MTHFR testing: Not previously done
- CRP: 4.2 mg/L (elevated - inflammation)

### Diagnosis

**Major Depressive Disorder, Recurrent Episode, Severe without Psychotic Features, Treatment-Resistant (F33.2)**

Definition of Treatment-Resistant Depression: Failure to respond to at least 2 adequate trials of antidepressants from different classes

### Treatment Plan

**Re-evaluate Current Regimen:**
- Continue sertraline 200 mg
- Discontinue aripiprazole (insufficient response)

**Advanced Treatment Options Discussed:**

1. **Esketamine (Spravato) Nasal Spray:**
   - FDA-approved for treatment-resistant depression
   - Administer in certified healthcare setting
   - REMS program enrollment required
   - Twice weekly initially, then weekly
   - Discussed dissociative side effects, monitoring requirements

2. **Electroconvulsive Therapy (ECT):**
   - Highly effective for treatment-resistant depression
   - Response rates 50-70% in treatment-resistant cases
   - Right unilateral electrode placement to minimize cognitive effects
   - Discussed cognitive side effects, need for anesthesia
   - Recommended given severity and lack of response

3. **Transcranial Magnetic Stimulation (TMS):**
   - Non-invasive, outpatient
   - Daily sessions for 4-6 weeks
   - Less effective than ECT but fewer side effects

**Patient Decision:**
- Agreed to trial of esketamine
- ECT reserved if esketamine insufficient

**Additional Interventions:**
- Testosterone supplementation considered pending endocrinology consultation
- Continue psychotherapy (supportive therapy currently)
- Address sleep hygiene, encourage light physical activity

**Follow-up:**
- Esketamine initiation scheduled
- Weekly visits during acute treatment phase

---

## Case 3: Depression with Psychotic Features

### Patient Demographics
- **Age:** 67 years old
- **Sex:** Female
- **Occupation:** Retired nurse

### Chief Complaint
Brought by daughter who states: "She thinks she's dying from a disease that's eating her insides."

### History of Present Illness
The patient is brought to the emergency department by her adult daughter, who reports progressive deterioration over the past 6 weeks. The patient has been convinced that she has a fatal illness that doctors have "missed," believing her "organs are rotting away." She has refused to eat, stating "there's no point, I'm already dead inside," and has lost 20 pounds. She has stopped bathing and changing clothes, saying "why bother when I'll be dead soon." She sits in her chair for hours staring at nothing. She was found this morning trying to give away her belongings, telling her daughter "you'll need these after I'm gone." The patient's husband passed away 8 months ago, and she had a previous depressive episode 10 years ago that responded well to sertraline.

### Mental Status Examination

**Appearance:** Elderly woman appearing cachectic and frail, malodorous, wearing stained nightgown, unkempt hair

**Behavior:** Psychomotor retardation severe - minimal spontaneous movement, does not make eye contact, whispers responses

**Speech:** Markedly decreased rate and volume, latency of several seconds before responding

**Mood:** "I'm already dead"

**Affect:** Flat, blunted, no emotional reactivity

**Thought Process:** Slowed, poverty of content, goal-directed when engaged

**Thought Content:**
- Nihilistic delusions: Believes her body is dead/dying, organs rotting
- Somatic delusions: Convinced of fatal illness despite no medical evidence
- Guilt delusions: "I deserve this suffering for all the bad things I've done"
- Passive suicidal ideation: "I wish it would end soon"
- No homicidal ideation

**Perceptions:** Endorses olfactory hallucination - "I can smell my body decaying"

**Cognition:** Alert, oriented to person only, disoriented to place and time; attention impaired; unable to complete cognitive testing due to poor engagement

**Insight:** Poor - convinced delusions are real

**Judgment:** Poor - not eating, poor self-care, giving away possessions

### Psychiatric Workup

**Screening Tools:**
- PHQ-9: Unable to complete (severely impaired)
- Clinical assessment indicates severe depression with psychotic features

**Laboratory Studies:**
- CBC: WBC 5.8, Hgb 10.2 (mild anemia)
- CMP: BUN 32, Cr 1.4 (mild dehydration), albumin 2.9 (malnutrition)
- TSH: 3.1 mIU/L (normal)
- Urinalysis: Concentrated, no infection
- B12: 220 pg/mL (low)
- Folate: 5 ng/mL (low-normal)
- CT Head: Age-appropriate atrophy, no acute abnormality

### Diagnosis

**Major Depressive Disorder, Recurrent Episode, Severe with Psychotic Features (F33.3)**

**DSM-5 Criteria:**
- Meets criteria for major depressive episode (depressed mood, anhedonia, weight loss, psychomotor retardation, worthlessness, passive SI)
- Psychotic features present:
  - Nihilistic delusions (body is dead/dying)
  - Somatic delusions (fatal illness)
  - Delusions of guilt
  - Olfactory hallucination (mood-congruent)
- Delusions are mood-congruent (themes of death, disease, guilt consistent with depressive themes)

**Differential Diagnosis:**
- Delirium (ruled out by normal workup except mild metabolic derangements)
- Dementia with behavioral disturbance (less likely given acute onset, no prior cognitive complaints)
- Medical illness causing symptoms (workup negative)

### Treatment Plan

**Acute Management:**
- Psychiatric admission (voluntary status - daughter has healthcare POA and patient assented)
- IV fluid resuscitation
- Nutritional support, B12 supplementation
- 1:1 observation for safety

**Pharmacotherapy:**
- Start olanzapine 5 mg QHS (for psychotic symptoms)
- Start sertraline 50 mg daily (previous good response)
- Monitor for refeeding syndrome given malnutrition

**Consider ECT:**
- Depression with psychotic features responds particularly well to ECT
- May be first-line given severity, psychosis, and poor oral intake limiting medication absorption
- Family meeting to discuss ECT as preferred treatment
- Consent obtained from healthcare POA

**ECT Course:**
- Bilateral electrode placement (more effective for psychotic depression)
- 3 times weekly
- Typical course 6-12 treatments

**Prognosis:**
- Depression with psychotic features has high response rate to ECT (80-90%)
- Maintenance treatment needed after acute stabilization (antidepressant + low-dose antipsychotic or maintenance ECT)

**Follow-up:**
- Daily evaluation during inpatient stay
- Involve family in treatment planning and psychoeducation