depression case study questions

Mental Health Case Study: Understanding Depression through a Real-life Example

Imagine feeling an unrelenting heaviness weighing down on your chest. Every breath becomes a struggle as a cloud of sadness engulfs your every thought. Your energy levels plummet, leaving you physically and emotionally drained. This is the reality for millions of people worldwide who suffer from depression, a complex and debilitating mental health condition.

Understanding depression is crucial in order to provide effective support and treatment for those affected. While textbooks and research papers provide valuable insights, sometimes the best way to truly comprehend the depths of this condition is through real-life case studies. These stories bring depression to life, shedding light on its impact on individuals and society as a whole.

In this article, we will delve into the world of mental health case studies, using a real-life example to explore the intricacies of depression. We will examine the symptoms, prevalence, and consequences of this all-encompassing condition. Furthermore, we will discuss the significance of case studies in mental health research, including their ability to provide detailed information about individual experiences and contribute to the development of treatment strategies.

Through an in-depth analysis of a selected case study, we will gain insight into the journey of an individual facing depression. We will explore their background, symptoms, and initial diagnosis. Additionally, we will examine the various treatment options available and assess the effectiveness of the chosen approach.

By delving into this real-life example, we will not only gain a better understanding of depression as a mental health condition, but we will also uncover valuable lessons that can aid in the treatment and support of those who are affected. So, let us embark on this enlightening journey, using the power of case studies to bring understanding and empathy to those who need it most.

Understanding Depression

Depression is a complex and multifaceted mental health condition that affects millions of people worldwide. To comprehend the impact of depression, it is essential to explore its defining characteristics, prevalence, and consequences on individuals and society as a whole.

Defining depression and its symptoms

Depression is more than just feeling sad or experiencing a low mood. It is a serious mental health disorder characterized by persistent feelings of sadness, hopelessness, and a loss of interest in activities that were once enjoyable. Individuals with depression often experience a range of symptoms that can significantly impact their daily lives. These symptoms include:

1. Persistent feelings of sadness or emptiness. 2. Fatigue and decreased energy levels. 3. Significant changes in appetite and weight. 4. Difficulty concentrating or making decisions. 5. Insomnia or excessive sleep. 6. feelings of guilt, worthlessness, or hopelessness. 7. Loss of interest or pleasure in activities.

Exploring the prevalence of depression worldwide

Depression knows no boundaries and affects individuals from all walks of life. According to the World Health Organization (WHO), an estimated 264 million people globally suffer from depression. This makes depression one of the most common mental health conditions worldwide. Additionally, the WHO highlights that depression is more prevalent among females than males.

The impact of depression is not limited to individuals alone. It also has significant social and economic consequences. Depression can lead to impaired productivity, increased healthcare costs, and strain on relationships, contributing to a significant burden on families, communities, and society at large.

The impact of depression on individuals and society

Depression can have a profound and debilitating impact on individuals’ lives, affecting their physical, emotional, and social well-being. The persistent sadness and loss of interest can lead to difficulties in maintaining relationships, pursuing education or careers, and engaging in daily activities. Furthermore, depression increases the risk of developing other mental health conditions, such as anxiety disorders or substance abuse.

On a societal level, depression poses numerous challenges. The economic burden of depression is significant, with costs associated with treatment, reduced productivity, and premature death. Moreover, the social stigma surrounding mental health can impede individuals from seeking help and accessing appropriate support systems.

Understanding the prevalence and consequences of depression is crucial for policymakers, healthcare professionals, and individuals alike. By recognizing the significant impact depression has on individuals and society, appropriate resources and interventions can be developed to mitigate its effects and improve the overall well-being of those affected.

The Significance of Case Studies in Mental Health Research

Case studies play a vital role in mental health research, providing valuable insights into individual experiences and contributing to the development of effective treatment strategies. Let us explore why case studies are considered invaluable in understanding and addressing mental health conditions.

Why case studies are valuable in mental health research

Case studies offer a unique opportunity to examine mental health conditions within the real-life context of individuals. Unlike large-scale studies that focus on statistical data, case studies provide a detailed examination of specific cases, allowing researchers to delve into the complexities of a particular condition or treatment approach. This micro-level analysis helps researchers gain a deeper understanding of the nuances and intricacies involved.

The role of case studies in providing detailed information about individual experiences

Through case studies, researchers can capture rich narratives and delve into the lived experiences of individuals facing mental health challenges. These stories help to humanize the condition and provide valuable insights that go beyond a list of symptoms or diagnostic criteria. By understanding the unique experiences, thoughts, and emotions of individuals, researchers can develop a more comprehensive understanding of mental health conditions and tailor interventions accordingly.

How case studies contribute to the development of treatment strategies

Case studies form a vital foundation for the development of effective treatment strategies. By examining a specific case in detail, researchers can identify patterns, factors influencing treatment outcomes, and areas where intervention may be particularly effective. Moreover, case studies foster an iterative approach to treatment development—an ongoing cycle of using data and experience to refine and improve interventions.

By examining multiple case studies, researchers can identify common themes and trends, leading to the development of evidence-based guidelines and best practices. This allows healthcare professionals to provide more targeted and personalized support to individuals facing mental health conditions.

Furthermore, case studies can shed light on potential limitations or challenges in existing treatment approaches. By thoroughly analyzing different cases, researchers can identify gaps in current treatments and focus on areas that require further exploration and innovation.

