depression case study examples

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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Recurrent Major Depressive Disorder of a Young Woman

• Ian A. Cook , M.D.

Search for more papers by this author

This exercise is designed to test your comprehension of material relevant to this issue of Focus as well as your ability to evaluate, diagnose, and manage clinical problems. Answer the questions below to the best of your ability with the information provided, making your decisions as if the individual were one of your patients.

Questions are presented at “consideration points” that follow a section that gives information about the case. One or more choices may be correct for each question; make your choices on the basis of your clinical knowledge and the history provided. Read all of the options for each question before making any selections. You are given points on a graded scale for the best possible answer(s), and points are deducted for answers that would result in a poor outcome or delay your arriving at the right answer. Answers that have little or no impact receive zero points. At the end of the exercise, you will add up your points to obtain a total score.

Case Vignette

Brenda Madison is a 30-year-old multiracial female who was referred to you by her primary care physician for help with managing a recurrent depression that has been refractory to treatments thus far.

“I’ve been struggling with this depression for months, and nothing seems to be helping this time around,” the patient said when she first met you. Brenda reported two previous lifetime episodes of major depression, both with clear remissions: one at age 20 during her sophomore year in college at a large university (remitted with cognitive-behavioral therapy provided through campus counseling services) and a second at age 26 (remitted with citalopram from her primary care physician). “This time, it began with trouble sleeping, like it always does,” she said, “and then there was the anxiety, the pacing and fidgeting, and the crying.” She further revealed that she was experiencing decreased appetite and enough weight loss that her clothing all “felt baggy.” In your interview, she reported feeling “like I’m a loser, with this damn depression coming back again,” but denied having feelings of guilt. She acknowledged that she could still enjoy getting together with friends for an activity, “but the good feelings fade fast—a few hours later and I’m back down in the dumps.” She noted that she felt fatigued most days, “but with only a few hours of sleep a night, who wouldn’t?” She denied having suicidal thoughts or plans, adding, “I had a friend in college who overdosed on some pills, and she ended up needing a liver transplant. I would never want to inflict that on my family and friends.”

Consideration Point A.

Case vignette continues.

As you asked more questions about Brenda’s current episode, you learned that concentrating at work was difficult for her. She was lead Web designer for a local TV station’s online presence and reported it was challenging to keep the site up to date with the latest news. “It’s pretty noisy in here,” she said, tapping her head, “with worries about ‘am I doing this right?’ ‘did I forget something?’ ‘did I check these details?’ and on and on and on . It’s exhausting! It’s really hard to stay focused on the present.” In response to your question about what things may relieve her symptoms, she volunteered, “When I was in college, I tried to use marijuana and alcohol to calm myself down, but the weed made me too stoned to do well in class, and a couple of hours of being buzzed with alcohol was never worth it. And I didn’t want to go down that road, like my mother’s brother. He was in and out of rehab when I was a kid, and that messed up my cousins.” She confirmed that she would limit herself to one drink when getting together with friends, imbibing maybe twice a month, and she did not smoke marijuana or tobacco at present. She denied using any other substances.

Brenda denied ever having racing thoughts, a reduced need for sleep, periods of excessive goal-directed activity, or engagement in high-risk behaviors. She acknowledged that “sometimes I’m more creative than other times, but it’s just like a day of being ‘in the zone’ when the ideas flow effortlessly, and then on other days it can take forever to come up with something new and different.”

During the current episode, Brenda and her primary care physician had first tried citalopram; the final dose attained was 40 mg/day for eight weeks without any real symptomatic relief or changes on the ECGs done by her primary care physician. They then had tried sertraline and got to 100 mg/day for 12 weeks before Brenda was referred to you. She tolerated both medications adequately, with minimal gastrointestinal upset when first starting out and some reduction in libido.

When you asked about Brenda’s lifetime history, you learned that she was “pretty anxious” in social settings as a child, “but my parents pushed me to join the debate team in junior high and high school, and that helped me learn not to be so anxious when people are watching. ” She denied having gastrointestinal discomfort, sweaty palms, racing pulse, or other panic symptoms when being watched by others. Aside from her anxious worries, she denied experiencing other intrusive thoughts, hallucinations, compulsive rituals, or obsessions. She also denied having problems in childhood with interrupting others, waiting to take turns, climbing on furniture, concentrating at school, acting impulsively, or having difficulty listening to instructions or organizing tasks; if anything, she said, she had been well organized and effective in activities throughout her life, except during the periods of depression.

When recounting her medical history, the patient denied having major medical conditions. During your evaluation, Brenda reported taking sertraline at 100 mg/day and oral contraceptive pills.

Brenda had learned during a prior depressive episode to self-monitor her symptoms with the nine-item Patient Health Questionnaire (PHQ-9) ( 1 ) and brought in a spreadsheet graph showing that her symptoms had not varied much with either prior medication trial, although her score had improved slightly, from 19 prior to starting sertraline to 16. Still, her score was indicative of a moderately severe symptom burden.

