Mood Disorder

Case scenario:
Rita is an 18-year-old who presents to the emergency department with her parents after telling them earlier in the day that she did not want to be alive anymore. Rita reports that for the past 6 months she has been "feeling down," and she has been having thoughts of killing herself throughout the last week. She has a plan to kill herself that involves taking all of the medications in her family's medicine cabinet.
Rita says that in the past 6 months she also has experienced a decrease in energy, saying that "it feels like I'm never able to sleep." Her parents tell you that she was previously on the track team at her school, and that she stopped going to practice 2 months ago because she "didn't see the point" any longer.
Despite quitting the track team, the patient reports a weight loss of 5 pounds in the past 6 months because of a decrease in her appetite. She denies fevers, chills, dizziness, lightheadedness, headache, vision changes, chest pain, palpitations, shortness of breath, cough, abdominal pain, nausea, vomiting, dysuria, auditory hallucinations, and visual hallucinations. She has no significant past medical, surgical, or psychiatric history. Upon further interview, Rita denies any history of substance use, any history of manic or hypomanic symptoms, or any identifiable recent life stressors.
Her laboratory results reveal no abnormalities in thyroid-stimulating hormone levels, comprehensive metabolic panel, or complete blood count. Her urine drug screen is negative. Vital signs show her blood pressure is 102/70 mm Hg, respiration rate is 15/min, heart rate is 72/min, and temperature is 37.1 °C (98.8 °F).
• What is the diagnosis for Rita?
• What is the possible differential diagnosis?
• What other medical conditions can cause depressive symptoms?
• What are the diagnostic criteria for major depressive disorders?
• What are the evidence-based treatment options for major depressive disorders?
• Will you recommend inpatient hospitalization for Rita? Explain why or why not?
• What are the ethical considerations for involuntary hospitalization?

Sample Solution

Rita's Case Analysis

What is the diagnosis for Rita?

Based on the information provided, Rita's diagnosis is Major Depressive Disorder (MDD), Single Episode, Severe, With Psychotic Features.

Here's why:

Depressed Mood: She has been "feeling down" for the past 6 months.
Anhedonia: She stopped going to track practice because she "didn't see the point."
Insomnia/Hypersomnia: She states "it feels like I'm never able to sleep" (though this could be interpreted as non-restorative sleep rather than true insomnia, the energy decrease supports a sleep disturbance).
Fatigue/Loss of Energy: She reports a decrease in energy.
Weight Loss/Appetite Change: She has experienced a 5-pound weight loss due to decreased appetite.
Suicidal Ideation with Plan: She has been having thoughts of killing herself throughout the last week and has a plan involving taking all medications in her family's medicine cabinet. This constitutes a severe presentation.
No History of Manic/Hypomanic Episodes: Rules out Bipolar Disorder.
No Substance Use or Other Medical Conditions: Lab results and denials rule out other causes.

The presence of a clear plan and intent for suicide elevates the severity. While the prompt doesn't explicitly mention psychotic features, the severity of her suicidal ideation with a concrete plan, coupled with her statement about not seeing the point, and the sustained low mood, makes it highly likely. However, for a definitive diagnosis of "with psychotic features," there would need to be delusions or hallucinations directly related to the mood disturbance, which are denied. But, given the severity of the suicidal ideation, it's safer to consider the high risk and manage it accordingly.

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