In summary, case studies are a vital component of mental health research, offering detailed insights into the lived experiences of individuals with mental health conditions. They provide a rich understanding of the complexities of these conditions and contribute to the development of effective treatment strategies. By leveraging the power of case studies, researchers can move closer to improving the lives of individuals facing mental health challenges.

Examining a Real-life Case Study of Depression

In order to gain a deeper understanding of depression, let us now turn our attention to a real-life case study. By exploring the journey of an individual navigating through depression, we can gain valuable insights into the complexities and challenges associated with this mental health condition.

Introduction to the selected case study

In this case study, we will focus on Jane, a 32-year-old woman who has been struggling with depression for the past two years. Jane’s case offers a compelling narrative that highlights the various aspects of depression, including its onset, symptoms, and the treatment journey.

Background information on the individual facing depression

Before the onset of depression, Jane led a fulfilling and successful life. She had a promising career, a supportive network of friends and family, and engaged in hobbies that brought her joy. However, a series of life stressors, including a demanding job, a breakup, and the loss of a loved one, began to take a toll on her mental well-being.

Jane’s background highlights a common phenomenon – depression can affect individuals from all walks of life, irrespective of their socio-economic status, age, or external circumstances. It serves as a reminder that no one is immune to mental health challenges.

Presentation of symptoms and initial diagnosis

Jane began noticing a shift in her mood, characterized by persistent feelings of sadness and a lack of interest in activities she once enjoyed. She experienced disruptions in her sleep patterns, appetite changes, and a general sense of hopelessness. Recognizing the severity of her symptoms, Jane sought help from a mental health professional who diagnosed her with major depressive disorder.

Jane’s case exemplifies the varied and complex symptoms associated with depression. While individuals may exhibit overlapping symptoms, the intensity and manifestation of those symptoms can vary greatly, underscoring the importance of personalized and tailored treatment approaches.

By examining this real-life case study of depression, we can gain an empathetic understanding of the challenges faced by individuals experiencing this mental health condition. Through Jane’s journey, we will uncover the treatment options available for depression and analyze the effectiveness of the chosen approach. The case study will allow us to explore the nuances of depression and provide valuable insights into the treatment landscape for this prevalent mental health condition.

The Treatment Journey

When it comes to treating depression, there are various options available, ranging from therapy to medication. In this section, we will provide an overview of the treatment options for depression and analyze the treatment plan implemented in the real-life case study.

Overview of the treatment options available for depression

Treatment for depression typically involves a combination of approaches tailored to the individual’s needs. The two primary treatment modalities for depression are psychotherapy (talk therapy) and medication. Psychotherapy aims to help individuals explore their thoughts, emotions, and behaviors, while medication can help alleviate symptoms by restoring chemical imbalances in the brain.

Common forms of psychotherapy used in the treatment of depression include cognitive-behavioral therapy (CBT), interpersonal therapy (IPT), and psychodynamic therapy. These therapeutic approaches focus on addressing negative thought patterns, improving relationship dynamics, and gaining insight into underlying psychological factors contributing to depression.

In cases where medication is utilized, selective serotonin reuptake inhibitors (SSRIs) are commonly prescribed. These medications help rebalance serotonin levels in the brain, which are often disrupted in individuals with depression. Other classes of antidepressant medications, such as serotonin-norepinephrine reuptake inhibitors (SNRIs) or tricyclic antidepressants (TCAs), may be considered in specific cases.

Exploring the treatment plan implemented in the case study

In Jane’s case, a comprehensive treatment plan was developed with the intention of addressing her specific needs and symptoms. Recognizing the severity of her depression, Jane’s healthcare team recommended a combination of talk therapy and medication.

Jane began attending weekly sessions of cognitive-behavioral therapy (CBT) with a licensed therapist. This form of therapy aimed to help Jane identify and challenge negative thought patterns, develop coping strategies, and cultivate more adaptive behaviors. The therapeutic relationship provided Jane with a safe space to explore and process her emotions, ultimately helping her regain a sense of control over her life.

In conjunction with therapy, Jane’s healthcare provider prescribed an SSRI medication to assist in managing her symptoms. The medication was carefully selected based on Jane’s specific symptoms and medical history, and regular follow-up appointments were scheduled to monitor her response to the medication and adjust the dosage if necessary.

Analyzing the effectiveness of the treatment approach

The effectiveness of treatment for depression varies from person to person, and it often requires a period of trial and adjustment to find the most suitable intervention. In Jane’s case, the combination of cognitive-behavioral therapy and medication proved to be beneficial. Over time, she reported a reduction in her depressive symptoms, an improvement in her overall mood, and increased ability to engage in activities she once enjoyed.

It is important to note that the treatment journey for depression is not always linear, and setbacks and challenges may occur along the way. Each individual responds differently to treatment, and adjustments might be necessary to optimize outcomes. Continuous communication between the individual and their healthcare team is crucial to addressing any concerns, monitoring progress, and adapting the treatment plan as needed.

By analyzing the treatment approach in the real-life case study, we gain insights into the various treatment options available for depression and how they can be tailored to meet individual needs. The combination of psychotherapy and medication offers a holistic approach, addressing both psychological and biological aspects of depression.