Brenda was pleasant and cooperative with the interview, casually attired in a dress with bold colors. Mild psychomotor agitation was noted during the evaluation, as she crossed and uncrossed her legs and fidgeted with her hands. Eye contact was adequate. Speech was of a normal rate, with some monotonous prosody but at normal volume. Affect was fatigued and drained. She characterized her mood as “pretty sad today.” Her thought process was generally linear and coherent. Her thought content was without hallucinations, delusions, or current suicidal or homicidal intent. Cognitively, she was awake; alert; and oriented to self, place, date, and circumstances. Her memory registration was intact with three out of three stimuli, and her recall after delay was three out of three items, although this took some obvious mental effort. She recalled the prior six U.S. presidents without difficulty. Her interpretation of similarities between objects was appropriately abstract (apple/orange = “fruit”; hammer/screwdriver = “tools”). Her insight was good, in that she recognized that she could benefit from effective care. Her judgment was also currently good, in that she was open to considering all options for treatment despite the failure of recent treatment trials to help. Neurologically, her gait, arm swing, turning, stride length, and rapidly alternating movements were all normal. You detected no focal neurological deficits.

Consideration Point B.

In your discussion of the treatment options, the patient expressed that the most acceptable option to her was a trial of a higher dose of sertraline, rather than adding or switching to something new. You and Brenda agreed to increase her dose to 150 mg/day for two weeks and then go to 200 mg/day, as tolerated.

She returned for follow-up after two and four weeks and reported that she had experienced some clearer improvement in symptoms (less crying, better sleep) but was still experiencing a lot of inner agitation and anxiety. Her PHQ-9 score has decreased to 10.

Brenda was open to hearing your recommendations for modifications to the treatment plan, as she was still experiencing moderate symptom burden and trouble functioning at work.

Consideration Point C.

Case vignette concludes.

The patient was most interested in options that involved adding a nonpharmacologic treatment, given her past and current experiences with medication. Brenda had read a lot about rTMS online but believed she would not be able to take time off from work during the day to travel to the nearest center for treatment: “It sounds good, but I just can’t be gone from work that much—I’m already working from early morning ’til nighttime because ‘news happens,’ as we say at the station.” She thought that MBCT resonated better with what she perceived as her issues with “a busy mind, sad thoughts, and worries about the future and past.” You referred her to an MBCT therapist who ran an evening group on Sundays, which fit well with the patient’s weekly schedule. She continued sertraline at 200 mg/day.

The patient reported by phone after two weeks of MBCT that her symptoms had continued to decrease, and at an in-office visit after four weeks of therapy, her PHQ-9 score had declined to 6. After completing the eight-week course of MBCT group therapy, Brenda reported, “I’m myself again,” and she was eager to continue work with you to prevent a recurrence. “I’ve read about recurrence online; I am not thrilled with this, but the odds seem pretty strong that I’ll have another episode at some point, and I’d like to do a lot of living before that happens.” You reinforced the value of her own observation that sleep disturbance had been an early symptom in all three of her episodes and reminded her of her skills with self-monitoring using the PHQ-9. You discussed the value of MBCT practices in preventing relapse and the available data about maintenance medication. You scheduled her for a follow-up visit in three months with the understanding that she could always call for an earlier appointment if her symptoms started to return.

Answers: Scoring, Relative Weights, and Comments

Consideration point a, consideration point b, consideration point c.

Dr. Cook reports that his active biomedical device patents are assigned to the University of California. He has been granted stock options in NeuroSigma, the licensee of some of his inventions, and he currently serves as its chief medical officer and senior vice president. From 1994 to 2008, he served on the Steering Committee on Practice Guidelines of the American Psychiatric Association, and from 2002 to 2008 he served on its executive committee.

1 Kroenke K, Spitzer RL, Williams JB : The PHQ-9: validity of a brief depression severity measure . J Gen Intern Med 2001 ; 16:606–613 Crossref ,  Google Scholar

2 American Psychiatric Association : Diagnostic and Statistical Manual of Mental Disorders , 5th ed. Arlington, VA, American Psychiatric Publishing, 2013 Crossref ,  Google Scholar

3 American Psychiatric Association : Practice Guideline for the Treatment of Patients With Major Depressive Disorder , 3rd ed. Washington, DC, American Psychiatric Publishing, 2010 Google Scholar

4 Unützer J, Katon W, Callahan CM, et al. : Collaborative care management of late-life depression in the primary care setting: a randomized controlled trial . JAMA 2002 ; 288:2836–2845. Available at doi: 10.1001/jama.288.22.2836 Crossref ,  Google Scholar

5 Trivedi MH, Rush AJ, Wisniewski SR, et al. : Evaluation of outcomes with citalopram for depression using measurement-based care in STAR*D: implications for clinical practice . Am J Psychiatry 2006 ; 163:28–40. Available at doi: 10.1176/appi.ajp.163.1.28 Crossref ,  Google Scholar

6 Nierenberg AA, Fava M, Trivedi MH, et al. : A comparison of lithium and T 3 augmentation following two failed medication treatments for depression: a STAR*D report . Am J Psychiatry 2006 ; 163:1519–1530, quiz 1665. Available at doi: 10.1176/ajp.2006.163.9.1519 Crossref ,  Google Scholar

