A 38-year-old woman presents to the office with complaints of weight loss, fatigue, and insomnia of 3-month duration. She reports that she has been feeling gradually more tired and staying up late at night because she can’t sleep. She does not feel that she is doing as well in her occupation as a secretary and states that she has trouble remembering things. She does not go outdoors as much as she used to and cannot recall the last time she went out with friends or enjoyed a social gathering. She feels tired most of the week and states she feels that she wants to go to sleep and frequently does not want to get out of bed. She denies any recent medication, illicit drug, or alcohol use. She feels intense guilt regarding past failed relationships because she perceives them as faults. She states she has never thought of suicide, but has begun to feel increasingly worthless. Her vital signs and general physical examination are normal, although she becomes tearful while talking. Her mental status examination is significant for depressed mood, psychomotor retardation, and difficulty attending to questions. Laboratory studies reveal a normal metabolic panel, normal complete blood count, and normal thyroid functions. ➤ What is the most likely diagnosis? ➤ What is your next step? ➤ What are important considerations and potential complications of management?

The most likely diagnosis for this patient is major depressive disorder (MDD). MDD is a common psychiatric condition characterized by a persistent feeling of sadness or loss of interest or pleasure in activities. This is further supported by the patient’s symptoms of weight loss, insomnia, fatigue, poor concentration, and feelings of worthlessness. The diagnosis of MDD requires the presence of five or more depressive symptoms, including either depressed mood or loss of interest or pleasure, for at least two weeks.

The next step in the evaluation and management of this patient would be to conduct a thorough assessment of her psychiatric history, including any previous episodes of depression, family history of mood disorders, and any stressors or traumatic events that may have precipitated the current episode. It would also be important to screen for any comorbid psychiatric conditions, such as anxiety or substance use disorders, as these can impact treatment decisions.

In addition to the psychiatric assessment, a physical examination should be performed to rule out any underlying medical conditions that may be contributing to the patient’s symptoms. In this case, the normal metabolic panel, complete blood count, and thyroid functions indicate that there are no immediate medical causes of her symptoms.

Upon confirming the diagnosis of MDD, treatment should be initiated. This typically involves a combination of pharmacotherapy and psychotherapy. Selective serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors (SNRIs) are commonly used as first-line pharmacological treatments for MDD. These medications work by increasing the availability of serotonin and/or norepinephrine in the brain, which helps to alleviate depressive symptoms. The choice of medication should be tailored to the individual patient, taking into consideration factors such as previous response to treatment, side effect profiles, and potential drug interactions.

Psychosocial interventions, particularly cognitive behavioral therapy (CBT), have also been shown to be effective in the treatment of MDD. CBT focuses on identifying and changing negative patterns of thinking and behavior that contribute to depressive symptoms. It is important to involve a mental health professional in the patient’s care to provide ongoing support and guidance throughout the treatment process.

Important considerations in the management of MDD include monitoring for treatment response and adjusting the treatment plan as needed. It may take several weeks for antidepressant medications to take full effect, so it is important to reassess the patient’s symptoms regularly during this time. If the patient does not show an adequate response to initial treatment, a dose adjustment or switch to a different medication may be necessary.

It is also important to educate the patient about the nature of MDD and the importance of adherence to treatment. Many individuals with depression may experience feelings of guilt or shame, and it is essential to provide reassurance and support to help them overcome these barriers to recovery. Additionally, the patient should be educated about potential side effects of medications and the need to report any concerning symptoms to their healthcare provider.

Potential complications of management include medication side effects, treatment resistance, and the risk of relapse or recurrence of depressive episodes. Side effects of antidepressant medications can vary and may include gastrointestinal symptoms, sexual dysfunction, or changes in appetite or sleep patterns. It is important to monitor for these side effects and discuss any concerns with the patient.

Some individuals with MDD may not respond adequately to initial treatment, leading to treatment-resistant depression. In these cases, referral to a mental health specialist, such as a psychiatrist, may be necessary to explore alternative treatment options, such as augmentation strategies or electroconvulsive therapy.

Depression is a chronic and recurrent condition, and individuals with MDD have an increased risk of relapse or recurrence of depressive episodes. It is important to provide ongoing support and monitoring to these patients, even after they have achieved remission of symptoms. This may involve regular follow-up appointments, continued therapy, and long-term maintenance treatment with medications.