The important elements of the description of depression
The client is concerned about her mood swings, cyclic aggressive behavior, unwillingness to communicate with other people, and severe problems with the sleep-wake cycle. These elements to the description of the client’s condition are extremely important because they indicate the lack of energy that is typical for the cases of depression. Also, it is important that the client fully understands the impact that her behavior may have on the safety of her children and the relationships with other people. This awareness of risks that exist for other people due to her abnormal behavior is a pivotal element since it helps exclude abnormal conditions with a lack of self-consciousness.
Apart from that, two more elements of the description should be emphasized to understand the client’s problem. To begin with, it is obvious that the woman feels guilty about being aggressive, and the presence of guilt pangs is often indicative of depression (Kendler & Gardner, 2014). More than that, the client’s depression is likely to be related to the most recent changes in her life such as the birth of her fifth child preceded by the history of anxiety. The occurrence or worsening of the symptoms of depression during the postnatal period may indicate the presence of post-partum depression, the problem experienced by more than ten percent of mothers (Kettunen & Hintikka, 2017).
The DMV 5 definition of major depression
In general, the client’s complaints refer to sleep problems, frequent mood swings (she gets sad a lot), and the desire to stay away from social interactions. According to the widely accepted diagnostic criteria proposed by APA, MDD should be separated from BD (Uher, Payne, Pavlova, & Perlis, 2013). Nowadays, nine symptoms are widely used to define MDD, and at least five of them should be present in a patient to make a diagnosis.
The client from the case seems to have four symptoms: “loss of interest or pleasure” (she only wants to stay in her room), “depressed or irritable mood”, “insomnia or hypersomnia”, and “worthlessness or guilt” (she understands the impact of her behavior on children) (Uher et al., 2013, p. 461). To be indicative of MDD, the symptoms should lead to significant distress, be non-related to substance use, and hypomanic or manic episodes. Additional assessments are required to establish the presence of the episodes of mania/hypomania, whereas the first sign (distress) is observed. Marijuana used by the client is unlikely to be the cause of the symptoms. However, she has stopped taking Zoloft and buspirone at least three months ago, and some of her problems (insomnia and irritability) can be attributed to withdrawal symptoms. Therefore, the definition of MDD is partially met, and further assessments are required.
Other essential data for diagnostics
The following things may need to be clarified to better understand the situation:
- The presence of suicidal thoughts and frustration;
- The presence of a family history of type 1 or 2 bipolar disorder;
- The history of suicidal attempts (causes, intentions, mental state);
- Current pernicious habits apart from pot-smoking;
- Depressive episodes before pregnancy and their frequency;
- The periods of abnormally elevated mood or enthusiasm and their length;
- Sleep deprivation without being tired;
- The onset of the depressive episode;
- Any changes related to nutritional behavior, weight, and appetite;
- Problems with decision-making or difficulty concentrating;
- Any signs of cyclothymia.
Differential diagnosis
Differential diagnosis:
- MDD with peripartum onset;
- Bipolar disorder;
- Anxiety;
- Exogenous depression.
The variety of symptoms discussed by the patient allows making a range of hypotheses concerning her mental health condition. As is clear from the analysis, the manifestation of some MDD symptoms in the patient is still unclear. Also, the facts that speak in favor of bipolar disorder are the results of MDQ assessments and the ineffectiveness of Buspar and Zoloft for reducing anxiety. Even though a lot of factors will need to be assessed, bipolar disorder seems to be the first hypothesis to be checked.
Care plan
A thorough assessment of mood changes and the potential impact of medications on the patient’s physical and mental health should become the first component of the care plan. To confirm or exclude the presence of MDD, it can be important to test for endocrine disorders and physical traumas. Blood tests may need to be ordered to detect abnormalities related to TSH levels or vitamin deficiency. Various diagnostic tools such as the Beck Depression Inventory and mood questionnaires can be used to make a diagnosis.
If the presence of BD is confirmed, it will be necessary to choose medications that can be used in lactating mothers. Possible treatments include mood-stabilizing drugs (Neurontin, Depakote, Trileptal, etc.), medications with both antipsychotic and antidepressive effects such as Symbyax, and antipsychotics that manage the symptoms of mania (Saphris, Risperdal, etc.). Among possible psychotherapeutic interventions are CBT sessions with special attention to the triggers of mood swings, psychoeducation, or IPT (Miller et al., 2015). In the case of MDD, IPT, CBT, and psychoeducation can also be used to decrease the severity of symptoms. In terms of medications, the use of TCAs (clomipramine, doxepin, etc.) and SSRIs (citalopram, fluoxetine, or vilazodone) can be necessary (Nagane et al., 2014).
The difference of major depression and bipolar disease in women
The key difference between MDD and bipolar disorder in women is the absence of periods of elevated mood. Interestingly, it can be more difficult to differentiate between the two conditions in women than in men because female patients with BD have depressive episodes more frequently (Miller et al., 2015). Also, the level to which the two conditions impact the menstrual cycle is different – thus, women with BD report menstrual abnormalities more often than those with MDD (Miller et al., 2015).
References
Kendler, K. S., & Gardner, C. O. (2014). Sex differences in the pathways to major depression: A study of opposite-sex twin pairs. American Journal of Psychiatry, 171(4), 426-435.
Kettunen, P., & Hintikka, J. (2017). Psychosocial risk factors and treatment of new onset and recurrent depression during the post-partum period. Nordic Journal of Psychiatry, 71(5), 355-361.
Miller, L. J., Ghadiali, N. Y., Larusso, E. M., Wahlen, K. J., Avni-Barron, O., Mittal, L., & Greene, J. A. (2015). Bipolar disorder in women. Health Care for Women International, 36(4), 475-498.
Nagane, A., Baba, H., Nakano, Y., Maeshima, H., Hukatsu, M., Ozawa, K.,… Arai, H. (2014). Comparative study of cognitive impairment between medicated and medication-free patients with remitted major depression: Class-specific influence by tricyclic antidepressants and newer antidepressants. Psychiatry Research, 218(1-2), 101-105.
Uher, R., Payne, J. L., Pavlova, B., & Perlis, R. H. (2013). Major depressive disorder in DSM-5: Implications for clinical practice and research of changes from DSM-IV. Depression and Anxiety, 31(6), 459-471.