7 Kennedy SH, Milev R, Giacobbe P, et al. : Canadian Network for Mood and Anxiety Treatments (CANMAT) clinical guidelines for the management of major depressive disorder in adults. IV. Neurostimulation therapies . J Affect Disord 2009 ; 117(Suppl 1):S44–S53. Available at doi: 10.1016/j.jad.2009.06.039 Crossref ,  Google Scholar

8 Papakostas GI, Shelton RC, Smith J, et al. : Augmentation of antidepressants with atypical antipsychotic medications for treatment-resistant major depressive disorder: a meta-analysis . J Clin Psychiatry 2007 ; 68:826–831 Crossref ,  Google Scholar

9 Kuyken W, Hayes R, Barrett B, et al. : Effectiveness and cost-effectiveness of mindfulness-based cognitive therapy compared with maintenance antidepressant treatment in the prevention of depressive relapse or recurrence (PREVENT): a randomised controlled trial . Lancet 2015 ; 386:63–73. Available at doi: 10.1016/S0140-6736(14)62222-4 Crossref ,  Google Scholar

10 Carpenter LL, Janicak PG, Aaronson ST, et al. : Transcranial magnetic stimulation (TMS) for major depression: a multisite, naturalistic, observational study of acute treatment outcomes in clinical practice . Depress Anxiety 2012 ; 29:587–596. Available at doi: 10.1002/da.21969 Crossref ,  Google Scholar

• Cited by None

Successfully Overcoming Depression: A Case Study

By: Lauren McKinnon

When I look back at how my life used to be, it is almost impossible to believe the transformation.

Overcoming depression has been a long process, but it’s been worth it, because today I live my life as the person I know I as meant to be. It’s a vast difference from the miserable alcoholic that I once was.

How it started

I was born in Balham, London, where my family lived the first few years of my life. I remember being about three and my favourite thing being going to the park with my mother. She’d sit on a bench and I would run to a huge tree that was in the middle of the grass, wave at her, then run back, and she’d give me a big hug. Then I’d do it all over again.

I guess I thought she’d always be there for me to run back to. But that park was actually the very place she abandoned me.

She just left me on a park bench. I’ll never know how long I sat there before a family friend came to collect me. I wasn’t scared at the time, I knew the woman who came and was happy to go with her, and in my innocent child’s mind I had no reason to doubt my Mum. It simply it never occurred to me that she had left me.

I can’t remember when it hit me that she wasn’t coming back. It was a slow realisation because, as odd as it still seems to me now, no one mentioned her. I was returned home to my father and it was as if suddenly my mother didn’t exist. For years, there was just complete silence regarding her disappearance, and if I dared ask the subject was changed. And as my mother was from France, we didn’t really have much contact with her family, and if we did hear from them they, too. pretended she didn’t exist.

Like all children who are victims of an adult decision they are not made part of but suffer from, I blamed myself for what had happened. By the time I went to school I felt certain of two things; my mum had left me because I was bad, and because she didn’t love me. Yet I grew up holding tight to the dream that she would come back and prove me wrong.

But I never saw her again. To this day I have no idea why she left.

Sadly, my mother’s abandonment is only a small part of the story about how I ended up a depressed, anxious adult with no confidence. Because the worst thing about her leaving was that I was left with my father. Although I was given no reasons for my mother’s leaving, my father made good use of my mother’s disappearance as an excuse for anything and everything. I was a very timid and nervous child and whenever teachers would express their concern, my dad would automatically lay the blame on my mother. “She’s like that because her mother left her,” he was fond of saying. And when he was being critical of me it was always, “It’s no wonder your mum left you”. Or, “No one will ever love you – your mother never did”. And then there was, “You’re so like your mother”.

And I wonder why I blamed myself!

By: Lisa Cyr

I didn’t tell anyone about the things he said. He was a very charming man, admired by others for raising his kids alone (not common in the 1970s), so who would have believed me anyway? Who would have known that he was a manipulative man who thrived on demeaning and degrading others?

He had a particular hatred of women. I remember being told off by a primary school teacher because I was trying to find a word in the dictionary, a name that my father called me . I had been looking at words beginning with ‘h’ and asked my teacher how to spell ‘whore’. She thought I was being rude and I didn’t dare tell her the truth.

As I got older, it became my looks my father judged me more and more on. As a teenager he was obsessed with my having a waist that was 22 inches, but mine was only 23 inches, and it wasn’t good enough. As for schoolwork, if I got 98%, he would focus on the 2% that I didn’t get.

Controlling is an understatement. It shocks me now the way my father monitored me, but at the time I didn’t know any different.

Everything was part of a deal. If I wanted to eat a certain food then I had to do something for him. Even when I moved out he would turn up wherever I was living and refuse to leave. Even when I was an he would ring up the manager wherever it was I worked (particularly when I was working as a social worker) and tell them what a dreadful person I was and try to get me sacked. In fact I remember the first job I got after I finished my degree. I was so excited. He asked me how much they would be paying me, and when I told him, he replied, “You’re not worth that”.

As for any attempt I made to find love? My father would try to sabotage any relationship I attempted through intimidation, making the man’s life misery with threats and turning up uninvited to sit outside their house. It sounds like a movie writing it, but it was honestly my life.

In summary, I grew up fearing everything and everybody, believed I was worthless and unlovable. The foundations for a twenty-five year struggle with depression were firmly in place.

