case study of depression disorder

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

Through the lens of a gripping real-life case study, we delve into the depths of depression, unraveling its complexities and shedding light on the power of understanding mental health through individual experiences. Mental health case studies serve as invaluable tools in our quest to comprehend the intricate workings of the human mind and the various conditions that can affect it. By examining real-life examples, we gain profound insights into the lived experiences of individuals grappling with mental health challenges, allowing us to develop more effective strategies for diagnosis, treatment, and support.

The Importance of Case Studies in Understanding Mental Health

Case studies play a crucial role in the field of mental health research and practice. They provide a unique window into the personal narratives of individuals facing mental health challenges, offering a level of detail and context that is often missing from broader statistical analyses. By focusing on specific cases, researchers and clinicians can gain a deeper understanding of the complex interplay between biological, psychological, and social factors that contribute to mental health conditions.

One of the primary benefits of using real-life examples in mental health case studies is the ability to humanize the experience of mental illness. These narratives help to break down stigma and misconceptions surrounding mental health conditions, fostering empathy and understanding among both professionals and the general public. By sharing the stories of individuals who have faced and overcome mental health challenges, case studies can also provide hope and inspiration to those currently struggling with similar issues.

Depression, in particular, is a common mental health condition that affects millions of people worldwide. Disability Function Report Example Answers for Depression and Bipolar: A Comprehensive Guide offers valuable insights into how depression can impact daily functioning and the importance of accurate reporting in disability assessments. By examining depression through the lens of a case study, we can gain a more nuanced understanding of its manifestations, challenges, and potential treatment approaches.

Understanding Depression

Before delving into our case study, it’s essential to establish a clear understanding of depression and its impact on individuals and society. Depression is a complex mental health disorder characterized by persistent feelings of sadness, hopelessness, and loss of interest in activities. It can affect a person’s thoughts, emotions, behaviors, and overall well-being.

Some common symptoms of depression include:

– Persistent sad, anxious, or “empty” mood – Feelings of hopelessness or pessimism – Irritability – Loss of interest or pleasure in hobbies and activities – Decreased energy or fatigue – Difficulty concentrating, remembering, or making decisions – Sleep disturbances (insomnia or oversleeping) – Appetite and weight changes – Physical aches or pains without clear physical causes – Thoughts of death or suicide

The prevalence of depression worldwide is staggering. According to the World Health Organization, more than 264 million people of all ages suffer from depression globally. It is a leading cause of disability and contributes significantly to the overall global burden of disease. The impact of depression extends far beyond the individual, affecting families, communities, and economies.

Depression can have profound consequences on an individual’s quality of life, relationships, and ability to function in daily activities. It can lead to decreased productivity at work or school, strained personal relationships, and increased risk of other health problems. The economic burden of depression is also substantial, with costs associated with healthcare, lost productivity, and disability.

The Significance of Case Studies in Mental Health Research

Case studies serve as powerful tools in mental health research, offering unique insights that complement broader statistical analyses and controlled experiments. They allow researchers and clinicians to explore the nuances of individual experiences, providing a rich tapestry of information that can inform our understanding of mental health conditions and guide the development of more effective treatment strategies.

One of the key advantages of case studies is their ability to capture the complexity of mental health conditions. Unlike standardized questionnaires or diagnostic criteria, case studies can reveal the intricate interplay between biological, psychological, and social factors that contribute to an individual’s mental health. This holistic approach is particularly valuable in understanding conditions like depression, which often have multifaceted causes and manifestations.

Case studies also play a crucial role in the development of treatment strategies. By examining the detailed accounts of individuals who have undergone various interventions, researchers and clinicians can identify patterns of effectiveness and potential barriers to treatment. This information can then be used to refine existing approaches or develop new, more targeted interventions.

Moreover, case studies contribute to the advancement of mental health research by generating hypotheses and identifying areas for further investigation. They can highlight unique aspects of a condition or treatment that may not be apparent in larger-scale studies, prompting researchers to explore new avenues of inquiry.

Examining a Real-life Case Study of Depression

To illustrate the power of case studies in understanding depression, let’s examine the story of Sarah, a 32-year-old marketing executive who sought help for persistent feelings of sadness and loss of interest in her once-beloved activities. Sarah’s case provides a compelling example of how depression can manifest in high-functioning individuals and the challenges they face in seeking and receiving appropriate treatment.

Background: Sarah had always been an ambitious and driven individual, excelling in her career and maintaining an active social life. However, over the past year, she began to experience a gradual decline in her mood and energy levels. Initially, she attributed these changes to work stress and the demands of her busy lifestyle. As time went on, Sarah found herself increasingly isolated, withdrawing from friends and family, and struggling to find joy in activities she once loved.

