Depression

This is a case of a 22-year-old female with no past psychiatric history who presents herself for outpatient medical evaluation after being hospitalized for a suicide attempt. This case demonstrates the importance of identifying, carrying out the appropriate diagnosis and treating patients with major depressive disorders.

Case Presentation

HPI:

A 22-year-old female was presented as a new patient to an outpatient facility for a one month follow up after a suicide attempt by overdosing melatonin due to marital and scholastic problems. According to the patient, she was married at the age of 18, and since then, she has had one child aged three years. Despite being married, she is enrolled in school, full time. She states that her husband is not very supportive when it comes to her education and contributing to the family finances should be part of his obligations. According to her report, it shows that she is on a scholarship and that her son attends school free of charge. She further adds that her husband is struggling to pay all the bills and that it has caused a lot of animosities.

According to her claims, her marriage was a happy one in the first years, but since the birth of their child, they have struggled financially; and she denies being abused by her husband. She narrates that over the past six months; she has become more depressed and has lost interest in everything about her life. This depression has led to her losing twenty pounds; sleep all the time and the feeling of being exhausted.

A month ago, she found out that her husband was in an affair with a coworker. In response to this finding, all she ever wanted is to end it all by going to sleep and not waking up. This pushed her to take an unknown amount of melatonin. Subsequently, she was taken to an emergency department on an involuntary baker act. She underwent a medical examination which included a CBC, CMP, TSH/T4, HIV, RPR, and a drug screen which yielded no findings of abnormality.

After medical clearance, she was evaluated by the psychiatrist and later discharged for outpatient management at home. Since she was discharged, she has remained at home with her husband and her three-year-old son. She reports that they are currently trying to work their marriage out; prior to this event, there was no documented psychiatric history although the patient reports previous symptoms. The patient also reports no medical history but admits that she did report symptoms of sadness and fatigue to her primary care provider four months prior during a routine appointment and that they suggested exercise and journaling. Her family psychiatric history shows a mother and paternal grandmother with depression, and a brother with ADHD. She is unsure of what drugs her mother is on because they are not in contact any longer.

During the follow-up evaluation, she appeared to be well-nourished at her stated age, she appeared tired, and her clothing was messy. She was cooperative during the exam but had poor concentration and minimal eye contact. Her speech coherent and at a normal rate but in a low tone. Her mood was depressive, but her thought process was coherent and logical. She denied delusions or hallucinations but reported passive suicidal thoughts. Her memory, judgement, and insight were intact, and her intelligence was coherent with education level. A PHQ9 was obtained and was found to be at 22.

Assessment and Plan:

The patient was diagnosed with major depressive disorder. The DSM5 criteria were satisfied by the patient as she had more than 5 symptoms of depression for at least 2 weeks to include; depressed mood, loss of interests, decreased appetite, weight loss, fatigue, decreased concentration, and passive suicidal thoughts. Her PHQ-9 score of 22 in addition to her mental status exam further supported the diagnoses to a larger extent.

The patient was started on Zoloft 50mg PO qd and was also referred for cognitive behavioral therapy. Although she continued to report passive suicidal thoughts, she agreed to go to the ED or call 911 if she has any desire to act on those thoughts. She agreed that she was educated on the diagnosis and the medication. Short term goal was made to take all medications as prescribed. The long term goal was to be symptom-free as evidenced by PHQ-9 score decreasing. The patient also agreed to the plan of care and was scheduled for a 2 week follow up.

Discussion

Epidemiology

According to a number of studies, it has been found that major depression has the highest lifetime prevalence ranging between 5-17 percent (Kessler et al., 2003). It is more prevalent in women, and more than fifty percent of cases are diagnosed between ages 20-50.

Diagnosis

Identification and diagnosis of patients with a major depressive disorder were critical to prevent the worsening of symptoms or suicide. Diagnosis should be conducted according to the report on symptoms and/or screening tools. The PHQ-9 is very useful in this diagnosis as it makes it easy to administer and assists in identifying a patient with major depressive disorders. According to the DSM-V, patients must have at least five of the typical symptoms for at least two weeks for the diagnosis criteria to be met (Belmaker & Agam, 2008).

Treatment

According to The Handbook of Clinical Psychopharmacology for Therapists, cognitive behavioral therapy, in addition to antidepressant therapy, is recommended for major depressive disorders. Although no antidepressants have proven efficiency over the other, SSRI’s are generally preferred for treatment as opposed to other antidepressants due to their side effect profile and tolerance (Detke et al., 2002).

Sertraline 50mg is an appropriate starting dose and is generally well tolerated with minimal side effects. Most common side effects are GI-related and improve with treatment (Detke et al., 2020). SSRI’s should be titrated to improve symptoms until full resolution of symptoms or side effects occur. Although the medication may begin to work sooner, it takes 4-6 weeks to achieve maximal effectiveness (Davidson, 2010).

References

Belmaker, R. H., & Agam, G. (2008). Major depressive disorder. New England Journal of Medicine, 358(1), 55-68.

Spaner, D., Bland, R. C., & Newman, S. C. (1994). Major depressive disorder. Acta Psychiatrica Scandinavica, 89, 7-15.

Davidson, J. R. (2010). Major depressive disorder treatment guidelines in America and Europe. The Journal of Clinical Psychiatry, 71, e04-e04.

Kessler, R. C., Berglund, P., Demler, O., Jin, R., Koretz, D., Merikangas, K. R., … & Wang, P. S. (2003). The epidemiology of major depressive disorder: results from the National Comorbidity Survey Replication (NCS-R). Jama, 289(23), 3095-3105.

Detke, M. J., Lu, Y., Goldstein, D. J., Hayes, J. R., & Demitrack, M. A. (2002). Duloxetine, 60 mg once daily, for major depressive disorder: A randomized double-blind placebo-controlled trial. The Journal of Clinical Psychiatry, 63(4), 308-315.