Being diagnosed as depressed

When I was 18 I went back and told him that I felt like killing myself. He acted immediately and was very supportive, and I was admitted to hospital for a few days and put on anti-depressants. Looking back, and hearing other people’s stories, I do feel I really have been very fortunate to have had sympathetic doctors all of my life.

Like many who suffer depression, mine was an ongoing condition that worsened during stressful or challenging life events. During those episodes I was offered short-term psychotherapy and my medication was increased. This relieved my anxieties and raised my sense of well-being for a while, but the depths of the scars to my emotional self were going to require a much more intensive intervention to come.

The effects of depression on my adult life

As an adult, on the outside I appeared to be functioning as a successful, carefree professional. I was awaeded a BA Honors in Applied Social Science (Psychology and Social Policy) and a CQSW (Certificate in Qualification of Social Work) and worked for 15 years as a children and families social worker in England and Germany. It was like I could easily help others but could not help myself.

Because the reality was that I was really a very unhappy, troubled, isolated woman. Depression for me was like looking out from the inside of a goldfish bowl. I could see and hear everyone, but I couldn’t connect.

The abandonment by my mother combined with the criticism I put up with from my father left me severely under confident, and with a fear of rejection that progressed into a fear of attachment . In other words, I couldn’t do intimacy . I just couldn’t develop relationships on anything more than a superficial level.

Even in friendships I always maintained a distance. At school and college I had a few close friends but I would often take time out to be on my own because I just couldn’t bear to be around people, especially if they seemed happy and were easily getting on with their lives. It just made me so aware that I secretly was neither.

As for intimate relationships, I really struggled. Even when my friends were getting married and settling down, I was still avoiding any commitment at all. To be fair, I was briefly engaged aged 20, but I bailed because even though I loved him I told myself there must be more to life and that the marriage would just fail. That was my pattern; I’d get into a serious relationship, convince myself it would all go wrong, and end it. Then I gave up on even trying to be serious and moved into a pattern of consciously having superficial relationships or dating men who were upfront in not wanting commitment. Instead of close relationships I turned to alcohol…

Alcoholism and depression

By: jenny downing

My dad once remarked that he would rather I got pregnant than drunk. I was around 14 at the time and looking for any opportunity to go against him, and so when I got the opportunity to try wine at a friends’ house I didn’t need persuading. I loved it from the first sip.

When I was legally old enough to buy drink for myself, my dad knew I was hooked. He hated it. But I was an adult and he could do nothing about it. I loved that it upset him.

Unfortunately, in my attempt to get my own back on him, I ended up abusing drink and becoming dependent. He never knew that I was drinking excessively before he died, but by the time he did die I couldn’t give up even though I wanted to.

I see now that alcohol was my way to numb my emotional pain and feel confident. By the time I was in my twenties I regularly spent whole weekends not talking to anyone, preferring to get drunk, comfort eat and detach from reality. Friends did notice and were not at all surprised when I did eventually have a complete breakdown.

Inevitably the calming, soothing effects of occasional alcohol ceased . Alcohol is of course a depressant, so rather than alleviating my symptoms it began to make them much worse. But it was too late, I couldn’t stop – I had crossed the line into dependency.

Looking back I can see there was really never anything social about my drinking – I always drank to get drunk. I drank regularly for five years in increasing amounts, and eventually I was drinking every day and night, from first thing on waking to the last thing I did before I went to sleep.

Alcohol took me from being depressed to being suicidal. I looked terrible – my eyes were always bloodshot, I reeked of booze, I put on a couple of stone and everything ached. In the last couple of years of my alcoholism I was taking more and more time off work, avoiding friends and generally hiding from the world.

There were two major events that led to my eventual breakdown. First was the decision to search for my mother when I was 22. As agonising as it was, I had prepared myself for the fact that she would have another family, so that I was ready to deal with. I managed to find her next husband. It turned out though she hadn’t had any further kids with him, although he had had a daughter of his own.

But who could have prepared me to find out that my own mother had told everyone that her daughter, aka me, had been killed in a car crash? That she would have tried to erase me from existence?

The crazy thing was that she had abandoned her second family without a trace, too.

I suppose hearing that she had told others I didn’t exist wasn’t enough to stop me, as I did ask Salvation Army for help tracing her (at the time they were the biggest organisation to trace family members). Unfortunately if they trace someone and that person says they don’t want to be contacted by whoever is looking for them, the Salvation Army can’t give away any details. So they weren’t allowed to tell me for definite if they had found her, but I am fairly certain they did and she didn’t want to have contact with me or know about me.

The second event that knocked me down was when my father died unexpectedly when I was 27. I’d always believed that his death would mean instant emotional healing and freedom, but instead I found that my depression intensified to a much deeper and darker level than ever before.

This all led to me eventually being off work for several months, getting into terrible debt , drinking very heavily, and finally getting dumped by the man I was with. And that all led to an alcohol induced-suicide attempt and voluntary admission to a psychiatric ward where I stayed for several weeks, because amongst all that I had lost was my will to live.