The Outcome and Lessons Learned

After undergoing treatment for depression, it is essential to assess the outcome and draw valuable lessons from the case study. In this section, we will discuss the progress made by the individual in the case study, examine the challenges faced during the treatment process, and identify key lessons learned.

Discussing the progress made by the individual in the case study

Throughout the treatment process, Jane experienced significant progress in managing her depression. She reported a reduction in depressive symptoms, improved mood, and a renewed sense of hope and purpose in her life. Jane’s active participation in therapy, combined with the appropriate use of medication, played a crucial role in her progress.

Furthermore, Jane’s support network of family and friends played a significant role in her recovery. Their understanding, empathy, and support provided a solid foundation for her journey towards improved mental well-being. This highlights the importance of social support in the treatment and management of depression.

Examining the challenges faced during the treatment process

Despite the progress made, Jane faced several challenges during her treatment journey. Adhering to the treatment plan consistently proved to be difficult at times, as she encountered setbacks and moments of self-doubt. Additionally, managing the side effects of the medication required careful monitoring and adjustments to find the right balance.

Moreover, the stigma associated with mental health continued to be a challenge for Jane. Overcoming societal misconceptions and seeking help required courage and resilience. The case study underscores the need for increased awareness, education, and advocacy to address the stigma surrounding mental health conditions.

Identifying the key lessons learned from the case study

The case study offers valuable lessons that can inform the treatment and support of individuals with depression:

1. Holistic Approach: The combination of psychotherapy and medication proved to be effective in addressing the psychological and biological aspects of depression. This highlights the need for a holistic and personalized treatment approach.

2. Importance of Support: Having a strong support system can significantly impact an individual’s ability to navigate through depression. Family, friends, and healthcare professionals play a vital role in providing empathy, understanding, and encouragement.

3. Individualized Treatment: Depression manifests differently in each individual, emphasizing the importance of tailoring treatment plans to meet individual needs. Personalized interventions are more likely to lead to positive outcomes.

4. Overcoming Stigma: Addressing the stigma associated with mental health conditions is crucial for individuals to seek timely help and access the support they need. Educating society about mental health is essential to create a more supportive and inclusive environment.

By drawing lessons from this real-life case study, we gain insights that can improve the understanding and treatment of depression. Recognizing the progress made, understanding the challenges faced, and implementing the lessons learned can contribute to more effective interventions and support systems for individuals facing depression.In conclusion, this article has explored the significance of mental health case studies in understanding and addressing depression, focusing on a real-life example. By delving into case studies, we gain a deeper appreciation for the complexities of depression and the profound impact it has on individuals and society.

Through our examination of the selected case study, we have learned valuable lessons about the nature of depression and its treatment. We have seen how the combination of psychotherapy and medication can provide a holistic approach, addressing both psychological and biological factors. Furthermore, the importance of social support and the role of a strong network in an individual’s recovery journey cannot be overstated.

Additionally, we have identified challenges faced during the treatment process, such as adherence to the treatment plan and managing medication side effects. These challenges highlight the need for ongoing monitoring, adjustments, and open communication between individuals and their healthcare providers.

The case study has also emphasized the impact of stigma on individuals seeking help for depression. Addressing societal misconceptions and promoting mental health awareness is essential to create a more supportive environment for those affected by depression and other mental health conditions.

Overall, this article reinforces the significance of case studies in advancing our understanding of mental health conditions and developing effective treatment strategies. Through real-life examples, we gain a more comprehensive and empathetic perspective on depression, enabling us to provide better support and care for individuals facing this mental health challenge.

As we conclude, it is crucial to emphasize the importance of continued research and exploration of mental health case studies. The more we learn from individual experiences, the better equipped we become to address the diverse needs of those affected by mental health conditions. By fostering a culture of understanding, support, and advocacy, we can strive towards a future where individuals with depression receive the care and compassion they deserve.

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Evidence-Based Case Review

Identifying and treating adolescent depression, martha c tompson.

1 Department of Psychology Boston University 64 Cummington St Boston, MA 02215-2407

Fawn M McNeil

Margaret m rea.

2 Department of Psychiatry and Biobehavioral Sciences University of California Los Angeles, CA 90095

Joan R Asarnow

• Understand the importance of diagnosing and treating depression in adolescents
• Identify the symptoms of depression in adolescents and the difference between depression and normal adolescent moods
• Identify suicidal risk in a depressed adolescent
• Understand when a specialty consultation is needed
• Understand what effective treatments are available

By age 18, about 20% of our nation's youth will have had depressive episodes, 1 , 2 with girls at substantially higher risk. 2 Major depressive episodes in adolescence last an average of 6 to 9 months, 2 , 3 6% to 10% of depressed adolescents have protracted episodes, and the probability of recurrence within 5 years is about 70%. 3 Given that depressed people are as likely to seek help in primary care settings as in mental health establishments, 4 primary care physicians may be the first to be aware of this problem in their adolescent patients.

Case history

Wanda S, aged 16 years, comes for her checkup accompanied by her mother. She is in good health and has had no notable illnesses in the past year. However, Wanda complains of difficulty sleeping in the past few months and of frequently being tired. Her mother asks for a few minutes alone to discuss her concerns about her daughter. She states that “Wanda has been much more irritable than her usual self” and that “her teachers have been complaining that she doesn't seem to attend to her work lately and her grades are slipping.” Wanda's mother remembers being an unhappy adolescent herself and asks your advice on how to help her daughter.

