Patient evaluation on intake

18-year-old man states he has been “depressed all year”

He has been reasonably successful in high school, enjoys athletics, has a girlfriend, and should be happy

He is not, he is despondent to the point of being suicidal

Psychiatric history

Reports increasing MDD symptoms over the last several months

• – Cannot sleep without medication

• – Is fatigued and cannot concentrate at school, and is allowed to attend for half days as a result

• – Reports marked guilt as he is letting others down

• – He is convinced he will never get better

• – Admits daily suicidal thinking that so far he has not acted on, but states it is “a struggle every day”

• – Experiences intrusive “images” where he sees himself hurting himself or others that he deems separate from his suicidal thinking, which he states are “clearly his own thoughts”

  • These images started shortly after the depression began

These MDD symptoms started after a break up with a girlfriend, but never remitted, even as his social life improved

He has long-standing feelings that people do not like him and has low self-esteem despite being a well-rounded and accomplished teenager, as he was picked on for being overweight as a child

• – He is not overweight now

There is no evidence of sustained manic episodes, anxiety disorder, eating disorder, or SUD, confirmed by corroborative history and diagnostic rating scales

• – Interestingly, his previous provider had diagnosed him with bipolar disorder and ADHD

• – He transitioned to this provider on a stimulant, a mood stabilizer, and an antidepressant

Social and personal history

Due to graduate high school on time this year but has had academic accommodations given his MDD

Parents are married and supportive

Has no siblings

Does not abuse substances, nicotine, or caffeine

Medical history

There are no medical issues

Family history

There is no family history of bipolar disorder or schizophrenia

Uncles may have AUD

Aunts may have MDD

Medication history

First took an SSRI, fluoxetine (Prozac) 20 mg/d, without effect, one and a half years ago

• – This did not alleviate MDD symptoms and next was augmented with the atypical antipsychotic aripiprazole (Abilify) 5–10 mg/d

• – This caused a marked increase in suicidal thinking and symptoms consistent with EPS-based akathisia

Since this time, he has been taking

• – Escitalopram (Lexapro) 10 mg/d (SSRI)

• – d/l-amphetamine salts (Adderall) 15 mg/d (stimulant)

• – Divalproex sodium-ER (Depakote-ER) 750 mg/d (mood stabilizer)

Psychotherapy history

Sees a clinical social worker routinely for supportive psychotherapy

He is given supportive, problem-oriented psychotherapy, and has a good rapport with this provider

He looks forward to sessions

Patient evaluation on initial visit

Patient suffers from a single, severe, and possibly psychotic MDD

He sees images that look like “videos playing” vividly in front of him

• – These are intrusive and ego-dystonic

• – Tries to avoid thinking of these images

• – They sound like obsessive, intrusive images consistent with OCD but could be ruminations or even psychotic visual hallucinations

He has a blunted affect, concrete thoughts, and mild thought slowing

• – This could be from MDD

• – Also need to consider these as negative symptoms, that his obsessive images are frank hallucinations, and that this is a schizophrenia prodrome

Has been compliant with medication management and psychotherapy

Suicidal thinking is readily apparent, serious, and problematic

There is no evidence of bipolarity