Getting my life back

Admittedly, being in the hospital was pretty scary at first. They took me off all medication and what I remember most was crying for hours on end. But the nursing staff was kind, understanding, patient and encouraging. I was surprised at the amount of professionals who were in there with me – a musician, a professor, a midwife. I guess I had my own set of stigmas about depression.

After my hospital stay I was fortunate enough to be offered a six-month spot in residential rehab. Gradually I confronted my past and learnt not only to accept what had happened, but to replace my mistaken perceptions with the truth. A faith-based 12-step programme of all women, it was all group work and very intense and hard. But it was what I needed. Reclaiming my faith also allowed me to come to a place of acceptance and forgiveness .

The upside to depression

Whilst depression had brought me to the point of giving up, it was also the catalyst for my healing. It gave me the opportunity to work through my shame and to grasp the truth that I had the choice within myself to choose my life instead of live as a prisoner of my past. I wasn’t unlovable and inadequate. I was powerful.

Living my life as the person I was meant to be

My recovery has continued for many years since I left hospital and rehab. Sixteen years on, I am still on my journey. Learning how to love myself and then love someone else was a big part of my healing process, as was learning how to forgive.

Today I take care of myself physically and emotionally. I try to eat healthily, exercise regularly and get enough sleep . No matter how busy I am I always find a few minutes of serenity. Sometimes that’s in a prayer, or music, or reading a book. I’m also am mindful of those triggers which may jeopardise my mental health or my sobriety, such as confrontation or fatigue.

I can honestly now say I love myself and my life . It is a life I share with great friends, inspiring colleagues, a wonderful husband (we met six months after I left rehab) as well as two amazing daughters who constantly inspire me to keep well and enjoy myself. It’s good to be me.

Are you depressed? A few words of advice

If you are tired of feeling hopeless and helpless then it’s time to reach out and seek help (you might want to start by reading a comprehensive guide to depression and resources available ). Whoever you are and whatever your circumstances, it is possible to overcome those events that underlie your symptoms and make the transition to long-term restoration. With the right support you can learn to overcome your past, embrace who you are today, and think positively about tomorrow. You deserve it.

Thank you for this article. While reading it, I began to walk through my own life and struggles. Reading this helped me have a framework that I am not alone and I am not helpless. Reflecting on some of the memories that popped up while reading, I was reminded of the numbness and silence and sense of disconnection that I experienced from my childhood into my teenage years and now. This article has been such an encouragement to honor the ways in which I have grown and changed and the ways in which I have learned to seek help and be more self-aware. Most definitely it has helped in understanding that I am not as strange as I once believed because of my past experiences

Hi Kyra, we are so glad that it was helpful. And we assure you are far, far from alone. So many of us have a complicated past and suffer depression, but feel we have to pretend things are fine to those around us. As for helpless, you sound very self aware and reflective, and it’s wonderful you have learned to seek help. We wish you ongoing courage in the journey! Best, HT.

The article is so encouraging.Thank you for sharing.

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Chief Complaint

“I don’t want to live. I just can’t take it anymore.”

History of present illness

Ashley is a 14 year old white female, who was brought to the emergency room by her step-father after mentioning that she was having suicidal ideation. Ashley has a pertinent medical history of cutting that began at the age of 12. She reports that she has begun “feeling down” since the beginning of her freshman year in high school, which was approximately 3 months ago. She states that she “feels down” every day. “I just feel worthless.” She reports that she began having intermittent feelings of self harm approximately 2-3 weeks ago. Ashley does not currently have a plan on how she would follow through with harming herself. She denies homicidal ideation. She denies having a history of depression. She states that she hasn’t been able to concentrate as well lately. She also reports that she isn’t sleeping much at night and has lost 15 pounds in two months. “I have a hard time at volleyball practice and with my school work because I don’t have any energy at all.” Ashley reports that she feels safe at home in her environment. Her biological mother is not present as she is at home with a younger sibling. 

Past medical history

• Cutting, began at age 12
• Left knee anterior cruciate ligament tear, October 2013
• Recurrent otitis media as a toddler
• Chronic strep throat
• Current on routine immunizations
• Gardasil x 2, last injection was September 2015. Last of the series is due February 2016

Past surgical history

• Wisdom teeth extraction, June 2014
• Bilateral eustachian tubes, March  2000
• Tonsillectomy and adenoids, November 2002
• Bilateral eustachian tubes removed, February 2003
• Left knee anterior cruciate ligament repair, July 2014

Pertinent family history

• Biological mother is 40 years old, alive and healthy
• Biological father is 42 years old, alive but has not been in contact with Ashley for the last 10 years
• Half sister age 5, alive and healthy
• No known family history of depression

Pertinent social history

• Full time high school student
• Participates on the freshman volleyball team
• No illicit drug use
• No etoh use
• Amoxicillin (skin rash as a child)
• Bicillin L-A (skin rash as a child)
• Norco (nausea and vomiting)
• Phenergan (hives)

Medications

• Tylenol and/or ibuprofen prn

Focused physical exam

• Lungs are clear to auscultation bilaterally
• Well groomed, skin pink, warm and dry
• Respirations easy and non-labored
• Vital signs are within normal limits
• Avoids eye contact
• Verbalizes anger that her step-father “made me come here”
• Healed scars noted to bilateral wrists (horizontal in nature)
• Recent superficial self-inflicted cuts to pt’s upper bilateral thighs
• Last menstrual period 1 one week ago

Photo credit: http://hecticparents.com/tag/depression/

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• v.17(1); 2022 Mar 28

Case scenario: Management of major depressive disorder in primary care based on the updated Malaysian clinical practice guidelines

Uma visvalingam.