Presentation of Symptoms: When Sarah finally sought help from a mental health professional, she presented with the following symptoms:

– Persistent feelings of sadness and emptiness – Loss of interest in hobbies and social activities – Difficulty concentrating at work – Insomnia and daytime fatigue – Unexplained physical aches and pains – Feelings of worthlessness and guilt – Occasional thoughts of death, though no active suicidal ideation

Initial Diagnosis: Based on Sarah’s symptoms and their duration, her therapist diagnosed her with Major Depressive Disorder (MDD). This diagnosis was supported by the presence of multiple core symptoms of depression that had persisted for more than two weeks and significantly impacted her daily functioning.

The Treatment Journey

Sarah’s case study provides an opportunity to explore the various treatment options available for depression and examine their effectiveness in a real-world context. Supporting a Caseworker’s Client Who Struggles with Depression offers valuable insights into the role of support systems in managing depression, which can complement professional treatment approaches.

Overview of Treatment Options: There are several evidence-based treatments available for depression, including:

1. Psychotherapy: Various forms of talk therapy, such as Cognitive Behavioral Therapy (CBT) and Interpersonal Therapy (IPT), can help individuals identify and change negative thought patterns and behaviors associated with depression.

2. Medication: Antidepressants, such as Selective Serotonin Reuptake Inhibitors (SSRIs), can help regulate brain chemistry and alleviate symptoms of depression.

3. Combination Therapy: Many individuals benefit from a combination of psychotherapy and medication.

4. Lifestyle Changes: Exercise, improved sleep habits, and stress reduction techniques can complement other treatments.

5. Alternative Therapies: Some individuals find relief through approaches like mindfulness meditation, acupuncture, or light therapy.

Treatment Plan for Sarah: After careful consideration of Sarah’s symptoms, preferences, and lifestyle, her treatment team developed a comprehensive plan that included:

1. Weekly Cognitive Behavioral Therapy sessions to address negative thought patterns and develop coping strategies.

2. Prescription of an SSRI antidepressant to help alleviate her symptoms.

3. Recommendations for lifestyle changes, including regular exercise and improved sleep hygiene.

4. Gradual reintroduction of social activities and hobbies to combat isolation.

Effectiveness of the Treatment Approach: Sarah’s response to treatment was monitored closely over the following months. Initially, she experienced some side effects from the medication, including mild nausea and headaches, which subsided after a few weeks. As she continued with therapy and medication, Sarah began to notice gradual improvements in her mood and energy levels.

The CBT sessions proved particularly helpful in challenging Sarah’s negative self-perceptions and developing more balanced thinking patterns. She learned to recognize and reframe her automatic negative thoughts, which had been contributing to her feelings of worthlessness and guilt.

The combination of medication and therapy allowed Sarah to regain the motivation to engage in physical exercise and social activities. As she reintegrated these positive habits into her life, she experienced further improvements in her mood and overall well-being.

The Outcome and Lessons Learned

Sarah’s journey through depression and treatment offers valuable insights into the complexities of mental health and the effectiveness of various interventions. Understanding the Link Between Sapolsky and Depression provides additional context on the biological underpinnings of depression, which can complement the insights gained from individual case studies.

Progress and Challenges: Over the course of six months, Sarah made significant progress in managing her depression. Her mood stabilized, and she regained interest in her work and social life. She reported feeling more energetic and optimistic about the future. However, her journey was not without challenges. Sarah experienced setbacks during particularly stressful periods at work and struggled with the stigma associated with taking medication for mental health.

One of the most significant challenges Sarah faced was learning to prioritize her mental health in a high-pressure work environment. She had to develop new boundaries and communication strategies to manage her workload effectively without compromising her well-being.

Key Lessons Learned: Sarah’s case study highlights several important lessons about depression and its treatment:

1. Early intervention is crucial: Sarah’s initial reluctance to seek help led to a prolongation of her symptoms. Recognizing and addressing mental health concerns early can prevent the condition from worsening.

2. Treatment is often multifaceted: The combination of medication, therapy, and lifestyle changes proved most effective for Sarah, underscoring the importance of a comprehensive treatment approach.

3. Recovery is a process: Sarah’s improvement was gradual and non-linear, with setbacks along the way. This emphasizes the need for patience and persistence in mental health treatment.

4. Social support is vital: Reintegrating social activities and maintaining connections with friends and family played a crucial role in Sarah’s recovery.

5. Workplace mental health awareness is essential: Sarah’s experience highlights the need for greater understanding and support for mental health issues in professional settings.

6. Stigma remains a significant barrier: Despite her progress, Sarah struggled with feelings of shame and fear of judgment related to her depression diagnosis and treatment.

Sarah’s case study provides a vivid illustration of the complexities of depression and the power of comprehensive, individualized treatment approaches. By examining her journey, we gain valuable insights into the lived experience of depression, the challenges of seeking and maintaining treatment, and the potential for recovery.

