Psychotherapy history

Patient #1 has never been involved in psychotherapy

Patient #2 has just started supportive psychotherapy on a weekly basis

Social and personal history

Patient #1

• – Graduated high school

• – Worked in law enforcement for many years and now is a disabled delivery driver since his accident

• – Does not use drugs or alcohol

Patient #2

• – Attends high school, and despite her symptoms, is passing her classes for the most part

• – However, her grades have dropped from their usual levels

• – She only attends school 50% of the time

• – She does not use drugs or alcohol

Medical history

Patient #1 has suffered a head injury, is overweight but otherwise in good health

Patient #2 is healthy and has no history of eating disorder or epilepsy

Family history

Patient #1 denies any known psychiatric illness in any family member

Patient #2 has a family history of

• – MDD and GAD in her mother

• – AUD and questionable bipolar illness in her father

Patient evaluation on initial visit

Patient #1

• – Acute onset of anxious and agitated MDD after head injury one to two years ago

• – Has not been compliant with medication and declines psychotherapy

• – Admits passive suicidal ideation

• – He has taken a few antidepressants at moderately therapeutic levels

Patient #2

• – Gradual onset of symptoms as she entered her teenage years

• – There is no single stressor identified that predates her symptoms

• – She is gradually getting worse and is at risk of failing her classes and her grade level

• – She has been compliant with her medication but may have become more symptomatic with its use, and has only taken subtherapeutic doses as such

Current medications

Patient #1

• – None

Patient #2

• – Sertraline (Zoloft) 25 mg/d (was recently lowered from 50 mg/d), an SSRI

Question

In your clinical experience, which patient has a worse prognosis?

Not sure, it is too early to tell

Patient #1 is older, has failed more antidepressant trials, and has a worse prognosis

Patient #1 has more comorbidity and has a worse prognosis

Patient #2 is younger and cannot tolerate her medications and may be activated by them and has a worse prognosis

Not sure as this is like comparing apples and oranges as they are both depressed, but for very different reasons, and both have different phenomenology for their depressive symptoms

Attending physician’s mental notes: initial evaluation

Patient #1

• – This patient has his first MDE now with associated anxiety features (subsyndromal PTSD likely)

• – It is acute and triggered by the psychosocial stressor but complicated by a traumatic brain injury (TBI)

• – It seems more than an adjustment disorder as it is pervasive, lasting over time, and clearly disabling at this point

• – His prognosis is likely fair but made worse by his medication resistance and non-adherence

Patient #2

• – This patient is relatively untreated due to medication intolerance but psychotherapy and family interventions should be helpful

• – The reported activation and escalation is concerning on her current SSRI

  • Will need to work with the patient and family regarding safety planning, given FDA suicidal warnings associated with antidepressants in her age group

  • There is no clear family history of bipolarity, but “mood swings, alcoholism, and possible bipolar illness” have been noted in a first-degree relative

  • The SSRI activation may be a precursor of true bipolarity