MBBS (MAHE), Master of Medicine (Psychiatry) (UKM), Department of Psychiatry and Mental Health, Hospital Putrajaya, Putrajaya, Malaysia

Umi Adzlin Silim

MD (UKM), M. Med (Psychiatry) (UKM), Department of Psychiatry and Mental Health, Hospital Serdang, Serdang, Selangor, Malaysia

Ahmad Zahari Muhammad Muhsin

MB., BCh., BAO (UCD, Ireland), M. Psych Med (Malaya), Department of Psychological Medicine, Faculty of Medicine Universiti Malaya, Kuala Lumpur, Malaysia

Firdaus Abdul Gani

MBBS (Malaya) M.Med (Psy) (USM) CMIA (NIOSH), Department of Psychiatry and Mental Health, Hospital Sultan Haji Ahmad Shah, Temerloh, Pahang, Malaysia

Noormazita Mislan

MB, BCh, BAO (Ireland), M Med. (Psychiatry) (UKM), Department of Psychiatry and Mental Health, Hospital Tuanku Ja'afar, Seremban, Negeri Sembilan, Malaysia

Noor Izuana Redzuan

MBBS (Malaya), Dr in Psychiatry (UKM), Department of Psychiatry and Mental Health, Hospital Raja Permaisuri Bainun, Ipoh, Perak, Malaysia

Peter Kuan Hoe Low

MB, BCh, BAO (Ireland), M.Psych Med (UM), Department of Psychiatry and Mental Health, Hospital Kuala Lumpur, Kuala Lumpur, Malaysia

Sing Yee Tan

MBBS (Malaya), M.Med (Family Med) (UM), Klinik Kesihatan Jenjarom, Jenjarom Selangor, Malaysia

Masseni Abd Aziz

MD (USM) M Med (Fammed) USM, Klinik Kesihatan Umbai, Merlimau, Melaka, Malaysia

Aida Syarinaz Ahmad Adlan

MBBS (Malaya), M. Psych Med (UM), PostGrad. Dip. (Dynamic Psychotherapy) (Mcgill University), Department of Psychological Medicine, Faculty of Medicine, Universiti Malaya Kuala, Lumpur, Malaysia

Suzaily Wahab

MD (UKM), MMed Psych (UKM), Hospital Canselor Tuanku Muhriz UKM, Kuala Lumpur, Malaysia

Aida Farhana Suhaimi

B. Psych (Adelaide), M. Psych (Clin. Psych) (Tasmania), PhD (Psychological Medicine) (UPM), Department of Psychiatry and Mental Health, Hospital Putrajaya, Putrajaya, Malaysia

Nurul Syakilah Embok Raub

BPharm (Hons) (CUCMS), MPH (Malaya), Pharmacy Enforcement Branch, Selangor Health State Department, Shah Alam, Selangor, Malaysia

Siti Mariam Mohtar

BPharm (UniSA), Malaysian Health Technology Assessment Section (MaHTAS), Ministry of Health Malaysia, Putrajaya, Malaysia

Mohd Aminuddin Mohd Yusof

MD (UKM), MPH (Epidemiology) (Malaya), Malaysian Health Technology Assessment Section (MaHTAS), Ministry of Health Malaysia, Putrajaya, Malaysia, Email: moc.oohay@rd2ma

Major depressive disorder (MDD) is a common but complex illness that is frequently presented in the primary care setting. Managing this disorder in primary care can be difficult, and many patients are underdiagnosed and/or undertreated. The Malaysian Clinical Practice Guidelines (CPG) on the Management of Major Depressive Disorder (MDD) (2nd ed.), published in 2019, covers screening, diagnosis, treatment and referral (which frequently pose a challenge in the primary care setting) while minimising variation in clinical practice.

Introduction

MDD is one of the most common mental illnesses encountered in primary care. It presents with a combination of symptoms that may complicate its management.

This mental disorder requires specific treatment approaches and is projected to be the leading cause of the disease burden in 2030. 1 Patients experiencing this ailment are at elevated risk for early mortality from physical disorders and suicide. 2 In Malaysia in particular, MDD contributes to 6.9% of total Years Living with Disability. 3

Ensuring full functional recovery and prevention of relapse makes remission the targeted outcome for treatment of MDD. In contrast, nonremission of depressive symptoms in MDD can impact functionality 4 and subsequently amplify the economic burden that the illness imposes.