The significance of case studies in understanding and treating mental health conditions cannot be overstated. They offer a level of detail and nuance that complements broader research methodologies, providing clinicians and researchers with invaluable insights into the diverse manifestations of mental health disorders and the effectiveness of various interventions.

As we continue to explore mental health through case studies, it’s important to recognize the diversity of experiences within conditions like depression. Personal Bipolar Psychosis Stories: Understanding Bipolar Disorder Through Real Experiences offers insights into another complex mental health condition, illustrating the range of experiences individuals may face.

Furthermore, it’s crucial to consider how mental health issues are portrayed in popular culture, as these representations can shape public perceptions. Understanding Mental Disorders in Winnie the Pooh: Exploring the Depiction of Depression provides an interesting perspective on how mental health themes can be embedded in seemingly lighthearted stories.

The field of mental health research and treatment continues to evolve, driven by the insights gained from individual experiences and comprehensive studies. By combining the rich, detailed narratives provided by case studies with broader research methodologies, we can develop more effective, personalized approaches to mental health care. As we move forward, it is essential to continue exploring and sharing these stories, fostering greater understanding, empathy, and support for those facing mental health challenges.

References:

1. World Health Organization. (2021). Depression. Retrieved from https://www.who.int/news-room/fact-sheets/detail/depression

2. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

3. Beck, A. T., & Alford, B. A. (2009). Depression: Causes and treatment. University of Pennsylvania Press.

4. Cuijpers, P., Quero, S., Dowrick, C., & Arroll, B. (2019). Psychological treatment of depression in primary care: Recent developments. Current Psychiatry Reports, 21(12), 129.

5. Malhi, G. S., & Mann, J. J. (2018). Depression. The Lancet, 392(10161), 2299-2312.

6. Otte, C., Gold, S. M., Penninx, B. W., Pariante, C. M., Etkin, A., Fava, M., … & Schatzberg, A. F. (2016). Major depressive disorder. Nature Reviews Disease Primers, 2(1), 1-20.

7. Sapolsky, R. M. (2004). Why zebras don’t get ulcers: The acclaimed guide to stress, stress-related diseases, and coping. Holt paperbacks.

8. Yin, R. K. (2017). Case study research and applications: Design and methods. Sage publications.

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Patient Case Presentation

Figure 1.  Blue and silver stethoscope (Pixabay, N.D.)

Ms. S.W. is a 48-year-old white female who presented to an outpatient community mental health agency for evaluation of depressive symptoms. Over the past eight weeks she has experienced sad mood every day, which she describes as a feeling of hopelessness and emptiness. She also noticed other changes about herself, including decreased appetite, insomnia, fatigue, and poor ability to concentrate. The things that used to bring Ms. S.W. joy, such as gardening and listening to podcasts, are no longer bringing her the same happiness they used to. She became especially concerned as within the past two weeks she also started experiencing feelings of worthlessness, the perception that she is a burden to others, and fleeting thoughts of death/suicide.

Ms. S.W. acknowledges that she has numerous stressors in her life. She reports that her daughter’s grades have been steadily declining over the past two semesters and she is unsure if her daughter will be attending college anymore. Her relationship with her son is somewhat strained as she and his father are not on good terms and her son feels Ms. S.W. is at fault for this. She feels her career has been unfulfilling and though she’d like to go back to school, this isn’t possible given the family’s tight finances/the patient raising a family on a single income.

Ms. S.W. has experienced symptoms of depression previously, but she does not think the symptoms have ever been as severe as they are currently. She has taken antidepressants in the past and was generally adherent to them, but she believes that therapy was more helpful than the medications. She denies ever having history of manic or hypomanic episodes. She has been unable to connect to a mental health agency in several years due to lack of time and feeling that she could manage the symptoms on her own. She now feels that this is her last option and is looking for ongoing outpatient mental health treatment.

Past Medical History

• Hypertension, diagnosed at age 41

Past Surgical History

• Wisdom teeth extraction, age 22

Pertinent Family History

• Mother with history of Major Depressive Disorder, treated with antidepressants
• Maternal grandmother with history of Major Depressive Disorder, Generalized Anxiety Disorder
• Brother with history of suicide attempt and subsequent inpatient psychiatric hospitalization,
• Brother with history of Alcohol Use Disorder
• Father died from lung cancer (2012)

Pertinent Social History

• Works full-time as an enrollment specialist for Columbus City Schools since 2006
• Has two children, a daughter age 17 and a son age 14
• Divorced in 2015, currently single
• History of some emotional abuse and neglect from mother during childhood, otherwise denies history of trauma, including physical and sexual abuse
• Smoking 1/2 PPD of cigarettes
• Occasional alcohol use (approximately 1-2 glasses of wine 1-2 times weekly; patient had not had any alcohol consumption for the past year until two weeks ago)

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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