Mrs. Debra is a 76-year old African American woman who, with her spouse Mike, managed a
small restaurant for many years. Mike died two years ago and now their son, Paul , does most
of the daily work, but Debra remains involved- going to the restaurant daily, seating customers
and helping at the cash register. Working at the restaurant used to be a haven for her- she
enjoyed it tremendously. Lately, she finds it difficult to get out of bed to go to work- "it's just
not the same, I feel empty and lost." She endorses difficulty sleeping, often waking up early in
the morning and cannot get back to sleep. Her appetite has been down and she has lost 2lbs
since her last visit 3 months ago.
You examine Mrs. Debra in the office. She is pleasant and cooperative and in no acute distress.
Her blood pressure is 128/70, HR 82 and regular. RR 12. She is afebrile. The rest of her exam,
including the neurologic exam is essentially within normal limits. Throughout the interview,
however, she cries frequently about living without her dear husband, Mike. They were very
happy together and she misses him terribly. She tells you that her son is trying to run her life.
She often feels useless, in the way and hopeless.
Questions:
1. What is your differential?
2. Based on the information you now know, what is your leading diagnosis in your
differential?
3. What are the patient's risk factors?
4. What diagnostic tests and laboratory evaluation would you consider?
5. What are the most common signs and symptoms of this disorder?
6. How would this condition be treated?
7. When would you follow-up with this patient and would you consider any referrals?
1. The diagnosis for Mrs. Debra is Major Depressive Disorder
2. Based on the Diagnostic and Statistical Manual of Mental Disorders
(DSM-V), the patient must satisfy at leadt 5 of the clinical criteria to be
diagnosed with Major Depressive Disorder. The following are present in
the case of Mrs. Debra:
o Depressed mood as indicated by subjective report (feels sad,
empty, hopeless), or observation made by others (tearful)
o Diminished interest or pleasure in all or all most all activities
o Unintentional weight loss of more than 5% of body weight in a
month or change in appetite
o Insomnia
o Fatigue or loss of energy
o Feelings of worthlessness
3. The risk factors of Mrs. Debra are the following:
76 years old - A journal that relates old age to incidence of
depression: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC584
0909/
o African American and woman - A journal that relates race,
ethnicity and sex to incidence of
depression: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC639
0869/
o Loss of spouse - A journal that relates the death of spouse to
incidence of
depression: https://onlinelibrary.wiley.com/doi/abs/10.1002/hec.
3443
Major Depressive Disorder is diagnosed clinically with the guide of
diagnostic criteria and risk factors from DSM-V and as reported or
observed to the patient. As a physician, I can also utilize questionnaires
such as the widely used Patient Health Questionnaire - 9 (PHQ-9) or the
questionnaire designed for elderlies, Geriatric Depression Scale (GDS).
I will also investigate for an organic medical cause for the patient's
condition. I may initially request for complete blood count (CBC) and
thyroid-stimulating hormone (TSH) to detect anemia and thyroid
dysfunction which may also mimic some of the manifestations of
depression such as fatigue, insomnia, and weight loss.
Patients with Major Depressive Disorder will manifest with depressed
mood, diminished interest to activities that are pleasurable to him/her
before, weight loss or weight gain, insomnia, loss of energy, feelings of
worthlessness, and suicidal thoughts.
Major Depressive Disorder is primary treated with anti-depressants as
well as with congnitive behavioral therapy. The most important factor in
the management with these patients is a strong social support from
his/her family and friends.
As a physician, I will request for workup and will prescribe antidepressant such as Fluoxetine 20mg per capsule once a day for 30
days. I will also refer the patient to a psychologist for a cognitive
behavioral therapy as well as to a support group in her locality. I will ask
her to see me again after a month but will encourage her to call or visit
me any time if there are concerns that will arise.
o
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