About the new edition

The highlights of the updated CPG MDD (2nd ed.) are as follows:

• emphasis on psychosocial and psychological interventions, particularly for mild to moderate MDD
• inclusion of all second-generation antidepressants as the first-line pharmacotherapy
• introduction of new emerging treatments, ie. intravenous ketamine for acute phase and intranasal esketamine for next-step treatment/treatment-resistant MDD
• improvement in pre-treatment screening and monitoring of treatment
• integration of mental health into other health services with emphasis on collaborative care
• addition of 2 new chapters on special populations (pregnancy and postpartum, chronic medical illness) and table on safety profile of pharmacotherapy in pregnancy and breastfeeding
• comprehensive, holistic biopsychosocial-spiritual approaches addressing psychospirituality

Details of the evidence supporting the above statements can be found in Clinical Practice Guidelines on the Management of Major Depressive Disorder (2nd ed.) 2019, available on the following websites: http://www.moh.gov.my (Ministry of Health Malaysia) and http://www.acadmed.org.my (Academy of Medicine). Corresponding organisation: CPG Secretariat, Health Technology Assessment Section, Medical Development Division, Ministry of Health Malaysia; contactable at ym.vog.hom@aisyalamath .

Statement of intent

This is a support tool for implementation of CPG Management of Major Depressive Disorder (2nd ed.).

Healthcare providers are advised of their responsibility to implement this evidence-based CPG in their local context. Such implementation will lead to capacity building to ensure better accessibility of psychosocial and psychological services. More options in pharmacotherapy facilitate flexibility in prescribing antidepressants among clinicians. Further integration of mental health into other health services, upscaling of mental health service development in perinatal and medical services, and enhancement of collaborative care will incorporate holistic approaches into care.

Case Scenario

Tini is a female college student aged 24 years old. She comes to the health clinic accompanied by a friend and complains of several symptoms that she has experienced over the past 4 weeks. She reports:

• difficulty falling asleep, feeling tired after waking up in the morning and experiencing headaches
• difficulty staying focused during classes. These symptoms have led to deterioration in her study and prompted her to seek advice from the doctor.

Will you screen her for depression?

Yes, because the patient presents with multiple vague symptoms and sleep disturbance. 5 (Refer to Subchapter 2.1, page 3 in CPG.)

What tools are used to screen for depression?

Screening tools for depression are:

• Beck Depression Inventory (BDI)
• Depression Anxiety and Stress Scale (DASS)
• Patient Health Questionnaire-9 (PHQ-9)
• Hospital Anxiety and Depression Scale (HADS)
• Whooley Questions

Screening for depression using Whooley Questions in primary care may be considered in people at risk. 5

( Refer to Subchapter 2.1, pages 3 and 4 in CPG. )

• “During the past month, have you often been bothered by feeling down, depressed or hopeless?”
• “During the past month, have you often been bothered by having little interest or pleasure in doing things?

The doctor decides to use Whooley Questions, and Tini answers “yes” to both questions.

How would you proceed from here to further assess for depression?

Assessment of depression consists of:

• detailed history taking (Refer to Subchapter 2.2, page 4 in CPG.)
• mental state examination (MSE), including evaluation of symptom severity, presence of psychotic symptoms and risk of harm to self and others
• physical examination to rule out organic causes
• investigations where indicated — biological and psychosocial investigations

Upon further assessment, Tini reveals that she feels overwhelmingly sad. She is frequently tearful and reports feeling excessively guilty, blaming herself for not performing well enough in her studies. Her postings on social media have been revolving around themes of self-defeat. Despite feeling low, she still strives to attend classes and complete her assignments. However, her academic performance has exhibited a marked deterioration. There is no history to suggest hypomanic, manic or psychotic symptoms. She denies using any illicit substances or alcohol. Her menstrual cycle is normal and does not correspond to her mood changes.

MSE reveals a young lady who appears to be in distress. Rapport is easily established, but her eyes are downcast. Her speech is relevant, with low tone. She describes her mood as sad; she is tearful while talking about her poor results, with appropriate affect. She harbours multiple unhelpful thoughts, eg. “I’m a failure” and “I’m useless”. She exhibits no suicidal ideations, delusions or hallucinations. Her concentration is poor, and insight is partial.

Physical examination reveals no recent selfharm scars, and examination of other systems is unremarkable. Biological investigations such as full blood count and thyroid function test are within normal range. Corroborative history is taken from accompanying person to verify the symptoms.

How would you arrive at the diagnosis and severity?

Diagnosis of depression can be made using the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) or the 10th revision of the International Statistical Classification of Disease and Related Health Problems (ICD-10). 5 (Refer to Appendix 3 and 4, pages 73-76 in CPG.) 6 , 7

In the last 2 weeks, Tini has been experiencing:

• poor concentration
• excessive guilt

These symptoms have caused marked impairment in her academic functioning. Thus, she is diagnosed as having MDD with mild to moderate severity in acute phase and can be treated in primary care.

Severity according to DSM-5

• Five or more symptoms are present, which cause distress but are manageable
• Result in minor impairment in social or occupational functioning
• Symptom presentation and functional impairment between 2 severities
• Most of the symptoms are present with marked impairment in functioning

What can be offered to this patient?

Psychosocial interventions and psychotherapy with or without pharmacotherapy. 5 (Refer to Algorithm 1. Treatment of Major Depressive Disorder, page xii in CPG)

ALGORITHM 1. TREATMENT OF MAJOR DEPRESSIVE DISORDER

Psychosocial interventions include the following:

• symptoms and course of depression
• biopsychosocial model of aetiology
• pharmacotherapy for acute phase and maintenance
• drug side effects and complications
• importance of medication adherence
• early signs of recurrence
• management of relapse and recurrence
• counselling/non-directive supportive therapy - aims to guide the person in decision-making and allow to ventilate their emotions
• relaxation - a method to help a person attain a state of calmness, eg. breathing exercise, progressive muscle relaxation, relaxation imagery
• peer intervention - eg. peer support group
• exercise - activity of 45-60 minutes per session, up to 3 times per week, and prescribed for 10-12 weeks

(Refer to subchapter 4.1.1, pages 9-12 in CPG.)