When directly questioned, Wanda admits to “feeling pretty bad for the last few months, since school began.” She concedes that she feels sad and blue most days of the week and believes that she is “a loser.” She's been spending more time alone and, despite complaining of chronic boredom, has little energy or desire to engage in recreational activities.

Our conclusions are based on literature searches using both MEDLINE and PsychLIT databases, and most are derived from empiric findings and clinical trials. Because of the relatively modest literature, particularly on treatment, some suggestions are based on published opinions of experts. We have noted when expert opinion is our source.

What does depression look like in adolescents?

According to the Diagnostic and statistical manual of mental disorders , fourth edition, 5 an adolescent must have five out of nine characteristic symptoms most of the time for at least 2 weeks for a diagnosis of major depressive disorder. At least one of these symptoms must be either depressed or irritable mood or a pervasive loss of pleasure or interest in events that were once enjoyed. Many seriously depressed adolescents experience both. For example, a depressed adolescent may feel sad most of the day, act crabby, stop hanging out with friends, and seem to lose her love of soccer.

Summary points

• Adolescent depression is common, and primary care physicians are often in a position to first identify the symptoms
• Depression includes changes in moods, thoughts, behaviors, and physical functioning. Among adolescents, depression may include irritable as well as sad moods
• Unlike normal adolescent moods, depression is severe and enduring and interrupts the adolescent's ability to perform in school, to relate to peers, and to engage in age-appropriate activities
• In assessing the risk of suicide, ask straightforward questions about the adolescent's intent, plan, and means
• Antidepressant medication and psychotherapy may be effective treatments; a combination of these is frequently optimal
• Education about depression with both the adolescent and parents provides a rationale for treatment, may alleviate family misunderstandings, and facilitates recovery

Although all adolescents occasionally become sad, and adolescent angst may be normal and common, symptoms of major depression are more severe in intensity, interfere with social, academic, and recreational activities, and last for months at a time, 2 instead of fluctuating like more typical adolescent ups and downs. 6 Depression occurs as a cluster of signs and symptoms, including emotional, physical, and mental changes that usually signify an alteration from the adolescent's normal personality. 3

Some adolescents present with depressive symptoms but do not meet the full criteria for having major depression. Dysthymic disorder is characterized by milder but more persistent symptoms than major depression. In dysthymic disorder, symptoms are present much of the time for at least one year in adolescents (2 years in adults).

Wanda's physician prescribes a low dose of fluoxetine hydrochloride (Prozac), a selective serotonin reuptake inhibitor. In addition, the physician refers Wanda for interpersonal therapy to help her cope with the losses and disappointments of the past year, develop new peer relationships, and reintegrate herself into high school activities.

This multifaceted approach will address the physical and psychological symptoms Wanda has been experiencing and provide her with skills she can use to combat future depressive symptoms and interpersonal problems.

What contributes to adolescent depression?

The vulnerability-stress model is useful for understanding depression. According to this model, adolescent depression results from a predisposition for depression, which is then triggered or complicated by environmental stress. The exact nature of the predisposition may include biologic and cognitive factors. This interplay between life's stresses and cognitive and biologic vulnerabilities is important in conceptualizing depression in an adolescent.

An accumulation of adverse life circumstances and events can trigger depression. Family adversity, 7 academic difficulties, 3 chronic medical conditions, 8 and loss in the adolescent's life may increase risk. As Wanda's history illustrates, losses such as her breakup with a boyfriend and failure to make the track team may serve as triggers. Illnesses such as asthma, sickle cell anemia, irritable bowel syndrome, recurrent abdominal pain, and diabetes mellitus may put an adolescent at particular risk. 8

Cognitive models of depression suggest that it is not stressful events and circumstances but rather the tendency toward negative interpretations about these situations that initiates and maintains depression. 9 , 10 When an adverse event occurs, the depressed adolescent often understands the cause of the event as something stable, internal, and global. For example, Wanda fails to make the track team and attributes this failure to being a “loser.” This cause is stable (unlikely to change), internal (her own fault), and global (affecting everything she does).

Vulnerability to depression may result from biologic or genetic factors and lead to numerous biologic changes. First, studies of family history show that offspring of depressed parents are at high risk for depression 11 and that depressed adolescents have high rates of depression among their family members. 12 Wanda's mother may have been depressed during adolescence. Second, as depressions become more severe, biologic changes may occur, including dysregulation of growth hormone and changes in sleep architecture. 6

How do you assess adolescent depression?

The diagnosis of depression is made clinically. Physicians need to ask about changes in an adolescent's moods, feelings, and thoughts; behaviors; daily functioning; and any impairment in that functioning, as well as physical symptoms. Furthermore, a medical explanation (for example, thyroid disease or adrenal dysfunction) or substance misuse needs to be ruled out as possible causes. The best methods of assessment supplement the adolescent's selfreport with reports from parents or guardians and other outside sources. 2 Whereas youths tend to be better reporters of their internal experiences, such as their mood and thoughts, parents tend to be better reporters of overt behaviors, such as disruptive behavior in the classroom and defiance. 13 As in all primary care evaluations, ethnic and cultural factors must also be considered. For example, in some cultures, making eye contact with an authority figure may not be considered proper etiquette, and the failure to do so may not reflect a depressed mood. 3 In recent years, several screening tools for depression have been adapted for use in primary care settings. 14 , 15 The use of these screening techniques can improve the quality of assessments of depression while reducing the time needed for questioning during routine examinations.

