The case: You have been asked to evaluate a 50-year-old woman with a chief complaint of unremitting depression for 30 years (this is a continuation of the case from 5).


Psychiatric history

  • Onset of depression in late teens/early 20s
  • MDEs sometimes due to stressful events, but most often occur regardless of adjustment stressors
  • MDD became chronic in the patient’s early 40s without any clear inter-episode recovery
  • The patient likely has “double depression” where she meets dysthymic level (persistent depression disorder in DSM-5) criteria with full MDEs superimposed intermittently
  • History includes no hospitalizations. She had one suicide attempt as a teenager

–          Review of psychiatric systems revealed no formal anxiety disorder; however, she reports situational panic attacks at work when she feels overwhelmed with tasks

–          There is no evidence of schizophrenia or mania

–          History of AUD for which she went for rehabilitation and remains sober – there is no liver disease or damage from alcohol use

–          Previous psychiatric treatments included:

o   Consistent supportive psychotherapy with CBT intervention

o   Amitriptyline (Elavil), a tricyclic antidepressant (TCA), was used for approximately 20 years, with partial response but no sustained remission

o   Fluoxetine (Prozac), a selective serotonin reuptake inhibitor (SSRI), up to 120 mg/d, allowed for a response but effect was lost over time

o   Sertraline (Zoloft), an SSRI, up to 100 mg/d and another SSRI, paroxetine (Paxil), 40 mg/d failed altogether


Social and personal history

  • The patient is single, never married
  • Is college-educated and works in management and has routinely been gainfully employed
  • Grew up with parents who abused alcohol but without any abuse
  • Grew up in relative poverty


Medical history

  • Successful gastric bypass surgery (100-pound weight loss)
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