Depression Case Study

• Depression x three years (diagnosed by PCP)
• Hypothyroidism x four years
• Prediabetes x two years ago

Cesarean section with second daughter

Dysmenorrhea X three months

• Patient denies any psychiatric hospitalizations.
• Previous pastoral counseling with late husband.
• Endorses previous times in life when she felt anxious and depressed but did not seek treatment. Most notably, she remembers being depressed for over a year after the birth of her second child and again directly after she stopped breastfeeding.
• Her PCP diagnosed her for the first time two years ago, and she started medication at that time, recently changed from Prozac to Lexapro due to anxiety side effects.

Diagnosis(es): MDD, mild-recurrent; GAD.

Treatments: Medications only.

Medications: Lexapro 10 mg PO QD.

Previous Medication Trials: Prozac for 18 months then changed to Lexapro three months ago.

Therapy: Referred to CBT but never attended.

Previous Therapy Trials: None.

Outcomes: Had response to medication two years ago; now having worsening symptoms.

• Birth history: Unknown
• Developmental delays: Unknown
• How were they managed? None identified.
• If any delays, what therapies were used, and did they help? N/A

Mrs. Lane is the youngest of six children born to biological parents who raised her in South Korea. She completed high school and has a bachelor of science degree in mathematics. Came to the U.S. as a young adult, at age 21. Received a Green Card and then became a U.S. citizen years after. All her family of origin live in South Korea, and she visits every two to three years. Recently widowed, two years ago. No history of alcohol or drug use. Currently works as a middle school math teacher. She has two grown children, both daughters, and one grandson who is five years old. One daughter lives in Washington DC, and the other lives in town with her husband and son. They visit frequently and live only a few houses down from her.

• Father: deceased, age of death 80, MI
• Mother: alive, lives in South Korea, HTN, HLD, DMII
• Paternal and maternal grandmother: deceased, DMII
• Maternal aunts (2): deceased, DMII, HTN, GAD
• Paternal uncles (3): deceased, DMII
• Sister 1: alive, DMII
• Sister 2: alive, older, lives in South Korea, HTN
• Sister 3: alive, older, lives in South Korea, unknown
• Brother 1: alive, older, lives in South Korea, unknown
• Brother 2: alive older, lives in South Korea, unknown

Last immunizations: Flu vaccine, one year ago, recent Covid vaccine, plus boosters X 2.

Visited family in South Korea one year ago.

• Last gyn exam and Pap: normal three years ago.
• Menses have recently started to be every other month in frequency.
• Last PCP visit: two months ago.
• Dental visit last week for annual cleaning.

Reports usual health as “fine, no issues.” Denies fever, chills, weight changes.

• Denies cough, dyspnea, or wheezing.
• Denies history of asthma, recurrent infections.

Denies chest pain, palpitations.

• G2T1P1A0L2
• Menses have recently started to occur every other month in frequency, last 3 months very scant bleeding with pain
• Menarche age 13, cycle 30 days
• One cesarian, one vaginal delivery
• Baby 1: vaginal delivery, 9 pounds
• Baby 2: cesarean delivery 9.5 pounds, gestational diabetes, postpartum depression

• Denies coordination problems, numbness, tingling, weakness, tremors. Denies seizures and frequent headaches. Not aware of memory problems.
• Denies history of head injury.

Admits depressed mood, although she is “frustrated” that she is having worse anxiety again as well. Admits to some apathy and decreased motivation. Denies suicidal or homicidal ideations.

Admits insomnia, difficulty falling asleep, some middle-night awakening, and disruption of 24-hour sleep cycle. Does report “wanting to sleep much more” and “no energy in the morning.” Additionally reports waking up in sweats.

Admits loss of interest or pleasure in activities, and social isolation. Specifically, her favorite thing, Saturday cooking, is no longer a priority.

Denies feelings of helplessness, hostility, low self-esteem, guilt, or shame. Endorses some feelings of hopelessness in her condition not improving.

Denies increased energy but does occasionally feel fatigued.

Has noticed she has some difficulty concentrating, has stopped watching TV, and is very forgetful at times. “I leave my keys everywhere and misplace my phone all day. That’s not normal for me.”

Denies increased or decreased appetite.

Denies delusions, hallucinations, feelings of persecution, hearing sounds that seem to be voices, or preoccupation with religion.

Denies self-inflicted injuries; has no frequent thoughts of death, lack of desire to continue living, or suicidal tendency.

Denies homicidal thoughts.

Denies family problems, poor school/work performance, recent separation, job loss, and legal problems; not under stress other than worrying about increased anxiety and feeling overall worse.

A&O x 4, disheveled appearance. No spontaneous speech, but answers questions when asked.

No noted hypervigilance, heightened startle reflex, abnormal mannerisms, or uncommunicative/disinterested/hostile/inattentive attitude.

No tremor or tics; normal gait and stance; no involuntary movements.

No refusal to speak or loosening of association/word salad; not slowed, rapid, or difficult; normal rhythm of speech, speech tone, and speech volume.

Appears depressed; does not appear anxious, dysphoric, euphoric, elevated, expansive, irritable, or angry.

Full ranging, not blunted, constricted, flat, incongruent with mood, inappropriate, labile, sad, or tearful.

No language abnormalities; speech fluent; no dysphonia; no stuttering; language fluent and intact for naming; normal sentence structure.

Patient oriented x4; no disorientation, short-term memory impairment, reduced abstraction ability, or diminished cognitive functioning.

No deficiency on evaluation of connectedness; organized.

No thought content impairment; no suicidal ideation, homicidal ideations, paranoid ideations, poverty of thought, thought insertions, obsessions, irrational fears, delusions, or hallucinations.

No impaired insight, impaired judgment, or poor problem solving.