How do you assess and intervene when an adolescent is suicidal?

Depression is associated with a markedly increased risk of suicide and attempted suicide. 16 , 17 , 18 About 41% of depressed youths have suicidal ideation, and 21% report a past attempt at suicide. 2 Although many people are concerned that asking directly about suicide may suggest the idea, most depressed youths have suicidal thoughts and are relieved at the opportunity to share them. Unfortunately, adolescents may not volunteer this information unless directly questioned. Often depressed youths have thoughts of death, a desire to die, or a more overt suicidal intention. Asking straightforward, unambiguous questions to assess the risk of suicide is the best strategy. Questions may include “Have you thought that life was not worth living?” “Have you wished you were dead?” “Have you thought about killing yourself?” “What have you thought about doing?” “Have you ever tried to hurt yourself?” or “Have you ever actually tried to kill yourself?” If there is evidence of suicidal thoughts or attempts, it is then critical to establish if the adolescent has the intent, plan, and means to attempt suicide. Questions to ask may include “Are you going to try?” “How would you do it?” and “Do you have a gun (knife, pills)?”

When is a specialty consultation needed?

Depression in adolescents is frequently complicated by other mental health and life problems. Because these additional problems affect management strategies, it is important to screen for comorbid disorders and problems with psychosocial functioning and life stress. If at any point the primary care physician feels uncertain about the diagnosis and/or management strategy, specialty mental health consultation is recommended. Primary care physicians should obtain a consultation with a specialist if any of the following are present: current or past mania, two previous episodes of depression, chronic depression, substance dependence or abuse, eating disorder, a history of being admitted to a hospital for psychiatric problems, or a history of suicide attempts or concerns regarding the risk for suicide.

TREATMENTS EFFECTIVE FOR ADOLESCENT DEPRESSION

Although research on the treatment of adolescent depression is limited, recent clinical trials have identified promising interventions, both pharmacologic and psychotherapeutic. The physician also needs to help the family to understand the adolescent's symptoms.

Although research has clearly documented the use of antidepressant medication for adults with depression, 19 far fewer studies have examined the use of these agents in adolescents. Selective serotonin reuptake inhibitors are the first choice in medication for depressed adolescents because of their relatively benign side effects, their safety in overdose, and because they only need to be taken once daily. 3 Both tricyclic antidepressants and monoamine oxidase inhibitors are less efficacious in adolescents, are more lethal in overdose, 20 and are not recommended at this time. 3

Cognitive behavior therapies are effective in treating adolescent depression. 21 , 22 They assume that developing more adaptive ways of thinking, understanding events, and interacting with the environment will reduce depressive symptoms and improve a youth's ability to function. The cognitive component of the treatment focuses on helping adolescents identify and interrupt negative or pessimistic thoughts, assumptions, beliefs, and interpretations of events and to develop new, more positive or optimistic ways of thinking. The behavioral component focuses on increasing constructive interactions with others to improve the likelihood of receiving positive feedback.

Interpersonal therapy emphasizes improving relationships. The therapy is brief and focuses on the problems that precipitated the current depressive episode. It helps the adolescent to reduce and cope with stress. Two studies 23 , 24 have shown its effectiveness in reducing depression.

No definitive guidelines have been published for deciding when to begin with medication, psychotherapy, or a combination of medication plus psychotherapy. We have, however, suggested several considerations based on common sense to help clinicians make this decision. 25 , 26 , 27 For example, medication should be considered if an adolescent does not seem interested in thinking about problems, has limited cognitive abilities, is severely depressed with vegetative symptoms, has had two or more episodes of depression, has not responded to 8 to 12 weeks of psychotherapy, or cannot regularly get to therapy sessions. Conversely, psychotherapy should be considered as the first alternative for adolescents who fear medication or do not like taking pills, prefer talking about problems, have complex life stressors that need sorting out, have contraindications to medication (such as pregnancy or breast-feeding), or have not responded to an adequate trial of medication. For some adolescents who have combinations of severe depression, limited cognitive skills, and complex life stressors, it may be best to begin with both medication and psychotherapy.

Parents may have little understanding of the adolescent's symptoms and sometimes interpret falling grades and lack of interest as willful behavior. By giving parents information about the symptoms, causes, and treatments of depression, the physician can help them to help their child to recover, to monitor symptoms, and to facilitate ongoing care. 3 Families differ in their willingness to consider the possibility that their child may have a psychological or psychiatric problem. For personal and/or cultural reasons, some families may be more receptive to a medical model, which identifies the depressive symptoms as part of an illness, and so they are more comfortable with a pharmacologic intervention. Other families may find a cognitive explanation more acceptable and see psychotherapy as a more palatable option. Further, primary care physicians may note that on finding out about their adolescent's depression, parents may feel guilty or feel they are being blamed and thus be resistant to suggestions for interventions. Appropriate education about depression and possible causes may help allay these concerns.