However, the doctor may choose to start antidepressant medication as an initial measure in some situations, for example:

• past history of moderate to severe depression
• patient’s preference
• previous response to antidepressants
• lack of response to non-pharmacotherapy interventions

What are the types of psychotherapy that can be offered in mild to moderate MDD, and what factors should be considered before starting psychotherapy?

Psychotherapy for the treatment of MDD has been shown to reduce psychological distress and improve recovery through the therapeutic relationship between the therapist and the patient.

In mild to moderate MDD, psychosocial intervention and psychotherapy should be offered, based on resource availability, and may include but are not restricted to the following 5 :

• Cognitive behavioural therapy (CBT)
• Interpersonal therapy
• Problem-solving therapy
• Behavioural therapy
• Internet-based CBT

The type of psychotherapy offered to the patient will depend on various factors, including 5 :

• patient preference and attitude
• nature of depression
• availability of trained therapist
• therapeutic alliance
• availability of therapy

(Refer to Subchapter 4.1.1, page 17 in CPG.)

After shared-decision making, Tini receives psychosocial intervention, that includes:

• psychoeducation
• non-directive supportive therapy
• lifestyle modification, e.g. restoring healthy sleep hygiene and adopting healthy eating habits
• relaxation, e.g. progressive muscle relaxation, imagery and breathing technique

Tini will benefit from CBT due to her multiple unhelpful thoughts, for example, “I’m a failure” and “I’m useless”.

CBT helps improve understanding of the impact of a person’s unhelpful thoughts on current behaviour and functioning through cognitive restructuring and a behavioural approach. By learning to correctly identify these negative thinking patterns, Tini can then challenge such thoughts repeatedly to replace disordered thinking with more rational, balanced and healthy thinking. However, she is not able to commit to regular sessions of CBT due to a demanding academic schedule and upcoming final examination. After further discussion, Tini opts for pharmacotherapy.

What are the options for pharmacotherapy?

The choice of antidepressant medication will depend on various factors, including efficacy and tolerability, patient profile and comorbidities, concomitant medications and drug-drug interactions, cost and availability, as well as the patient’s preference. Taking into account efficacy and side effect profiles, most second-generation antidepressants, namely selective serotonin reuptake inhibitors (SSRIs), serotonin noradrenaline reuptake inhibitors (SNRIs), noradrenergic and specific serotonergic antidepressants (NaSSAs), melatonergic agonist and serotonergic antagonist, noradrenaline/dopamine-reuptake inhibitors (NDRIs) and a multimodal antidepressants may be considered as the initial treatment medication, while the older antidepressants such as tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs) may be subsequently considered for a later choice. 5 (Refer to Subchapter 4.1.2, page 18 in CPG.)

Since Tini is being seen at a health clinic, the widely available SSRIs are sertraline and fluvoxamine. Sertraline has fewer gastrointestinal side effects and drug interactions compared with fluvoxamine. TCAs are not the treatment of choice due to prominent side effects. Tini is put on tablet sertraline 50 mg daily and educated on the anticipated onset of response and possible side effects. Short-term and low dose benzodiazepine, eg. alprazolam or lorazepam, may be offered as an adjunct to treat her insomnia. (Refer to Subchapter 4.1.2, page 24 in CPG.) Tini is given tablet lorazepam 0.5 mg at night for 2 weeks. She is asked to come in for a follow-up.

What is her follow-up and monitoring plan?

The following should be done:

(Refer to Appendix 8, page 81 in CPG.)

• Titrate up by 50 mg within 1-2 weeks (but may be done earlier based on clinical judgement)
• Monitor biological parameters if indicated (Refer to Table 5. Ongoing monitoring during treatment of MDD, page 57 in CPG.)

During follow-up at 2 weeks, she is noted to show partial response despite being compliant with good tolerability. She is not experienceing nausea, diarrhoea, headache, constipation, dry mouth or somnolence. She reports being less tearful. Her sleep and ability to focus have improved. Tini has started engaging in regular exercise and practises relaxation, especially before sleep. Tablet sertraline is optimised to 100 mg daily, while tablet lorazepam is reduced to 0.5 mg PRN.

Tini is reviewed again within 4 weeks; during this subsequent follow-up, she achieves full remission. Tablet lorazepam is stopped. She is then advised to continue tablet sertraline for at least 6-9 months in maintenance phase. The aim in this phase is to prevent relapse and recurrence of MDD. In view of her young age, no comorbidities and good tolerability, repeated electrolyte monitoring is not indicated.

(Refer to Algorithm 2. Pharmacotherapy for Major Depressive Disorder, page xiii in CPG.)

ALGORITHM 2. PHARMACOTHERAPY FOR MAJOR DEPRESSIVE DISORDER