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A 37-year-old woman presents to establish care with you in the office today. She complains of low energy levels and difficulty sleeping for the past 4 years. She has gained 30 lb over the past 2 years. She reports a family history of alcoholism in her mother and her older brother, and completed suicide in her father. She thinks her mother was hospitalized for a suicide attempt many years ago, but she does not know any more details. When you ask about her social history, she hesitates in giving her answer, and then becomes tearful as she tells you with great difficulty that she was in a physically and sexually abusive marriage for 10 years. The marriage finally ended over 1 year ago, but the patient still expresses guilt about its end and says she feels worthless every day. She admits that she had suicidal thoughts on and off in the past but has none currently. She has never had a suicide attempt. She drinks 3 beers nightly. Her vital signs and complete physical examination are normal except for a labile affect.

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1. What is the most likely diagnosis?

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2. What is the next appropriate step in evaluation?

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3. What therapeutic options can you offer to this patient?

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Answers

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  1. This patient presents with classic symptoms of major depressive disorder (MDD), and meets diagnostic criteria for MDD, according to the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders, Revised (DSM-IV-R). She has depressed mood, insomnia, loss of energy, feelings of worthlessness, weight gain, and recurrent suicidal ideation without a specific plan. These symptoms have been present for 4 years, which is longer than the 2-week period required to meet DSM-IV-R criteria for MDD. She has multiple risk factors for MDD, most notably a family history of mood disorders and stressful life events, including a difficult marriage and history as a victim of intimate partner violence. She also drinks more than the recommended upper limit of alcohol daily for females, suggesting possible substance dependency or even abuse that needs further evaluation and directed management.

  2. The next appropriate step is to evaluate her depressive symptoms in an objective manner to guide diagnosis, evaluate severity, and establish a baseline of severity that can later be compared with treatment response to pharmacologic and behavioral therapies. Multiple rating scales and scores exist to assist with quantifying the severity of depression symptoms and their level of functional impairment, which will be explored further in this chapter.

  3. Therapeutic options for an episode of major depression include a wide variety of pharmacologic and behavioral therapies. Among pharmacologic therapies, selective serotonin reuptake inhibitors (SSRIs) are considered first-line agents in the treatment of an episode of major depression. The choice of SSRI depends in part on the side effect profiles for each medication in this class, as ...

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