Symptoms of major depressive disorder in adolescents

• Depressed or irritable mood
• Loss of pleasure or interest in activities that were once enjoyed
• Significant weight loss or gain when not dieting, or an increase or decrease in appetite
• Insomnia or hypersomnia
• Observable slowing of movements and speech or increased agitation
• Feelings of worthlessness or excessive and/or inappropriate guilt
• Difficulty concentrating and/or making decisions
• Recurrent thoughts of death or suicide or a suicide attempt
• For a diagnosis, an adolescent must have at least 5 symptoms, which must include at least one of either of the first 2 symptoms, for at least 2 weeks.

When assessing adolescents for depression who already have chronic illnesses, it is important to look at the symptoms that are less likely to overlap with the physical illness, such as feelings of guilt, worthlessness, and hopelessness. It may be difficult to decipher whether changes in sleep patterns, appetite, and increased fatigue are due to the illness or to depression. 3

Symptoms of dysthymic disorder in adolescents

Depressed or irritable mood must be present for most of the day, more days than not, for at least 1 year. In addition, 2 of the following 6 symptoms must be present:

• Poor appetite or overeating
• Low energy of fatigue
• Low self-esteem
• Poor concentration or difficulty making decisions
• Feelings of hopelessness

During this time, the adolescent has never been without the depressive symptoms for more than 2 months at a time but does not meet criteria for a major depressive episode.

Having assessed thoughts of death, the intention to die, plans for an attempt, the means to commit suicide, and the availability of support, the physician must estimate the degree of risk and make choices for managing the patient's risk of suicide. 3 First, although thoughts of death or thinking of suicide in vague terms suggests a low risk, such symptoms indicate a need for both immediate intervention and close monitoring (because suicidal risk can increase). Second, when the adolescent acknowledges having a plan or means but no intent, emergency care may not be needed if safety can be ensured through involving parents and other support systems. Parents need to be in close proximity and to remove potential means such as firearms, and the adolescent needs to be referred for psychotherapy. However, if the adolescent does not have a supportive family, has access to lethal means, or has other risk factors (for example, a past suicide attempt, family history of suicide, recent exposure to suicide, substance abuse, bipolar illness, mixed state, or severe stress), more intensive interventions are needed, and the adolescent needs to see a mental health specialist. Finally, when the adolescent has intent, plan, and means, the risk for suicide is high. Such adolescents need help immediately, and psychiatric emergency care may be needed. 3 Regardless of risk, follow-up care is essential to tackle the concerns that contributed to the adolescent's suicidal feelings.

Empirically supported treatment options

Selective serotonin reuptake inhibitors Alters dysfunctional neurotransmitter systems

Cognitive behavioral therapy Monitors and changes dysfunctional ways of thinking

Interpersonal therapy Improves interpersonal skills and problem-solving abilities

Funding: National Institutes of Health, Agency for Health Care Policy and Research

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Patient Case Presentation

Ms. A. M. is a 23 year old biracial female who arrives to her primary care clinic for her annual physical. Ms A.M. has had a 15lb weight gain since her last visit. She complains of feelings of guilt and sadness with her parents’ recent divorce. Patient states she is not sleeping well and feels that she cannot concentrate during her nursing orientation classes. When asked about her interpersonal relationships, she states that she just ended her two-year relationship with her boyfriend and she states that she hasn’t been able to meet new friends or keep up with current friendships.

Past Medical/Surgical History

• Asthma diagnosed at age 8
• Hypothyroidism diagnosed at age 16

Pertinent Family History

• Older sister with suicide attempt 3 years prior.
• Father diagnosed with Bipolar II in his thirties, currently taking medication.
• Mother alive and healthy at age 54
• Uncle with history of substance abuse

Pertinent Social History

• recently graduated college and is starting her career as a nurse at a large teaching hospital on the intensive care unit
• parents recently divorced
• moving out on her own for the first time

Patient Case #1: 27-Year-Old Woman With Bipolar Disorder

• Theresa Cerulli, MD
• Tina Matthews-Hayes, DNP, FNP, PMHNP

Custom Around the Practice Video Series

Experts in psychiatry review the case of a 27-year-old woman who presents for evaluation of a complex depressive disorder.

EP: 1 . Patient Case #1: 27-Year-Old Woman With Bipolar Disorder

Ep: 2 . clinical significance of bipolar disorder, ep: 3 . clinical impressions from patient case #1, ep: 4 . diagnosis of bipolar disorder, ep: 5 . treatment options for bipolar disorder, ep: 6 . patient case #2: 47-year-old man with treatment resistant depression (trd), ep: 7 . patient case #2 continued: novel second-generation antipsychotics, ep: 8 . role of telemedicine in bipolar disorder.

Michael E. Thase, MD : Hello and welcome to this Psychiatric Times™ Around the Practice , “Identification and Management of Bipolar Disorder. ”I’m Michael Thase, professor of psychiatry at the Perelman School of Medicine at the University of Pennsylvania in Philadelphia, Pennsylvania.

Joining me today are: Dr Gustavo Alva, the medical director of ATP Clinical Research in Costa Mesa, California; Dr Theresa Cerulli, the medical director of Cerulli and Associates in North Andover, Massachusetts; and Dr Tina Matthew-Hayes, a dual-certified nurse practitioner at Western PA Behavioral Health Resources in West Mifflin, Pennsylvania.

