Presenting Problem

Kel, a 42-year-old female accountant, has had a marked decrease in energy and as such a
decrease in her ability to perform routine activities including grocery shopping, personal
grooming, and connections with friends. Kel was noted to dream about going on a cruise the
day after Tax Day until this year and remarks that it is a “ridiculous idea.” Kel’s sister Sue reports
checking in on her sister after unreturned calls and e-mails caused her to be alarmed. Sue
observed Kel’s apartment to be disorganized and in need of cleaning and her sister to look
unkempt and sad. Kel admits to Sue in a monotone voice that she feels “sad and hopeless.
Nothing is ever going to change. I am a bad person and I can’t even do my work right.” Overall,
Kel reports feeling overwhelmed and it is affecting her job performance as well as her
attendance. Physically she is sleeping all the time but remains tired and no longer reports
having an appetite.

Diagnosis
Kel appears to be experiencing major depressive disorder (MDD) severe single episode (F32.2)
or recurrent episode (F33.2) with severe with melancholic features. A key indicator of MDD is
the somatic or vegetative symptoms in conjunction with behavioral and emotional standstill.
Kel’s presentation appears to have been going on for more than two weeks and does not report
an incidence of increased energy and productivity prior. Kel exhibits multiple characteristics of
major depressive disorder such as daily depressed mood, reports being sad and hopeless,
subjective report of diminished interest in activities like getting dressed or going to work, weight
loss and poor appetite, hypersomnia, loss of energy to even shop for food, feeling worthless at
work, and an inability to concentrate on work which she formerly enjoyed. Kel checks the
majority of the boxes for MDD indicating a severe presentation and her initial interview will
illuminate the details of her prior psychiatric history, past social history, past medical history and
substance use. Kel meets criteria for the specifier of melancholic features as evidenced by her
loss of pleasure in all activities, a noticeable depressed mood as reported by herself and sister,
weight loss of 15 pounds, and her associated guilt of being a “bad person” (American Psychiatric
Association [APA], 2022; Barlow et al., 2022).

The differential diagnosis of depressive disorder due to another medical condition (F06.34) such
as thyroid disease, diabetes, vitamin deficiency cannot be excluded at this time. Consideration
for preexisting persistent depressive disorder (F34.1) would depend on the psychiatric interview
and Kel would need a history of a depressed mood for the prior two or more years. Persistent
depressive disorder with an episode of major depressive disorder is also known as double
depression. Additional differential diagnosis may include bipolar w/ depressive mood onset
however this is dependent on her past history as it is unlikely at her age for a first presentation
(Barlow et al., 2022).

Treatment Plan
The initial priority of Kel’s treatment plan includes assessing for suicidal/homicidal ideation
which if positive would necessitate inpatient status for safety reasons. The next step would be
choosing an appropriate medication. Medication management is indicated according to the 2019
Clinical Practice Guidelines for the Treatment of Depression Across Three Age Cohorts from the
American Psychological Association (2019 Clinical Guidelines). The 2019 Guidelines
recommend the use of second-generation antidepressants as the initial treatment option for
depression (American Psychological Association, 2019). Generally speaking, prescribers should
consider the side effects, efficacy and availability before embarking on a treatment regimen.
Selective serotonin reuptake inhibitors (SSRIs) such as sertraline or escitalopram may be
beneficial for Kel. Sertraline dosing guidelines indicate an opening dose of 50mg daily by
mouth. It can be titrated up in increments of 25mg to 50mg per week with a max dose of 200mg
per day. It can take two to four weeks to notice improvements. Among the cautions with use
would be an assessment of concurrent alcohol use by the patient. Sertraline is FDA approved for
the treatment of major depression, panic disorder, post-traumatic stress disorder, social anxiety
disorder, and obsessive-compulsive disorder. It is generally well tolerated and has low drug
interaction making it a favorable medication choice for treatment. All patients should however be
monitored for worsening or unusual behavior changes with treatment initiation or changes in
dosing. Alternative medicines like bupropion might be avoided due to Kel’s pre-existing
malnourished state indicating possible electrolyte imbalances therefore increasing her risk for
seizures (Epocrates, 2024).

The 2019 Clinical Guidelines further recommend cognitive behavioral therapy in addition to
antidepressant medication as initial treatment for adult depression. Cognitive behavioral therapy
is a method of treatment where the goal is to shift a pattern of thinking from negativity, short
sighted or exaggerated to more balanced, accurate and insightful. The goal of CBT is to change
the internal response and relationship to a thought, not the content of a patient’s thought (Wenzel,
p. 52, 2021). Enlisting Kel’s social support system, her sister, can improve compliance with plan
of care both short term and long term. Kel should also be provided with follow up care
appointments in the following two to four days and weekly initially. She should also be provided
with the suicide hotline prevention number and create a contract for safety. Kel can also be
encouraged to perform some self-care activities such as awaking at a set time, simple hygiene
and eating meals more routinely to begin the process of healing and recovery (Barlow et al.,
2022).
Screening Instruments
The overarching goal of a suicide risk screening is to assess the propensity towards suicide. The
suicide risk assessment is the process used to determine the severity and level of risk. The
Patient Health Questionnaire two question rating scale (PHQ-2) followed by the nine-question
scale (PHQ-9) and the Columbia Suicide Severity Rating Scale (C-SSRS) are the most common
screening scales in outpatient settings. The final question of the PHQ-9 specifically asks about
thoughts of suicide. The C-SSRS is the short form of a much larger scale that asks questions in a
stepwise approach to assess desire, thoughts, plans and previous history of attempts at suicide.
Practitioners should be aware that the longer version of the C-SSRS is a validated tool and the
shorter version remains to be studied for this strength. The C-SSRS is useful nonetheless as it
does begin the assessment for suicide risk severity. Patients exhibiting positive scores for suicide
should be offered mental health treatment, crisis planning, risk factor reduction and means
reduction (Wang, 2022).

References
American Psychiatric Association. (2022). Depressive Disorders. In Diagnostic and statistical
manual of mental disorders (5th ed., text rev.).
[Link]
American Psychological Association. (2019.). Clinical practice guideline for the treatment of
depression across three age cohorts. [Link]
Barlow, D. H., Durand, V. M., & Hofmann, S. G. (2022). Psychopathology: An integrative
approach to mental disorders (9th ed.). Cengage Learning.
Epocrates. (2024). Sertraline in Epocrates medical references (Version 24.1.0) [Mobile app].
Apple store. [Link]
Wang, L. (2022). Suicide risk reduction in older adults. In Walaszek, A. (Ed.) Late-Life
Depression and Anxiety: Vol. First edition. (pp. 177-212). American Psychiatric
Association Publishing.
Wenzel, A. (Ed.). (2021). Handbook of cognitive behavioral therapy: Overview and approaches,
(Vol. 1). American Psychological Association. [Link]