Today we are going to highlight challenges with identifying bipolar disorder, discuss strategies for optimizing treatment, comment on telehealth utilization, and walk through 2 interesting patient cases. We’ll also involve our audience by using several polling questions, and these results will be shared after the program.

Without further ado, welcome and let’s begin. Here’s our first polling question. What percentage of your patients with bipolar disorder have 1 or more co-occurring psychiatric condition? a. 10%, b. 10%-30%, c. 30%-50%, d. 50%-70%, or e. more than 70%.

Now, here’s our second polling question. What percentage of your referred patients with bipolar disorder were initially misdiagnosed? Would you say a. less than 10%, b. 10%-30%, c. 30%-50%, d. more than 50%, up to 70%, or e. greater than 70%.

We’re going to go ahead to patient case No. 1. This is a 27-year-old woman who’s presented for evaluation of a complex depressive syndrome. She has not benefitted from 2 recent trials of antidepressants—sertraline and escitalopram. This is her third lifetime depressive episode. It began back in the fall, and she described the episode as occurring right “out of the blue.” Further discussion revealed, however, that she had talked with several confidantes about her problems and that she realized she had been disappointed and frustrated for being passed over unfairly for a promotion at work. She had also been saddened by the unusually early death of her favorite aunt.

Now, our patient has a past history of ADHD [attention-deficit/hyperactivity disorder], which was recognized when she was in middle school and for which she took methylphenidate for adolescence and much of her young adult life. As she was wrapping up with college, she decided that this medication sometimes disrupted her sleep and gave her an irritable edge, and decided that she might be better off not taking it. Her medical history was unremarkable. She is taking escitalopram at the time of our initial evaluation, and the dose was just reduced by her PCP [primary care physician]from 20 mg to 10 mg because she subjectively thought the medicine might actually be making her worse.

On the day of her first visit, we get a PHQ-9 [9-item Patient Health Questionnaire]. The score is 16, which is in the moderate depression range. She filled out the MDQ [Mood Disorder Questionnaire] and scored a whopping 10, which is not the highest possible score but it is higher than 95% of people who take this inventory.

At the time of our interview, our patient tells us that her No. 1 symptom is her low mood and her ease to tears. In fact, she was tearful during the interview. She also reports that her normal trouble concentrating, attributable to the ADHD, is actually substantially worse. Additionally, in contrast to her usual diet, she has a tendency to overeat and may have gained as much as 5 kg over the last 4 months. She reports an irregular sleep cycle and tends to have periods of hypersomnolence, especially on the weekends, and then days on end where she might sleep only 4 hours a night despite feeling tired.

Upon examination, her mood is positively reactive, and by that I mean she can lift her spirits in conversation, show some preserved sense of humor, and does not appear as severely depressed as she subjectively describes. Furthermore, she would say that in contrast to other times in her life when she’s been depressed, that she’s actually had no loss of libido, and in fact her libido might even be somewhat increased. Over the last month or so, she’s had several uncharacteristic casual hook-ups.

So the differential diagnosis for this patient included major depressive disorder, recurrent unipolar with mixed features, versus bipolar II disorder, with an antecedent history of ADHD. I think the high MDQ score and recurrent threshold level of mixed symptoms within a diagnosable depressive episode certainly increase the chances that this patient’s illness should be thought of on the bipolar spectrum. Of course, this formulation is strengthened by the fact that she has an early age of onset of recurrent depression, that her current episode, despite having mixed features, has reverse vegetative features as well. We also have the observation that antidepressant therapy has seemed to make her condition worse, not better.

Transcript Edited for Clarity

Dr. Thase is a professor of psychiatry at the Perelman School of Medicine at the University of Pennsylvania in Philadelphia, Pennsylvania.

Dr. Alva is the medical director of ATP Clinical Research in Costa Mesa, California.

Dr. Cerulli is the medical director of Cerulli and Associates in Andover, Massachusetts.

Dr. Tina Matthew-Hayes is a dual certified nurse practitioner at Western PA Behavioral Health Resources in West Mifflin, Pennsylvania.

The Week in Review: May 6-10

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Suicide and Other Deaths From Unnatural Causes in Bipolar Disorder

Four Myths About Lamotrigine

FDA Approves Fanapt for Mixed, Manic Episodes Associated With Bipolar I Disorder

An Update on Bipolar I Disorder

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Counseling Across the Lifespan: Prevention and Treatment

Student resources, case study questions.

CASE EXAMPLE

Allen is a 65-year-old who retired as a history teacher 10 years ago. He is coming to counseling at the insistence of his wife and adult children, although he states that he doesn’t think counseling can help him. He reports that his wife says he repeats things “constantly” and although he shares that he may say things “a few times” because she didn’t hear him, he does not believe that he does this “constantly” and does not really think it is a big problem. He also shares that his wife tells him he is very impatient, although he is dismissive of this concern, again saying he thinks he is “not that bad.” He does admit that he has been depressed in the past and that he has been having a difficult time more recently feeling any motivation or interest to do anything.

He expresses unhappiness because his wife recently retired from her full-time corporate position, but she continues to be very busy, continuing to work as a consultant and engaging in many activities with her friends. Allen, by comparison, reports that “all my friends are gone” and shares that although they are not deceased, they are spread out across the country where he does not have contact with any of them. Allen had looked forward to the time when his wife would retire, as he had expected that the two of them would spend more time together, travel, and enjoy retirement together.

Allen has been spending his time busying himself with household jobs, working on his own art, assisting his wife with her work projects, and planning their vacations. He enjoys a glass or two of wine with dinner and states that he is just a “social drinker.” He has experienced some times with sadness in the period of time since he retired but got through those times by focusing on his future hope about his wife retiring. At several points in the interview, Allen sighs and states, “I just feel like a total nothing.” He reports increasing disinterest in his previous interests and hobbies and that “I just can’t get interested in anything anymore.”

He admits that he has had some thoughts of suicide but then feels both ashamed and horribly guilty for how that would affect his family, which then serves to make him feel very sad. Allen says he is coming to counseling to see if the mental health provider can figure out what is wrong with him and admits that he is afraid he is “crazy.” On collateral consultation with Allen’s wife, it is apparent that Allen has minimized the intensity of his angry outbursts, and she admits that she has felt frightened by Allen’s outbursts.

DISCUSSION QUESTIONS

• What are the prominent clinical issues?
• What provisional diagnoses would be important to consider?
• What models discussed in the text would be useful?
• What other professional, medical, and/or social services may be important in this case?

IRIS MABRY-HERNANDEZ, MD, MPH, Medical Officer, U.S. Preventive Services Task Force, Agency for Healthcare Research and Quality

SUSAN J. CHING, DO, Preventive Medicine Resident, Uniformed Services University of the Health Sciences

Am Fam Physician. 2024;109(5):457-458

Related editorial:   Anxiety Screening Is Unlikely to Improve Mental Health Outcomes

Related USPSTF Clinical Summary:   Screening for Anxiety Disorders in Adults

Author disclosure: No relevant financial relationships.

A 34-year-old patient (gravida 2, para 2) presents for a well-woman examination and Papanicolaou smear. She feels healthy and has no significant medical history, aside from her uncomplicated pregnancies, which did not include postpartum depression or anxiety. She reports increased stress at home due to an upcoming move and some difficulty sleeping.

Case Study Questions

1 . According to the U.S. Preventive Services Task Force (USPSTF) recommendation, which one of the following is advised for this patient?

A. Screen for anxiety disorder.

B. Assess her anxiety in 6 months.

C. Refer her to an obstetrician-gynecologist for postpartum anxiety screening.

D. Recommend melatonin.

E. Refer her to a behavioral health professional for sleep management.

2 . According to the Diagnostic and Statistical Manual of Mental Disorders , 5th ed. (DSM-5), which of the following can be categorized as anxiety disorders?

A. Generalized anxiety disorder.

B. Obsessive-compulsive disorder.

C. Separation anxiety disorder.

D. Social anxiety disorder.

3 . Which one of the following populations should be screened for anxiety disorders, according to the USPSTF recommendation?

A. People already diagnosed with anxiety or another mental health disorder.

B. People younger than 18 years.

C. People older than 65 years.

D. People with no recognized signs or symptoms of anxiety disorders.

The correct answer is A . The USPSTF recommends screening all adults 19 to 64 years of age for anxiety disorder, including those who are pregnant and postpartum. The USPSTF notes there is little evidence for the ideal timing and frequency of anxiety screening for perinatal and general adult populations. 1 However, clinical judgment, particularly considering risk factors, comorbid conditions, and life events, can determine whether additional screening of high-risk patients is warranted. There is a lack of evidence on screening rates for anxiety disorders. Underdetection appears to be common. Patients with anxiety disorders may present with other concerns, such as sleep disturbances or somatic issues.

The correct answers are A, C, and D . The DSM-5 recognizes the following types of anxiety disorders: generalized anxiety disorder, social anxiety disorder, panic disorder, agoraphobia, specific phobias, separation anxiety disorder, selective mutism, substance or medication-induced anxiety disorder, anxiety disorder due to another medical condition, and anxiety not otherwise specified. 2 Obsessive-compulsive disorder is not considered an anxiety disorder.

The correct answer is D . The USPSTF recommendation statement applies to adults (defined as those 19 to 64 years of age), including people who are pregnant or postpartum, who do not have a diagnosed mental health disorder and are not showing recognized signs or symptoms of anxiety disorders. 2 For people 65 years or older, the USPSTF concludes that the evidence is insufficient to recommend for or against screening for anxiety disorders.

The views expressed in this work are those of the authors and do not reflect the official policy or position of the Uniformed Services University of the Health Sciences, the U.S. Department of Defense, or the U.S. government.

This PPIP quiz is based on the recommendations of the USPSTF. More information is available in the USPSTF Recommendation Statement and supporting documents on the USPSTF website ( https://www.uspreventiveservicestaskforce.org ). The practice recommendations in this activity are available at https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/anxiety-adults-screening .

O’Connor EA, Henninger ML, Perdue LA, et al. Anxiety screening: evidence report and systematic review for the US Preventive Services Task Force. JAMA. 2023;329(24):2171-2184.

Barry MJ, Nicholson WK, Silverstein M, et al. Screening for anxiety disorders in adults: US Preventive Services Task Force recommendation statement. JAMA. 2023;329(24):2163-2170.

This series is coordinated by Joanna Drowos, DO, contributing editor.

A collection of Putting Prevention Into Practice published in AFP is available at https://www.aafp.org/afp/ppip.

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